LEPAC Meeting 12-8-2022

Lead Exposure and Prevention Advisory Committee (LEPAC) Meeting – December 8, 2022

11:00 am     Welcome, Introductions, and Announcements

Paul Allwood, PhD, MPH, RS, Designated Federal Official, Branch Chief, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH

Patrick N. Breysse, PhD, CIH, Director, NCEH/ATSDR

Matthew Ammon, MS, Chair, LEPAC and Director, HUD Office of Healthy Homes and Lead Hazard Control

Perri Ruckart, DrPH, MPH, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH

11:20 am    American School Health Association (ASHA) Presentation and Q&A

Jeanie Alter, PhD, MCHES, Executive Director, American School Health Association

Derek Shendell, DEnv, MPH, Professor, Rutgers School of Public Health

12:00 pm     Public Comment

12:15 pm     Lunch

12:45 pm    National Association of School Nurses (NASN) Presentation and Q&A

Donna Mazyck, MS, RN, Executive Director, National Association of School Nurses

1:30 pm     Reducing Lead Levels in Drinking Water in Schools and Childcare Facilities

Treda Grayson, PhD, MS, Branch Supervisor, U.S. Environmental Protection Agency (EPA) Office of Ground Water and Drinking Water

2:15 pm      Break

2:30 pm     Lead Safe Toolkit for Home-Based Childcare

Amanda Reddy, MS, Executive Director, National Center for Healthy Housing

3:05 pm     Healthy Schools Network

Claire Barnett, MBA, Founder and Executive Director, Healthy Schools Network

3:45 pm     Facilitated Discussion

4:30 pm     Wrap Up and Discuss Topics for Next Meeting

Matthew Ammon, MS, Chair, LEPAC and Director, HUD Office of Healthy Homes and Lead Hazard Control

4:45 pm     Adjourn

The Lead Exposure and Prevention Advisory Committee (LEPAC) convened on December 8, 2022. Remote participation was achieved through a virtual ZOOM meeting. Approximately 138 public participants attended the meeting or a portion of the meeting. Approximately 55 Federal employees attended the meeting or a portion of the meeting. The meeting was open to the public.

Common Themes: Lead sources in schools and childcare facilities, school nursing practices, lead remediation in schools and childcare facilities, data and surveillance, outreach and communication, lead in aviation fuel, social determinants of health

Identified Research Gaps: Communication and outreach strategies to increase blood lead testing, adult lead exposure, long-term health effects from childhood exposures, impact of acute exposure on blood lead levels, lead exposure from contaminated products in schools, lead exposure from artificial turf. 

Attendees

Voting LEPAC Members Present (in alphabetical order)

• Matthew Ammon, M.S., LEPAC Chair, Director, Office of Lead Hazard Control and Healthy Homes, U.S. Department of Housing and Urban Development (HUD)

• Tammy Barnhill-Proctor, M.S., Supervisory Education Program Specialist, Office of Innovation and Early Learning, Office of Elementary and Secondary Education, U.S. Department of Education

• Jeanne Briskin, M.S., Director, Office of Children’s Health Protection, U.S. Environmental Protection Agency (EPA)
• Wallace Chambers, Jr., Ph.D., M.A.S., M.H.A., REHS, Deputy Director, Environmental Public Health, Cuyahoga County Board of Health

• Monique Fountain-Hanna, M.D., M.P.H., M.B.A., Senior Regional Medical Consultant, Maternal and Child Health Bureau, Health Resources and Services Administration (HRSA)
• Nathan Graber, M.D., M.P.H., FAAP, Clinical Associate Professor, Department of Pediatrics, Albany Medical Center

• Kristina M. Hatlelid, Ph.D., M.P.H., Toxicologist, Division of Health Sciences, U.S. Consumer Product Safety Commission (CPSC)
• Karla Johnson, M.P.H., Administrator, Marion County Public Health Department

• Erika Marquez, Ph.D., M.P.H., Assistant Professor, School of Public Health, University of Nevada, Las Vegas

