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Healthcare policy seminar. ( Topic : The Effect of Elevated Blood Lead Level in Children, Flint -" A policy perspective"

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    The NEW ENGLA ND JOURNAL of MEDICINE Perspective March 24, 2016 Lead Contamination in Flint — An Abject Failure to Protect Public Health David C. Bellinger, Ph.D.​​ Lead Contamination in Flint T he dangers of lead exposure have been recognized for millennia. In the first century a.d., Dioscorides observed in his De Materia Medica that “lead makes the mind give way.” The first in- dustrial hygiene act passed in the colonies, in 1723, prohibited the use of lead in the apparatus used to distill rum, because “the strong liquors and spirits that are distilld through leaden heads or pipes are judged on good grounds to be unwholsom and hurtful.” More recently, large amounts of lead were used to boost the octane rating of gasoline and improve the performance of paint. One would be challenged to design a better strategy for maximizing population exposure to a poison than to have it emitted by a ubiquitous mobile source and to line the surfaces of dwellings with it. The dramatic reduction over the past 40 years in blood lead levels in the U.S. population is rightly regarded as one of the cardinal public health success stories. It was achieved largely by phasing out lead as a gasoline additive and restricting the amount of lead permitted in paint. At the same time, because of research opportunities created by reductions in population exposures, the consensus view on how much lead is “too much” has also evolved. It is now established that there is no safe level of lead, particularly for children. The reference blood lead concentration for children set by the Centers for Disease Control and Prevention, 5 μg per deciliter, is meaningful only for risk stratification. n engl j med 374;12 nejm.org Water doesn’t receive as much attention as paint as a route of lead exposure, but the use of lead in water-distribution systems goes back to the Romans. Indeed, our word “plumbing” derives from the Latin for lead, and lead poisoning is often called “plumbism.” The recent episode in Flint, Michigan, has brought the issue of lead in water into the public eye. In 2014, solely as a cost-saving measure, the city began taking its water from the Flint River rather than Lake Huron. The corrosioncontrol treatments required by the Environmental Protection Agency’s Lead and Copper Rule1 were, for some reason, discontinued. To make matters worse, the addition of ferric chloride to reduce the formation of trihalomethanes from organic matter increased the corrosivity of the Flint River water. The water reaching consumers was therefore 19 times as corrosive March 24, 2016 The New England Journal of Medicine Downloaded from nejm.org on September 23, 2017. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved. 1101 Lead Contamination in Flint PERS PE C T IV E as it had been when the source was Lake Huron. The more corrosive water is, the more readily it can dissolve metals such as lead. So the lead concentration in Flint’s water began to rise. In six of nine city wards, the water in 20 to 32% of the homes had a lead concentration above 15 μg per liter, a concentration that triggers remedial action under the Lead and Copper Rule. The 90th percentile was 25 μg per liter, and in some samples the concentration exceeded 1000 μg per liter (www.FlintWaterStudy.org). fants’ dietary intake of lead ranges from 0.2 to 0.9 μg per kilogram of body weight per day, so a 5-kg infant typically takes in about 2.5 μg per day.3 If, however, the infant consumes 1 liter of water per day with a lead concentration of 25 μg per liter, the intake of 25 μg of lead would be 10 times higher day after day. Lead contamination of drinking water poses a particular public health challenge because it rarely originates in the source water. Rather, the problem usually lies near the point of consump- The burden of childhood lead poisoning has always weighed most heavily on populations that are politically and economically disenfranchised. This contamination had consequences. Hanna-Attisha et al. reported that among children in Flint, the incidence of blood lead concentrations above the reference value of 5 μg per deciliter rose from 2.4% to 4.9% between 2013 and 2015.2 The increase was greatest, from 4.0% to 10.6%, among children in neighborhoods with the highest lead concentrations in water. Children are more vulnerable to lead than adults because of their greater fractional absorption of ingested lead and greater intake on a body-weight basis and because development of the central nervous system is easily derailed in ways that result in cognitive and behavioral abnormalities. When lead concentrations in water are high, infants consuming reconstituted formula are at special risk. The European Food Safety Authority estimates that in- 1102 tion, in lead service pipes connecting the house to the water main or lead pipes, lead