Document Ra76rLVgDN5a1MgzgRrrMbbVa

^ iJ- >-L.U, >V :t: Philadelphia Combats "Silent Epidemic" in the Ghetto lead poisofiisig cntrt By Raymond L. Tyler, R.S., M.P.H. Chief, Accident Control Section Philadelphia, Pa., Department of Public Health Childhood lead poisoning, frequently called the "silent epidemic," afflicting preschool children of the urban ghetto has had a history in Philadelphia much like that of other large urban centers. It threatens the health and development of children who live in the "lead belt" sur rounding the inner city where high lead poisoning exists. Although fatal cases occur much more infrequently than here tofore, a substantial number of children sustain permanent brain damage and mental retardation. The pediatric problem of lead poison ing began to receive attention in cities in the 1920's and 1930's, and in 1950, lead poisoning was made a reportable condition in Philadelphia. During the first few years relatively few cases were diagnosed and reported. From 1950 to 1955, a total of 53 cases, or an average of 8 cases annually, were reported. Fif teen (15) of the 53 cases or 28 percent were fatal. However, in 1956, the Acci dent Control Section of the Philadelphia Department of Public Health in the ex pansion of poison control activities in vestigated the 38 cases of lead poison ing that were reported in that year. Epi demiological investigations were con ducted in all reported cases and aided in documenting the problem of lead poison ing in children. In an attempt to create awareness of the problem in the community, a Lead Presented at the 34th Annual Educa tional Conference in Environmental Health, June 24, 1970, Las Vegas, Nevada. Poisoning Advisory Committee composed of medical, professional, trade and civic groups to assist the Health Department in the development of a comprehensive plan was established. Through those ef forts, a greater awareness was created in the medical community and the number of reported cases climbed steadily, but the grossly inadequate and lacking lab oratory facilities to aid in the diagnosis of lead poisoning was a serious handi cap. In 1961, the Electric Storage Battery Company of Philadelphia, ESB, Inc., of fered to do up to 1,000 free blood and urine lead determinations as a public service. This service immensely aided diagnosis and stimulated reporting. As a result, 109 cases were reported in 1961 doubling the number of any previous year. Fatal cases reached a peak of 12 in 1959, which was also repeated in 1960 and 1962. ESB, Inc. has continued to provide this free public service and has done as many as 2,500 blood-lead de terminations in a given year. .The increased diagnosis, reporting and investigation of cases enabled the Ac cident Control Section in the documenta tion of the problem and in planning a program designed to control lead poison ing in Philadelphia. In each case investi gated, efforts were made to determine the source of lead in the environment. As in other cities, children who became lead poisoning victims had a condition known as pica, the compulsive habit of ingesting inedible substances, including paint chips and flakes, or chewing on painted sur- 64 Vol. 33, No. 1, J.E.H. N36895 DUP050312203 faces. Pica is believed to be a result of factors rooted deep in the psyche of the individual. The homes in which these victims lived were in the older parts of Philadelphia which surround the center city. Most of these homes, which were built at least 100 years ago, were row homes which are characteristic of Philadelphia hut now have been cut up into a number of small apartments and have many lay ers of paint on the interior surfaces. Paint samples from these homes were analyzed and most were found to con tain large concentrations of lead. Prac tically all of the paint which was ap plied before 1940 contained large amounts of lead. Although most of the homes had peeling, flaking and falling paint with walls and woodwork in dis repair, in some homes paint was found intact but toothmarks on window sills and woodwork indicated the extent of the child's pica condition. In a few cases, the source of lead was not found. In rare instances, cases were traced to ingestion of pieces of soft metal toys or flashlight batteries, to the practice of burning old battery casings or painted lumber, the intentional inhalation of tetra-ethyl lead gasoline by adolescents or lead absorbed by drinking illegal whiskey distilled in automobile radiators by adults. The need for legislation to control lead poisoning was cited by 1958, however, the community