• Howard Mielke, Ph.D., M.S., Professor, Department of Pharmacology, Tulane University School of Medicine
• Anshu Mohllajee, Sc.D., M.P.H., Research Scientist Supervisor I, Childhood Lead Poisoning Prevention Branch, California Department of Public Health
• Jill Ryer-Powder, Ph.D., M.N.S.P., Principal Health Scientist, Environmental Health Decisions

Non-Voting LEPAC Liaison Members Present

• Patrick Parsons, Ph.D., Director, Division of Environmental Health Sciences, Chief, Laboratory of Inorganic and Nuclear Chemistry, New York State Department of Health, liaison to Association of Public Health Laboratories (APHL)
• Amanda Reddy, M.S., Executive Director, National Center for Healthy Housing (NCHH), liaison to National Center for Healthy Housing (NCHH)
• Stephanie Yendell, D.V.M, M.P.H., Senior Epidemiology Supervisor, Minnesota Department of Health (MDH), liaison to Council for State and Territorial Epidemiologists (CSTE)
• Lauren Zajac, M.D., M.P.H, FAAP, Assistant Professor, Icahn School of Medicine at Mount Sinai, liaison to American Academy of Pediatrics (AAP) 

Absent Voting LEPAC Members

• Tiffany DeFoe, Ph.D., Director, Office of Chemical Hazards-Metals, Occupational Safety & Health Administration (OSHA), U.S. Department of Labor

• Michael Focazio, Ph.D., M.S., Program Coordinator, U.S. Geological Survey (USGS)
• Donna Johnson-Bailey, M.P.H., RD, Senior Nutrition Advisor, U.S. Department of Agriculture (USDA) 

Absent Non-Voting LEPAC Liaison Members

• Jamie Mack, M.A., Environmental Health Director, Delaware Division of Public Health, liaison to Association of State and Territorial Health Officials (ASTHO)
• Ruth Ann Norton, President and CEO, Green & Health Homes Initiative (GHHI), liaison to Green & Healthy Homes Initiative (GHHI)

Presenters (in alphabetical order)

• Jeanie Alter, Ph.D., MCHES, Executive Director, American School Health Association
• Claire Barnett, M.B.A., Founder and Executive Director, Healthy Schools Network
• Treda Grayson, Ph.D., M.S., Branch Supervisor, U.S. Environmental Protection Agency (EPA) Office of Ground Water and Drinking Water
• Donna Mazyck, M.S., R.N., Executive Director, National Association of School Nurses
• Amanda Reddy, M.S., Executive Director, National Center for Healthy Housing
• Derek Shendell, D.Env., M.P.H., Professor, Rutgers School of Public Health

Public Commenters (in alphabetical order)

• Diana Zuckerman, Ph.D., National Center for Health Research

CDC Attendees who presented in the LEPAC Meeting (in alphabetical order)

• Paul Allwood, Ph.D., M.P.H., RS, Branch Chief, LEPAC Designated Federal Officer (DFO), Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH/ATSDR, CDC
• Patrick N. Breysse, Ph.D., CIH, Director, NCEH/ATSDR, CDC
• Perri Ruckart, Dr.P.H., M.P.H., Team Lead/Health Scientist, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH/ATSDR, CDC

Lead Branch Updates

Paul Allwood, Ph.D., M.P.H., RS, LEPAC DFO, Branch Chief, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH/ATSDR, CDC

• The lead program at CDC continues their commitment and efforts to end childhood lead poisoning as a public health problem in the United States.
• The lead program published a supplement in the American Journal of Public Health in September 2021.
• The lead program partnered with the Council of State and Territorial Epidemiologists (CSTE) to update public health reporting and national notification for lead in blood.
• In 2021, the lead program received the CDC/ATSDR award for Excellence in Public Health Protection for the work done on the blood lead reference value (BLRV) update.

American School Health Association

Jeanie Alter, Ph.D., MCHES, Executive Director, American School Health Association

• The American School Health Association (ASHA) is a multidisciplinary professional association made up of various health professionals and educators, all within the school and community and focused on the health and well-being of students.
• ASHA is involved in lead exposure in the schools and in the community. ASHA is working to propose legislation related to lead in schools.
• ASHA publishes the Journal of School Health.