solder, or lead brass fixtures in the home. Large-scale contamination generally occurs when changes are made in water-treatment protocols without consideration of the effect of those changes on the amount of lead that will leach from these materials. A decade ago in Washington, D.C., a change from the use of free chlorine to chloramine to reduce disinfection by-products caused such a problem, and lead contamination of water has recently occurred in some new housing in Hong Kong because, against code, plumbers used lead solder. The burden of childhood lead poisoning has always weighed most heavily on populations that are politically and economically disenfranchised. In Flint, 4 in 10 families live below the poverty n engl j med 374;12 nejm.org line, unemployment is high, and the majority of the population is black. In general, disadvantaged children are exposed to more lead than their wealthier counterparts because they are more likely to live in houses in poor repair that still harbor deteriorating lead paint, to live in urban neighborhoods with greater soil and dust lead concentrations from traffic and industrial activities, and to have nutritional deficiencies that increase lead absorption. An elevated water lead concentration therefore adds to a background exposure that is already high. Indeed, Hanna-Attisha et al. showed that even before the water contamination began, the incidence of blood lead concentrations above 5 μg per deciliter was more than three times as high among children in Flint as among children in neighboring municipalities.2 Were Flint more affluent, it’s unlikely that the contamination would have continued for 18 months after citizens first voiced complaints about water quality. An institutional factor that probably contributed to the crisis is that Flint was in receivership because of severe financial difficulties. The decision to switch water suppliers was made by a state-appointed emergency manager rather than local officials, who might have been better positioned to make a decision reflecting concern for public health as well as the bottom line. Although the cost of repairing Flint’s water infrastructure is uncertain, estimates range as high as $1.5 billion. The cost of reducing the corrosivity of the Flint River water at the time of the change would have been minimal, perhaps $100 per day4 — proving again that prevention is generally cheaper March 24, 2016 The New England Journal of Medicine Downloaded from nejm.org on September 23, 2017. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved. Lead Contamination in Flint PE R S PE C T IV E brought to light had citizens not persisted in efforts to force local, state, and federal officials to take action. This is not the way public health protection should work, and the crisis appears to reflect failures at every level of government. In 1969, environmentalist René Dubos warned that the problem of childhood lead poisoning “is so well-defined, so neatly packaged, with both causes and cures known, that if we don’t eliminate this social crime, our society deserves all the disasters that have been forecast for it.”5 We have yet to fully respond to Dubos’s admonition. We have the knowledge required to redress this social crime. We know where the lead is, how people are exposed, and how it damages health. What we lack is the political will to do what should be done. than remediation and treatment. More money will be spent in the courts, since multiple lawsuits have already been filed. Imagine what could have been achieved for the people of Flint if the funds that will now be needed to repair the damage and litigate lawsuits could instead have been used to pursue goals such as improving the schools, de-leading homes, or funding programs providing job training, early education, or treatment and prevention for substance abuse An audio interview with Dr. Bellinger or domestic abuse. is available at NEJM.org Other costs that can be anticipated include developmental surveillance and treatment of the thousands of affected children. In coming years, parents will undoubtedly wonder, with anxiety and even guilt, whether their children’s every developmental stumble stems from this episode. It is notable that the Flint contamination might never have been Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From the Departments of Neurology and Psychiatry, Boston Children’s Hospital and Harvard Medical School, and the Department of Environmental Health, Harvard T.H. Chan School of Public Health — all in Boston. This article was published on February 10, 2016, at NEJM.org. 1. National primary drinking water regula- tions for lead and copper: short-term regulatory revisions and clarifications. Federal Register. October 10, 2007 (https:/​ /​ w ww​ .federalregister​.gov/​a rticles/​2007/​10/​10/​ E7-19432/​national-primary-drinking-water -regulations-for-lead-and-copper-short-term -regulatory-revisions-and-clarifications). 2. Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. Am J Public Health 2016;​106:​283-90. 