CASE STUDY

Collaboration, Communication and Enforcement to Effectively Manage Lead Poisoning Cases in Portland

Early and effective screening can make a big difference in the health of a community, especially regarding lead poisoning in children, as evidenced by new programs in the city of Portland, located in Multnomah County, Oregon. “In Portland and the vicinity, we have 80% of the lead poisoning caseload statewide,” said Perry Cabot, Senior Program Specialist, Environmental Health Services, Multnomah County Health Department.  “But until recently, we could only speculate as to the number of actual confirmed cases.” Good data, coordinated systems and improved patient follow-up mean that Portland is ensuring that more children with lead poisoning are getting the treatment they need.

Problem

Portland, OR

Portland, OR

The key to this public health problem is connecting the dots by following each patient over time. Lead poisoning is a ‘reportable disease’ in the state of Oregon.  If one’s blood lead level is found to be 5 micrograms or more, it must be reported to the state health authority.  In Multnomah County, as elsewhere, doctors are urged by the local health department to report all suspected lead poisoning cases. However, that did not always mean that cases were confirmed and addressed.

In 2011, Multnomah County reported almost 70% of residents tested had “presumptive cases” (positive results from a pinprick test) but only 22% of residents ended up with confirmed cases of lead poisoning.  In the balance of the reported cases, additional blood testing (a “venous test”) was not used to confirm the initial diagnosis, so the cases that were never confirmed were also not addressed.  Portland managed to dramatically decrease the number of residents with unconfirmed cases in only five years, ensuring that those with confirmed cases had the knowledge and care they needed to address the condition.

Lead paint is often, but not always, the culprit in a poisoning episode, and is a reoccurring menace in many older urban areas. While lead has been banned from household paints in the United States since 1978, older homes are especially prone to contamination. When houses are remodeled or when paint starts to peel, old lead paint debris or dust gets into the air and can be consumed, usually by children. In Oregon, the lead based paint hazard is “not going anywhere,” says Cabot, as the state does not require existing or new home owners to rid the house of lead paint. 

When a poisoning case is confirmed, it triggers action by the Multnomah County Health Department, and a Lead Risk Assessor conducts a Blood Level Risk Assessment Questionnaire.  This entails a walk-through, which includes a dust wipe, soil sample, and water test.  The results provide the homeowner with the information they need to deal with the issue and, hopefully, to address the health hazard.

In Multnomah County, like many urban areas, the problem is complicated by the fact that Portland is rapidly gentrifying. Anecdotally, doctors report that while the number of people of color and lower income residents with lead poisoning has dropped, the numbers of middle and upper income residents with lead contamination is rising. This trend has not been confirmed because racial and ethnic data  are not collected. 

Enforcement also remains a challenge. “We have an enforcement gap,” says Perry. In the Pacific Northwest, there are only two federal EPA enforcement officials assigned to four states.  This prohibits full enforcement of legal constraints for residents, builders, and businesses to address and prevent lead contamination.

 

Solution

Cabot credits a strong partnership with the Oregon State Health Authority as a key component in the improvement of case management. This partnership results in more effective communication with families and providers at the local level, which leads to children returning promptly for a confirmation test. The health department has instituted the following methods:

  • Phone calls from the local health department that urges parents to follow up with providers for an additional blood draw,
  • Local health department conversations directly with families (with permission from provider)
  • Strategic community education via health fairs and other public events.

There is less uncertainty now, due to clearer medical outcomes and thorough case management. The timing of communications such as those outlined above have sped up and become more reliable.  For instance, in some areas ‘point of care’ screening results are available within three minutes.  There are now monthly reports to the state health department, and lab results are sent immediately to providers and to the local health authority.  In Multnomah County, this report prompts Cabot to speak with the provider. The provider then calls the affected family and afterwards tells the health authority who, in turn, contacts the home owner or renter to offer a home investigation.

In addition, the Multnomah County Health Department provides a number of programs aimed at preventing lead paint poisoning.  These include:

  • Providing information to home improvement class participants, Head Start family advocates, groups of nurses, doctors and nurses on ‘grand rounds’, and realtors;
  • Better enforcement of housing regulations by working with the EPA; and
  • Improved collaboration between the local health authority and the state so resources can be shared. 

Results

Working closely with the state lead program, the county’s Environmental Health Services has significantly decreased the number of presumptive cases of lead poisoning and increased the number of confirmed cases, as seen in the table below.

“Presumptive”:  finger prick test of 5 micrograms or higher.  Note that ‘presumptive needs to be confirmed.

“Confirmed”: blood drawn from vein.  A ‘venous blood draw’.

 

Summary

Those looking for effective solutions to lead poisoning might consider:

  • Creating a strong partnership between the state and local health authorities to identify and manage cases.
  • Improving communication with families and providers.
  • Speeding up the amount of time between point of care screening and venous testing.
  • Providing timely information to those effected by lead poisoning and completing home investigations quickly and effectively.
  • Planning for expanded testing capacity in case of emergencies.
  • Help preventing lead poisoning with regular community education and increased EPA enforcement