had to be sold on the need. As the documentation continued and the number of cases rose steadily, community leaders became aware of the problem, and the need for legislation became more acute. In the continuing study of cases, the accident control sec tion attempted to achieve voluntary re moval of lead paint from the environ ment of a lead poisoning victim by appealing to landlords and tenants, but compliance was achieved in only 31 per cent of the cases. This data accentuated the need for legislation. In 1966, the Philadelphia city council passed an ordinance amending the Health Code which declared lead paint to he a health hazard and enabled the Board of Health to promulgate regulations to implement the ordinance. Specifically, the ordinance and regulations require percautionary labeling of lead paint stored, sold or transferred in Philadelphia, prohibits the application of lead paint on toys, furniture and any interior surface of dwellings or facilities occupied or used by children, prohibits the transfer and delivery of toys or furniture on which lead paint appears from any premises where the presence of such is creating a health hazard to children. Implementation of the ordinance and regulations have been carried on with existing personnel and without program re-direction until recently, when some re-direction has taken place so preven tive efforts could be initiated. This in cludes investigation in all cases where a child has a blood-lead level greater than .04- mgm/100 gms of blood and the detection of children with pica or other symptoms suggestive of lead poisoning by visits made by Community Health Workers in other programs. Up to 1970, implementation of the lead poisoning control program has been carried out on a decentralized basis utilizing sanitarians and public health nurses assigned to one of the 10 health districts. The administration of the pro gram is conducted by the Accident Con trol Section. With limited resources through the' years, we have conducted epidemiological investigations and the necessary follow-up inspections in en forcing regulations in all reported cases. In addition, we have examined the labels of lead paint sold in Philadelpia for con formance with labeling requirements. A case of lead poisoning is reported to the Division of Epidemiology; how ever, the Accident Control Section may have already become aware of the case through a copy of the blood-lead analysis done by ESB, Inc., and a check-list from the physician indicating symptoms and other clinical criteria which are com pleted when the blood is drawn. Table I shows blood-lead results in reported cases and numbers of symptoms re ported. Note that a number of cases which are asymptomatic are reported as July/Augysi, 1970 65 wiwiy?1 K i i r l l j 1 i i DUP050312204 TABLE 1 Lead Poisoning in Philadelphia Children Blood Lead Levels and Symptoms Noted by Attending Physicians ________ (1964-1968)______________________ Diagnosed Total Cases_______________________ Symptoms Lead Cum.NoneOne or More Not Reported Levels No. Percent Percent No. Percent No. Percent No. Total ............................. 777 ........ 100 116 100 265 100 396 0--.02 ........................... 13 .03 ........................... 30 .04 ........................... 46 .05 ............................107 .06 ............................140 .07 ...........................105 .08 ........................... 53 .09 ........................... 32 .10 --...................... 52 .20 ........................... 07 .30 ........................... 04 .40 --........................ 06 Unknown .......................182 I 2) ( 4) ( 6) (14) (181 (131 ( 7) ( 41 ( 7) ( I) < I) (13 (24) 23 67 12 II 26 23 44 30 57 17 64 9 68 4 75 8 76 0 77 0 78 2 100 2 28 6 14 9 18 20 54 26 51 15 (39) 8 23 3 15 7 31 03 03 22 2- 4 3 5 7 20 19 15 9 6 12 I I I I 2 9 17 30 59 49 21 13 13 4 I 2 176 Percent I 2 4 8 15 12 5 3 3 I I I 44 confirmed cases and also that some symp tomatic cases have shown relatively low blood-lead levels. Symptomatic cases normally show a lead level of at least .06 mgm. The official report is sent to the ac cident control section by the division of epidemiology which in turn notifies the environmental health supervisor and the nursing supervisor of the district where the victim resides. Visits to the home are made by both the sanitarians and the public health nurse. The object of each visit is different. The sanitarian is chiefly interested in the source of the lead in the child's en vironment and conducts an epidemiologi cal investigation including