3. European Food Safety Authority. Scientific opinion on lead in food. EFSA 2010;​8:​ 1570 (http://www​.efsa​.europa​.eu/​sites/​default/​ files/​scientific_output/​f iles/​main_documents/​ 1570​.pdf). 4. Poisoned water. That Flinty taste. Economist 2016;​418(8973):​23. 5. Oberle MW. Lead poisoning: a preventable childhood disease of the slums. Science 1969;​165:​991-2. DOI: 10.1056/NEJMp1601013 Copyright © 2016 Massachusetts Medical Society. Lead Contamination in Flint Mitochondrial Replacement Techniques Mitochondrial Replacement Techniques — Implications for the Clinical Community Marni J. Falk, M.D., Alan Decherney, M.D., and Jeffrey P. Kahn, Ph.D., M.P.H.​​ M itochondrial DNA (mtDNA) diseases may be the poster child for highly targeted, “personalized” medicine. These heterogeneous disorders, although rare individually, have well-defined genetic causes — more than 400 known pathogenic mutations or deletions in the 16,569-base-pair mitochondrial chromosome that contains only 37 genes. Affected persons may present at any age with some combination of severe, often progressive, and sometimes fatal neurologic, musculoskeletal, cardiac, gastrointestinal, renal, ophthalmologic, and audiologic involvement. No cures or therapies have been approved by the Food and Drug Administration (FDA) for any mtDNA disease, although symptom-based clinical management can be beneficial. Despite their precisely defined causes, it’s often difficult to predict the onset or severity of these diseases because of heteroplasmy: the culprit mtDNA mutation is n engl j med 374;12 nejm.org commonly present in only a fraction of the body’s mitochondria. Building on the principle that less is better, reducing mutant heteroplasmy loads below an often tissue-specific and difficult-todefine threshold presents a potential opportunity to improve health that is unique to these diseases. Research in animal and somatic cellular models has focused on this potential, using endonuclease, TALEN (transcription activator–like effector nuclease), or March 24, 2016 The New England Journal of Medicine Downloaded from nejm.org on September 23, 2017. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved. 1103 Vol. 58 / RR-9 Recommendations and Reports 1 Recommendations for Blood Lead Screening of Medicaid-Eligible Children Aged 1–5 Years: an Updated Approach to Targeting a Group at High Risk Anne M. Wengrovitz, MPH, Mary Jean Brown, ScD Advisory Committee on Childhood Lead Poisoning, Division of Environmental and Emergency Health Services, National Center for Environmental Health Summary Lead is a potent, pervasive neurotoxicant, and elevated blood lead levels (EBLLs) can result in decreased IQ, academic failure, and behavioral problems in children. Eliminating EBLLs among children is one of the 2010 U.S. national health objectives. Data from the National Health and Nutrition Examination Survey (NHANES) indicate substantial decreases both in the percentage of persons in the United States with EBLLs and in mean BLLs among all age and ethnic groups, including children aged 1–5 years. Historically, children in low-income families served by public assistance programs have been considered to be at greater risk for EBLLs than other children. However, evidence indicates that children in low-income families are experiencing decreases in BLLs, suggesting that the EBLL disparity between Medicaid-eligible children and non–Medicaid-eligible children is diminishing. In response to these findings, the CDC Advisory Committee on Childhood Lead Poisoning Prevention is updating recommendations for blood lead screening among children eligible for Medicaid by providing recommendations for improving BLL screening and information for health-care providers, state officials, and others interested in lead-related services for Medicaid-eligible children. Because state and local officials are more familiar than federal agencies with local risk for EBLLs, CDC recommends that these officials have the flexibility to develop blood lead screening strategies that reflect local risk for EBLLs. Rather than provide universal screening to all Medicaid children, which was previously recommended, state and local officials should target screening toward specific groups of children in their area at higher risk for EBLLs. This report presents the updated CDC recommendations and provides strategies to 1) improve screening rates of children at risk for EBLLs, 2) develop surveillance strategies that are not solely dependent on BLL testing, and 3) assist states with evaluation of screening plans. Introduction Substantial improvements have been made in reducing lead in the environment. During 1999–2004, 1.4% of children in the United States aged 1–5 years had elevated blood lead levels (EBLLs) (1), compared with 8.6% of children during 1988–1991. Despite this progress, some children remain at risk, and eliminating EBLLs among all children aged 1–6 years is a 2010 national health objective (objective 8–11) (2). To meet this objective, the limited available resources must be focused