Derek Shendell, D.Env., M.P.H., Professor, Rutgers School of Public Health

• Lead exposure is not a new problem.
• The United States has made incredible progress removing lead from the air, but there are still situations where lead is getting into the air (e.g., small aircraft).
• There are several pathways and routes of lead exposure. Public health professionals are most concerned with chronic exposures to lead and adverse health effects especially to the neurologic system.
• Routes of lead exposure are inhalation, dermal, and ingestion.
• The ideal way to prevent lead exposure is to remove the source. Since that is not possible with lead, public health needs to focus on reducing or eliminating exposure.
• Parents and students may be bringing lead-contaminated personal care, food, and consumer products into schools. Other lead sources in schools include paint and water.
• There is the potential for lead to be in old pipes in the school, either the service or main line, and in the plumbing and fixtures. Some schools have had to shut off their water and provide bottled water.
• Temperature and other factors affect the amount of lead in the water.
• There is no safe level of lead in the human body. There should be actions to reduce levels as close to zero as possible.
• ASHA recommends strengthening risk communication and extending EPA’s Renovation, Repair, and Painting Program (RRP) to apply to areas of a school where elementary school-aged children spend time. Currently, the RRP only applies to facilities for students younger than six years old.
• EPA’s Children’s Health Protection Advisory Committee recommends standards be updated to account for CDC’s most recent blood lead reference value. The new BLRV considers the higher cumulative and aggregate exposure that children may face when attending school or childcare in communities.
• Their website has checklists for use in K–12 schools to address various exposures.
• Following the presentation, LEPAC members discussed concerns about the following:
  • How to fund repairs if lead is found
  • Funding sources to replace plumbing fixtures in schools, including public-private partnerships
  • Avoidable sources of lead being brought into schools
  • Exposures from nearby airports
  • The need for research on the impact of acute exposures on blood lead levels
  • The need for more awareness among parents and stakeholders

Public Comment

Diana Zuckerman, Ph.D., President, National Center for Health Research

• The National Center for Health Research is a nonprofit research center in Washington,C. The center is staffed by scientists, medical professionals, and public health experts. They conduct and explain research that can improve the health and safety of adults and children, and they do not accept funding from companies whose products they evaluate.
• New sources of lead that can harm the health of children and adults include artificial turf and school playgrounds with spongy surfaces. Artificial turf and fields have infill made of rubber or crumb rubber that can contain lead.
• Recently, most of the attention on the health effects of artificial turf materials has been on endocrine-disrupting chemicals.
• Artificial turf presents a lead hazard because it releases lead into the air. Additionally, the rubber deteriorates, and children sometimes eat the particles that line the base layer of the playground surface.
• There are no tests to check if these materials contain lead.
• The government does not restrict lead in playgrounds or artificial turf because the companies claim they are not children’s products.
• Lead from the artificial turf can get into the water.
• A safer, lead-free alternative is engineered wood fiber, which costs the same amount as synthetic rubber.
• Zuckerman also raised concerns that playground equipment sometimes contains lead paint.
• She has recently spoken with the chairman of the Consumer Product Safety Commission about lead in artificial turf.

National Association for School Nurses

Donna Mazyck, M.S., RN, Executive Director, National Association of School Nurses