collecting a number of paint samples throughout the house. He may also take paint samples from another address such as a baby sitter's, the grandmother's or a previous address. Normally, the minimum num ber of samples taken include one from a window sill and one from a door or door frame from each room and any peeling or flaking paint which may exist. Samples of putty, painted plaster and painted wall paper may also be taken. The number of samples taken from homes average be tween 20 and 25. in other siblings, supervision of the child and other health needs of the family. When results of the paint analysis are received and samples indicate presence of lead in amounts of more than 1 per cent, the environmental health super visor will issue an order to the respon sible party for removal of paint. In most cases, this will be the owner of the property. In some cases it could he the tenant if the tenant applied the paint or if furniture or toys are involved. Paint with more than 1 percent lead is re garded as hazardous by Standard Z66.1 --1964 of the American Standards Asso- j elation. The belief is that lead ingested j in lesser amounts will he excreted and j not stored by the body. In the investiga- j lion of cases during the five year period, 1964-1968, a total of 5,466 paint samples were analyzed of which 57 percent were positive as indicated in Table 2. Although there was no significant difference in the results from one room to another, wood work samples were found to be hazardous with a much greater frequency (65-74 per cent) than samples from wall areas (17 per cent) ; and much more likely to be responsible for the intoxication be cause of easily accessible surfaces for chewing. The mtrse, on the other hand, is in terested in the health care of the child, that the mother is keeping clinic appoint ments, the possibility of lead poisioning Along with the order for removal that is issued, a specification sheet giving in structions as to the extent of the removal is included. Areas to he removed are 66 Vol. 33, No. 1, J.E.H. 'vrww'T DU P 050312205 -*0*0 TCO C=C CQ .S "W*r HOoeEI go a itt/a> i ----- -- o corvOfsr-'-O'-om ocOsoM*>--^oo<n*pm---'aN-m`'0 fSON*C --OlflO^O -- -- C4 -- <* -- -- mr-.^--t-mor^eoo*'** -- o"Oc Io_ _ >*o. o ??. * Si :: oo'-~2^>= v0 u6o i 'Va CO O /* O D"e HUo limited to all intact lead paint surfaces below a level of five feet where a chewable edge is presented and all areas where lead paint is loose, flaking, or fall ing. Holes in plaster and wall areas must be repaired. Removal of paint on surfaces which are intact and have no chewable edges is not required. Paint in designated areas must be removed andapproved by the sanitarian. Instead of removal, covering with a hard durable material is permitted. It is suggested that the person responsible' for the re-, moval meet with the sanitarian on the premises in order that the -procedure he adequately explained and there is no question as to the areas listed for re moval. Removal by burning is- the usual method although the owner is advised about the safety precautions he should use in whatever method he employs. The use of respirators approved by the U. S. Bureau of Mines when burning, sanding, scraping or using solvents is recom mended. Following inspection and approval, the responsible party is given permission to repaint with a. safe paint although he is not required to do so. Failure to comply with the order to remove hazardous paint results in a request for legal action. Ini tially, legal action was taken in a Magis trate's Court which was in existence at the time and fines ranging from $25.00 to $300.00 could be imposed. When a new Municipal Court system replaced the Magistrate's Courts, the same procedure was followed although there was a tendency to impose higher fines in second offenses. Beginning in 1970, the enforce ment procedures were revised, and cases are currently being heard in a Court of Common Pleas in which an injunction is requested by the Health Department for failure to comply. If awarded by the court, compliance must be effected with in a specified time or a contempt cita tion is issued with the violator subject to a fine and/or imprisonment. This nas resulted in compliance in difficult cases. In certain cases, where a summons can not he served, such as in the case of absentee owners of property, and inter- July/August, 1970 67 b< I i y f I' l ' r if DUP050312206 tain hardship cases, the Department of Licenses and Inspections is asked to abate the hazard by use of their abate ment fund for the abatement of housing