on the populations at highest risk for EBLLs. Since 1989, children who are eligible for Medicaid have been identified as having an increased risk for lead exposure. This finding forms the basis for the current national Medicaid policy, which targets Medicaid-eligible children for preventive and screening measures, including routine blood lead testing. However, evidence from several states indicates that children in low-income families are experiencing decreases in BLLs. This underscores the need for closer analysis of the lead risk patterns within variCorresponding preparer: Mary Jean Brown, ScD, Division of Environmental and Emergency Health Services, National Center for Environmental Health, CDC, 4770 Buford Highway, MS F-40, Atlanta, GA 30341. Telephone: 770-488-7492; Fax: 770-488-3635; E-mail: mjb5@cdc.gov. ous jurisdictions and suggests that children who are eligible for Medicaid can no longer be assumed to have an increased risk for EBLLs. Therefore, a new blood lead screening strategy is needed that accounts for local variations in risk and disparities at the local level. This report reviews available data on childhood lead exposure in the United States, especially among children aged 1–5 years who are eligible for Medicaid, updates screening recommendations for this population, and describes relevant Medicaid program requirements and changes. The national objective to eliminate EBLLs among children by 2010 is part of a larger national goal to eliminate health disparities among various segments of the population (Goal 2) (2). Improved blood lead screening policies and practices also support the “healthy people in healthy places” component of CDC’s core health protection goals, which aim to promote and protect health through safe and healthy home environments (3). In 2000, CDC, the Department of Housing and Urban Development (HUD), the Environmental Protection Agency (EPA), and other agencies developed a federal interagency strategy to eliminate EBLLs among children by 2010. An important element of this interagency strategy is identification and care of children with EBLLs, especially Medicaid-eligible children (4). 2 MMWR Methods The National Health and Nutrition Examination Survey (NHANES) is an ongoing series of cross-sectional surveys on health and nutrition designed to be nationally representative of the noninstitutionalized, U.S. civilian population by using a complex, multistage probability design. All NHANES surveys include a household interview followed by a detailed physical examination. NHANES data indicate substantial decreases since 1976 in both the percentage of persons in the United States with EBLLs and in mean BLLs among all age and ethnic groups. The CDC Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) makes recommendations to improve lead poisoning prevention measures. In 2001, in response to the decreased prevalence of EBLLs in the United States, ACCLPP formed a workgroup to 1) review the published research regarding screening of children at high risk for EBLLs and 2) outline recommendations for state Medicaid agencies to determine whether risk for lead exposure among Medicaid-eligible children overall is higher than for non– Medicaid-eligible children in their jurisdictions. The Centers for Medicare & Medicaid Services (CMS), which is the administrator of the Medicaid program, reviewed the recommendations developed by the workgroup. The recommendations were approved by ACCLPP in September 2008. Blood Lead Levels and Exposure Patterns Among Children Lead has been associated with numerous adverse health effects in humans (5). In children, even BLLs 20 µg/dL were Medicaid eligible (16). A subsequent analysis of all 1988–1994 NHANES data found that families who reported having Medicaid coverage were more likely to have EBLLs than those who were not enrolled in Medicaid (16). Such findings supported a focus on identifying cases of EBLL among Medicaid children to provide early intervention and treatment and develop focused prevention strategies (17). Medicaid eligibility, as well as eligibility for other programs for low-income families, is a proxy for poverty and therefore for living in old, poorly maintained housing, which is more likely to contain lead paint hazards. As a result of increased lead screening for Medicaid children, recent data are available that provide a more detailed characterization of this population’s risk for EBLLs. An analysis of Minnesota data indicated that the percentage of tested children aged
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    Lead Contamination in Flint – A policy Perspective
    In the article, “Lead Contamination in Flint — An Abject Failure to Protect
    Public Health” by David C. Bellinger, cases of the dangers of lead exposure in Flint have been
    reported for over 1000 years now. For instance, he made an observation that ‘lead makes the mind
    give away.’ Lead has been used to boost the octane rating of gasoline and also to improve t...


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