• The National Association of School Nurses (NASN) is a 501(c)(3). It is a professional association for school nurses, and it is an organization that is over fifty years old. Their mission is to make sure that students are healthy, safe, and ready to
• NASN has affiliates in 48 states and D.C. They do not have affiliates in Hawaii and North Dakota.
• The Whole School, Whole Community, Whole Child Model (WSCC) seeks to create a healthy, safe, engaged, and supportive environment for children. It features collaboration between health and education because healthy children learn better. One of the components is school health services.
• WSCC has ten components: physical education and physical activity; nutrition environment and services; health education; social and emotional climate; physical environment; health services; counseling, psychological, and social services; employee wellness; community involvement; and family engagement.
• The 21st Century School Nursing Practice framework features five key principles for how school nurses work: care coordination, leadership, quality improvement, standards of practice, and community and public health.
• In Fall 2021, 49.5 million students were enrolled in pre-K through 12th grade public schools. Of these, 1.4 million students attended prekindergarten and 3.6 million student attended kindergarten.
• School nurses play a role in addressing social determinants of health by connecting with families, community agencies, and community members to shed light to ensure that students are well.
• School nurses may be a suitable liaison for lead poisoning prevention and awareness within the school setting. School nurses collaborate with students and families, and they are advocates for students. School nurses also collaborate with community agencies and providers.
• NASN has a position statement on environmental health.
• Communication with families is a strength school nurses have in lead prevention work.
• Access to blood lead test results would help school nurses make a positive difference.
• School nurses need resources to connect at the state level. One challenge includes bidirectional data sharing with school information and patient information. Schools and healthcare providers have different privacy laws.
• NASN looks to CDC for tools and resources that they can use in schools and with families, community-based organizations, and providers to connect children to needed services.
• There is a need for teacher training resources and NASN is willing to help.
• Mazyck raised several discussion points including blood level surveillance by school nurses as part of Medicaid-eligible services in schools, school nurses having access to blood lead level test results, and surveillance requirements that are similar to immunization registries.
• Following the presentation, LEPAC members discussed multiple topics:
  • The importance of school nurses in keeping children safe and healthy
  • The need for strong collaboration and communication between school nurses and primary care providers
  • NASN’s participation on the AAP Council on School Health
  • Barriers to getting a blood lead test, including awareness and communication
  • How state health departments can connect with school nurses on messaging
  • Lack of access to immunization registries for some school nurses
  • Lack of bidirectional data sharing with healthcare providers
  • Factors to consider when deciding on an appropriate ratio of students to school nurses
  • Pediatric environmental health specialty units as a source of information and training for school nurses and other health professionals

Reducing Lead Levels in Drinking Water in Schools and Childcare Facilities

Treda Grayson, Ph.D., M.S., Branch Supervisor, U.S. Environmental Protection Agency (EPA) Office of Ground Water and Drinking Water