violations with a placement of a lien on the property for the cost of removal. This is provided for because of companion ordinance amending the Housing Code requiring the removal of lead paint when so certified by the Health Department which was adopted in 1966. Our enforcement program is working. We have found that by issuing orders for removal- of hazardous paint and court action in some cases through 1968, we achieved an overall compliance rate of 79 percent, show in Table 3. From 1966 through 1968, a total of 348 properties were made safer by eliminating the hazard of lead paint. The unsuccessful cases are, chiefly, those with absentee landlords- in which we are unable to ob tain service of the summons and hard ship cases where the owner is the oc cupant and financially unable to comply. During the 19 years since lead poison ing became a reportable condition, a to tal of 1,544 cases and 88 deaths were reported as shown in Table 4. In the five-year period, 1964-1968, 777 cases were reported with 13 deaths or an average of 155 cases and two deaths an nually. Compare this with the five-year period, 1956-1960, when activities in lead poisoning control began, when 225 cases and 38 deaths were reported on an average 45 cases a year with seven deaths. This statistic indicates that death from lead poisoning today is a much rarer in stance. By awakening the physician, the hospital staff, the community and mem bers of the Health Department team to the problem of lead poisoning, there has been intensive surveillance in early de tection and treatment and elimination of the hazard from the environment. Phy- TABLE III Effectiveness ef Enforcement of Regulations for the ____ Removal of Lead Paint Year No. of Cases No. of Orders Where Orders Compliance Issued Was Achieved 1966................... ...........-............................ ............. 163 110 90 1967 ............ ...... ...........--............... ...................... 176 153 124 1968 .. _______ ....................................................... 184 175 134 TOTAL ..... --...... -....................... ................. 523 -438 348 Percent of Compliance 81 84 77 Average 79 TABLE IV Lead Poisoning in Philadelphia Children by Year and Race Philadelphia 1950-1968 Year Total _Total.............. 1,544 1968 1967 ________ __ _ 184 176 __1966 .............. 1965 ------------ 163 132 1964 .............. 122 1963 .............. 136 1962 1961 --- ------------ ... 244 109 I960 ------------ 56 1959 .............. 50 _1958 .............. 1957 --------- :.. 53 28 1956 ------------ 3B 1950 to 1955. 50 CASES . White 177 22 8 8 7 15 15 21 9 14 7 22 7 14 8 NonWhite 1,357 162 168 149 125 103 121 223 100 42 43 31 21 24 45 Unknown 10 0 0 6 0 4 0 0 0 0 0 0 0 0 0 Total 88 1 2 3 5 2 3 12 7 12 . 12 6 3 5 15 Per cent 100 1 2 3 6 2 3 14 8 14 14 7 3 6 17 DEATHS Case Fatality Rate 6 1 1 2 4 2 2 5 6 21 2 11 11 13 28 White 26 1 0 1 2 0 2 2 0 4 4 1 0 4 5 NonWhite 62 0 2 2 3 2 1 10 7 8 8 5 3 \ 10 68 Vol. 33, No. 1, J.E.H. DUP050312207 TABLE V Lead Poisoning by Philadelphia Children by Age, Race and Sex Philadelphia 1964-1968 RACE Age in TotalWhite______ Non-White ` MonthsNo. Percent Male Female Male Female Total ........................................... 777 100 3t26 362 ~333 0 6- ................................................................... 7-12 ......................................... 13-18 ......................................... 19-24 ........................................ 25-30 ......................................... 31-36 ......................................... 37-42 ......................................... 43-68 .............................. 49-60 .................. 61+ ........................................... Unknown .................................... 0 16 134 243 139 ill 40 31 22 29 12 00 20 17 6 3] 7 18 8 14 7 52 42 3, 2 42 20 0 2 0 10 5 6 2 0 0 I _____ 044 00 77 55 70 123 99 69 55 51 46. 11 25 13 14 12 8 17 9 ___________ 0 Not Reported 20 0 0 0 4 2 I 0 2 0 0 8 sicians who see many of these cases tell us that they see the severely brain dam aged child less often and the grave con sequences of lead poisoning in children have been substantially reduced. Childhood lead poisoning is distributed in Philadelphia similarly to other cities where an awareness to the problem has been created. The victims range chiefly from 13-36 months in age. Non-white children outnumber white by a ratio of 11 to 1 with no appreciable difference in sex as shown in Table 5. The greater incidence during the warm months fits the pattern of other cities and this is shown in Table 6. The large majority of cases are found in the Philadelphia ghetto (encompassing Health Districts 1, 4, and 6), the areas which surround center city. This "lead belt" is depicted in Figure 1 and Table 7. In recent years, cases are found to be more common in the fringes of the belt as the population TABLE VI Lead Poisoning in Philadelphia Children by Month and Reported Outcome Philadelphia 1964-1968 MONTH Total ........... .......... January ......... .......... February......... .......... March ........................ April ............... ............ May .......................... June ................ July ................ .......... August ........... .......... September .... .......October ........ ........... November...... .......... December ................. Unknown........ ........... Total 777 64 49 47 59 52 57 71 100 100 57 51 34 36 OUTCOME Non-Fatai 764 63 48 47 58 SI 54 71 99 97 56 50 34 36 Fatal 13 1 1 0 1 1 3 0 | 3 1 | 0 0 TABLE VII Lead Poisoning in Philadelphia Children by Health District Philadelphia 1964-1963 Health District Total ...................... ...................... i ........................ ...................... 2 ........................ ........ ............. 3 ........................................... 4 ........................ ...................... 5 .............. ................................. 6 ................................................ 7 .............. ......... ....................... 8 ..... ......................................... 9 ........................ 10 ....... ................. ...................... Unknown ............... ...................... No. 777 102 53 41 95 217 152 S 61 1 1 18 CASES Percent 100 13 7 5 12 28 20 1 8 4 1 2 DEATHS Average Yearly Morbidity Rates! No- 6.4 13 22.7 4.6 3.8 8.2 14.7 13.5 0 2 0 2 2 5 .3 0 4.8 0 2.1 2 .1 0 00 Case Fatality Rate* 1.6 0 3.7 0 2.1 1 3.2 0 0 6.2 0 0 *To nearest I percent. tBased on I960 Health District Census; per 10.000 children in the age group through 5 years. July/August, 1970 69 h'. * L: l DU P050312208 r % i I ' :!! <3 *; moves outward. As the people move, the lead poisoning problem moves with them as old housing exists in most parts of the city and the socio-economic and cultural patterns have not substantially changed. The greatest activity of urban renewal and rehabilitation is occurring in the lead belt and it is helping to solve the problem by providing numbers of hous ing units free of lead paint, but the prob lem is of such great magnitude that an intensive preventive program is most' seriously needed, if it is hoped that the hazard of lead will be removed from the home environment during our lifetime. The community at large most recently has been awakened to this problem and tremendous interest has been generated on the national, state, and local level. prehensive plan for the eradication of lead poisoning in Philadelphia has been developed which encompasses these ele ments. For the first year of operation such a program would cost approximately $3 million and would provide mobile units for intensive health education about the dangers of lead poisoning and for drawing blood from all children be tween one and six in high risk areas for screening, mass inspection of houses for the presence of lead paint and orders for its removal, and establishing abatement crews for removing lead paint where en forcement procedures were not success ful. We estimate that approximately 45,000 children could be screened annually and the hazard of lead eliminated from 50,000 dwelling units each year with the lead belt cleared in five years. A continu ing program at a reduced level would be needed in succeeding years as the population at risk continues to move outward from the lead belt. The plan in cludes hiring people who live in the tar get areas and establishing a citizens board to advise the health department. The recent development of a portable fluorescent analyzer utilizing a radio isotope to detect lead in paint has brought such a massive program within the realm of practicality since heretofore paint samples could be collected at a much faster rate than they could be analyzed. In Philadelphia, citizen groups have become involved and have formed a coalition of citizen and professional groups to support the Health Department in expanding its program. Their request has been for the Health Department to mount a massive preventive program which would essentially screen every child at risk, and inspect each home for lead in the enforcement of regulations. These were the elements