• EPA’s newly formed Targeted Community and Compliance Assistance Branch in the Office of Groundwater and Drinking Water covers drinking water emergencies, such as the situation in Jackson, Mississippi. Emergencies include lead in schools and childcare facilities.
• EPA received $15 billion in dedicated funding through the Bipartisan Infrastructure Law (BIL) to replace lead pipes and service lines and remove lead from soil and contaminated sites.
• On October 27, 2022, EPA released it’s first-ever agency-wide Strategy to Reduce Lead Exposures and Disparities in U.S. Communities. This presentation focused on efforts related to this strategy, including providing and awarding funding and grants for public water systems, schools, and childcare facilities and reducing lead exposures nationally through protective standards, tools, and outreach via the Lead and Copper Rule Revisions (LCRR) and the Lead and Copper Rule Improvement (LCRI).
• EPA works with partners such as the U.S. Department of Health and Human Services (HHS) and CDC to ensure the best lead testing practices.
• EPA initiatives for reducing lead in drinking water in schools and childcare facilities include the Voluntary Program for Lead Testing and Remediation, a memorandum of understanding (MOU) on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities between several federal and non-federal organizations, the 3Ts Program (Training, Testing, and Taking Action), and the Voluntary School and Child Care Lead Testing and Reduction Grant Program.
• The MOU was established in 2005 and revised in 2019. It provides a framework for a coordinated approach between critical partners across the federal government, tribes, water utilities, and the public health community.
• The Safe Drinking Water Act gives EPA the authority to set regulations for public water systems. It does not provide the authority to regulate schools and childcare facilities or require them to test their water supply.
• EPA provides funding through the Water Infrastructure and Improvements for the Nation (WIIN) Act and the 3Ts Program to voluntarily test and remediate lead in drinking water.
• LCRI which will be effective in 2024, will require community water systems, elementary schools, and childcare facilities to test for lead.
• The 3Ts Program is a connector between the MOU and the Voluntary Grant Program. The 3Ts Manual, which is in English and Spanish, is available on the website and includes modules, customizable templates, checklists, and toolkits to implement a lead testing and remediation program in schools and childcare facilities.
• The 2019 document entitled “Potential Funding Sources for Reducing Lead in Drinking Water in School and Childcare Facilities” assists schools and childcare facilities in identifying potential funding sources for projects related to lead remediation and water quality in each state.
• EPA prioritizes communities that are disadvantaged, low-income, and underserved as well as small communities, older facilities that are more likely to contain lead plumbing and care for children six years old and under, and tribal communities.
• The Voluntary School and Childcare Lead Testing and Reduction Grant Program currently funds all 50 states, the District of Columbia, U.S. territories, and seven tribal consortia. Eligible participants are public or charter schools and childcare and early childhood care facilities. A total of $78.1 million has been awarded.
• The Voluntary School and Childcare Lead Testing and Reduction Grant Program is expanding the program to allow funding for lead remediation and to increase testing. Funds can be used to replace, remove, and install internal plumbing, faucets, water fountains, water filler stations, point-of-use devices, lead service lines, and other lead apparatus related to drinking water. As of September 2021, a total of 75,000 samples have been taken at 8,000 facilities. 1,000 facilities had lead levels that exceeded the level that triggers remediation. A total of $200 million is authorized for the program for the next five years.
• For 2023, there are four focus areas to help build state program capacity to address implementation challenges: building regulatory support, obtaining technical assistance, managing collected data, and communicating results.
• Following the presentation, LEPAC members discussed what determines how much states and localities receive for funding and how to notify qualifying groups of funding availability. Dr. Grayson shared the allocation formula. She also clarified the agency’s prioritization scheme for the BIL and discussed more about their technical assistance process.
• Grayson concluded by stating that EPA is proposing endangerment funding for lead emissions for aircraft engines that operate on leaded fuel. The public period for this proposal is open until January 17, 2023.

Lead Safe Toolkit for Home-Based Children

Amanda Reddy, M.S., Executive Director, National Center for Healthy Housing

• The National Center for Healthy Housing (NCHH) is a national nonprofit organization, founded over 30 years ago. Their original mission was to tackle the issue of childhood lead poisoning.
• A 2012 Child Trends analysis found that most children under five years of age are receiving care in a residential setting, whether in their own home, in the home of a relative, or in a licensed or unlicensed home-based daycare or childcare environment.
• Finding and fixing lead hazards in these homes provides an opportunity to prevent exposure for many children.
• Messages aimed at remediating lead hazards in homes do not always account for home-based childcare businesses.
• Environmental health is not often addressed in licensing, regulations, guidelines, or professional development opportunities. It’s also not addressed in support for childcare at the state and local levels.
• Last spring, NCHH hosted a discussion with home-based childcare providers and HUD lead hazard control grantees to understand more about the barriers and opportunities to reducing lead exposure in home-based childcare. Challenges included lack of awareness of lead exposure and lead sources, lack of awareness about resources to address the issue, testing and remediation costs, concern about business disruptions while remediation occurs, liability, and lack of regulations and mandates.
• In response to the barriers and opportunities, NCHH created a lead-safe toolkit for home-based childcare that reflects the work of and partnerships with the Children’s Environmental Health Network, the Eco-Healthy Childcare Program, the National Association of Family Childcare, and many others.
• The toolkit is available in English and Spanish. It helps increase awareness of lead hazards, resources, and programs available to home-based childcare providers. A companion document was created for center-based childcare facilities.
• Each section contains a sample policy and implementation worksheet with incremental steps to reduce lead exposure across four familiar sources: paint, water, soil, and consumer products.
• NCHH created a network of 31 home-based providers who have completed online and in-person training and implemented changes in their practices.
• NCHH developed a 4-part webinar series to increase awareness about lead in paint, drinking water, soil, and consumer products. Funding for approximately 300 scholarships is available for home-based childcare providers to access the webinar.
• NCHH is supporting efforts to embed lead into national standards, such as the
  • National Resource Council for Health and Safety in Child Care and Early Education (NRC): Updates to Caring for Our Children (CFOC) standards
  • National Association of Family Child Care (NAFCC): Quality standards for accreditation
  • Council for Professional Recognition (CPR): Opportunities to embed environmental health best practices into the core competencies of the credentialing program
• NCHH supported the City of Allentown’s Community Housing with a 2022 mini grant to help them overcome barriers to addressing lead in home-based childcare. Smaller awards were made to four other communities: Flint, MI; Gwinnet County, GA; the rural panhandle in Nebraska; and Allegheny County, PA. One community used the funding to temporarily relocate while remediations were done.
• NCHH will release a new round of community funding in the first quarter of 2023.
• Following the presentation, LEPAC members discussed resources for states to guide standards development, student volunteers, messaging and outreach about available funds, and linkages to support the work and leverage funding. 

Healthy School Network

Claire Barnette, M.B.A., Founder and Executive Director, Healthy Schools Network

• The Healthy Schools Network, a 30-year-old nonprofit founded in New York, believes that every child should have a right to an environmentally safe and healthy school that is clean and in good repair.
• To accomplish that mission, they established a nationwide coalition of education, environment, and public health professionals, labor groups, environmental health scientists, occupational health professionals, and facility directors to focus on policies, particularly in the poorest communities and schools that lack resources.
• There is a gap in addressing lead in schools.
• There is no such thing as a lead-free school.
• Children absorb more chemicals per body mass than adults.
• Schools tend to be in poor condition and more densely populated than other buildings, and every state compels children to attend them.
• Lead exposure sources in schools can include indoor/outdoor paint, products such as art supplies, turf, recycled rubber, tires, drinking water, and exposure from demolition and renovation.
• Lead poisoning is costly but preventable.
• Focusing on prevention is important.
• Expanding regulations, purchasing lead-free products, and lowering action levels are recommended.
• New York legislation regarding lead in drinking water is a good example. Every five years, every public school in New York must test every tap and report results to the New York Department of Health. The coalition helped to lower the state law to require remediation at five parts per billion of lead in water.
• The coalition faced opposition and challenges including providing water if taps were turned off and determining who is responsible for paying for testing and repairs.
• Filter First was an initiative to put lead filters on drinking water systems so testing for lead at the tap is not necessary. However, there are issues if filters are not replaced when needed.
• The coalition was involved in the New York State $4.2 Billion Bond Act for clean water, clean air, and green jobs.
• The coalition set up National Healthy Schools Day in April as part of Public Health Week.
• Following the presentation, LEPAC members discussed voluntary versus mandatory school programs and gaps in funding for remediation.
• In conclusion, Ms. Barnett noted National Healthy Schools Day is scheduled for April 4, 2023.

Facilitated Discussion

• Key takeaways from the meeting include the following needs:
  • Establishing coalitions to build momentum, create new ideas, and spur change for improving schools and children’s health
  • Building capacity, training, and education on lead poisoning prevention for school superintendents
  • Developing partnerships, including with private and non-profit organizations
  • Being persistent
  • Recognizing barriers to testing in schools and determining how to resolve them
  • Leveraging resources, including immunization registries
  • Recognizing the lack of awareness about available resources
  • Engaging in primary prevention
  • Recognizing the opportunity to remove lead from aviation gas
  • Addressing data sharing challenges
  • Reducing lead in consumer products
  • Improving services for lead-poisoned children as they get older
  • Taking action at the local level
  • Distributing information to schools and childcare providers 

• Based on recommendations from the May 2022 LEPAC meeting, the chair proposed establishing a new work group to gather and review information on relevant literature to define and update the status of adult lead exposures in the United States. Topics for the work group to consider include
  • Epidemiology of adult lead exposure
  • Take-home lead exposure from jobs and hobbies
  • Long-term effects from lead exposure
  • Best practices for preventing adult lead exposure
  • Communication strategies for adult lead exposure