of a resolution which was adopted by the American Public Health Association when it met in Philadelphia in, November 1909. A com The major concern of the community appears to be that a large number of children who are asymptomatic may be experiencing a certain degree of physi ological damage from the high level of lead in their system which prevents them from performing up to their fullest ca pacity in school and affects their future adversely. They contend that the di agnosed and reported cases are only the tip of the iceberg and that perhaps as many as 5-10 percent of the pre-school children in the ghetto may have absorbed more lead than is generally recognized as normal background, and if this ab sorption continues it will be sufficient to produce overt symptoms. While there is insufficient evidence to support these claims, it appears there is some merit 70 Vol. 33, No. 1, J.E.H. DUP050312209 Afp-^^yififr lo a massive program to detect sub-clini cal cases and eliminate the hazard from the environment not only in saving lives and preventing and minimizing injury, but insuring children of becoming use ful, productive citizens. Therefore, the need of a comprehensive prevention pro gram is justified. This program staggers the imagination when we compare it to the comprehensive plan to control lead poisoning which we conceived in 1958. The time seems ripe for lead poisoning to receive some well deserved attention by health departments. Unless lead poi soning control ranks as one of the mod urgent priorities in environmental health in other cities, the situation may become as explosive as it did in Philadelphia. REFERENCES 1. Ingalls, T. H-, Tiboni, E. A., and Weran, M.--Lead Poisoning in Philadelphia, 19551960, Arch, of Env. Health, 3:575-579, No vember 1961. 2, Tiboni, E. A., and Tyler, R. L.--Childhood Lead Poisoning in Philadelphia, Phila delphia Medicine, 56:22:668-669, May 1960. 3. Miano, S., The Problem of Lead Poisoning in Children, Journal of Environmental Health, 27:6, May, June 1965. G@@d Soot Trailer Aids Wcifer Scifefy With forecasts of increased boating as much as 100 percent during the 1970's, and new types of water craft for recrealion, we will need significant changes in today's boating laws and regulations to maintain safety on recreation waters. During the 1960's, boats registered under the Federal Boating Act. increased from 3.4 million to 4.7 million, and be tween 1962 and 1968 gained another 37 percent. Estimates are that by 1975, there will be as many as 6.5 million regis tered boats, and 8.5 million by 1985. If all boats become registered, there may be as many as 10 million pleasure craft registered by 1980. Since many boats are damaged while on a trailer, it is important to have a good, oversized trailer. Each keel roller should support its share of the weight. All points requiring lubrication should be attended to; all bolts should be kept tight, and long carpet covered pads should be inspected to insure equal dis tribution of weight over the hull. The trailer should be long enough. If aft supports are too far forward of the transom, the hull can be seriously dam aged. The combined dead weight of en gine, fuel tanks, battery and extras stowed in the hull create a good-sized load for the transom supports, so they must be placed and adjusted properly. It is important to have good tires on the boat trailer, and to have a good spare, and a small hydraulic jack or axle jack for the trailer. Two other important safety features are the tongue weight of the rig and the hitch to fasten the rig to the automobile. Tongue weight on a average 16 foot boat should be about 75 pounds. Too much or too little tongue weight will cause the trailer to nose dive. Since automobile bumpers are largely ornamental, bumper hitches are unsafe. A quality frame hitch, installed by a professional is the only acceptable route to safe trailering. The United States Coast Guard and the United States Power Squadron in your area offer courses in basic seamanship and small boat handling. Boaters should all take these courses. --Richard Waite Oil Spill Chemical Stacked in New York An oil spill dispersant. Polycomplex A-ll is being stocked at Bayonne, i\!. J. as a precautionary measure in case of any major oil spill in New York har bor. Guardian Chemical Corporation of ficials say that speed in treatment is im portant to control oil spills and prevent them from reaching beaches and rocks. The compound was used to treat spills in Puerto Rico harbor and Santa Bar bara channel. July/August, 1970 71 I r DU P 05031221 0