Disease Control Bulletin: January 1999
- Lead Poisoning Prevention in Vermont
- Selected Reportable Diseases 01/1998-12/1998
- Recommended Childhood Immunization Schedule January–December 1999
- Lyme Disease Vaccine
Volume 1, Issue 1, 1999
Lead Poisoning Prevention in Vermont
Reducing the incidence of childhood lead poisoning is a priority of Healthy Vermonters 2000, the state’s plan for improved public health. Since 1993, the Vermont Department of Health, the Ver-mont Housing and Conservation Board, and the Vermont legislature have worked together to reduce the numbers of children and families affected by this entirely preventable disease.PRIMARY PREVENTION ACTIVITIES
Reducing a child’s exposure to lead hazards is the most important step in reducing the incidence of childhood lead poisoning. In most cases, deteriorated lead paint is the major source of lead exposure. Blood lead testing data collected over the past four years indicate that children living in older rental housing, which is often poorly maintained, are at higher risk for lead poisoning. In response to this information, the 1996 Vermont legislature passed landmark legislation designed to reduce lead paint hazards, the leading cause of childhood lead poisoning, in children’s environments. Act 165 requires all owners of rental housing and child care facilities built before 1978 to perform a series of essential maintenance practices. These include:
- visually inspect painted surfaces for deterioration at least once a year, and repair those surfaces that need it
- clean rentals and child care facilities at each change of tenant, or annually if there are young children present, using special cleaning methods designed to reduce lead dust accumulation
- give building residents an informational pamphlet that describes the precautions parents can take to reduce lead exposure in their homes
- install aluminum or vinyl inserts in window wells to provide an easily cleanable surface so lead dust can be wiped away regularly
- post a notice asking building occupants to report deteriorated paint for repair
- ensure that anyone who performs these essential maintenance practices is trained or supervised by someone who has been trained in using lead-safe methods.
Each year, upon completion of these maintenance practices, property owners must file an affidavit of performance with the Department of Health. Since 1996, more than 6000 affidavits have been filed, and almost 7500 individuals have completed the required training course. Cleaning up Vermont’s housing stock is an important step in reducing childhood lead poisoning.
The Vermont Housing and Conservation Board (VHCB) has spent $4.8 million over the past five years to conduct lead hazard remediation in more than 598 Vermont homes and apartments. VHCB funds are used to perform a much higher level of lead hazard control than essential maintenance practices, including removing old windows and lead painted trim, replacing dilapidated lead painted porches, and covering lead painted floors with vinyl or carpet. These rental units will remain “lead safe” for years to come.
The Department of Health continues to target a wide variety of audiences with lead hazard information. Childhood Lead Poisoning Prevention Program staff present information to parent groups, providers, and others with an interest in lead poisoning. The Department has developed and disseminated numerous fact sheets and produced a 10 minute video, “Put Your Child to the Test,” which provides parents with guidance on how to reduce their children’s lead exposure.
SECONDARY PREVENTION ACTIVITIES
All blood lead results are reported directly to the Department by the analytical laboratory and are entered into a lead poisoning database. As of Decem-ber 31, 1998, the lead database contains 40,738 blood lead results representing 29,172 Vermont children.
Depending on the child’s blood lead result, the Department offers the following services:
- 10 - 14 µg/dL - Parents will receive written information on reducing lead exposure and will be asked to complete a demographic survey to gather more data on the age of the housing in which the child lives, possible hobby or occupational exposure, and other relevant demographics.
- 15 - 19 µg/dL- The parents will be offered all the above and a home visit by Department outreach workers or trained community volunteers. The visit will include information on the importance of nutrition, good housekeeping, and follow-up blood testing, and a lead cleaning kit for the parent to use in removing lead dust.
- 20 µg/dL or greater - The parents will be offered all the above and a complete environmental investigation of their home, with paint, dust, soil and water sampling. If the family lives in rental housing, the Department will work with the property owner to insure that lead hazard reduction work is completed. If the family owns its home, Department staff will provide technical assistance on ways of reducing lead hazards in the home.
BLOOD LEAD TESTING DATA
While the number of children screened each year has remained relatively constant since 1995, the percentage of those children identified with elevated blood lead results has seen a steady decline (Figure 1).
In June 1994, the Department issued lead screening guidelines for non-Med-icaid enrolled children. These guidelines called for universal screening of all 1-year-olds, regardless of perceived risk, and testing of older children if the parent or health care provider had concerns about lead exposure or if the 1-year-old test was elevated. These screening guidelines are still in place. Prior to that, the Health Care Finance Agency (HCFA) issued screening guidance for Medicaid-enrolled children. Medicaid-enrolled children were required to be assessed for risk at every well child checkup, beginning at six months of age, and tested for blood lead if risk was identified, in addition to universal testing at ages 1 and 2. Although the Department’s target is to see 75 percent of 1-year-olds tested, that goal has not yet been met (Figure 2).
In 1997, the Centers for Disease Control and Prevention revised their 1991 statement on lead poisoning prevention. Rather than suggesting a national screening policy, CDC advised each state or locality to develop their own screening guidance, based on lead screening and housing age data. In response, the Department has created a Lead Screening Advisory Committee to review Vermont data and make recommendations on screening policy. The Lead Screening Advisory Committee is also looking at health care provider education and access to screening issues.
The Health Care Finance Administration responded to CDC’s new guidance by revising their screening requirements. Rather than require a risk assessment at each well child visit as well as testing at ages 1 and 2, HCFA now requires only the 1 and 2-year-old tests. Health care providers are still expected to use their judgement to determine if more frequent testing is necessary.
For further information on this committee or other lead poisoning prevention program activities, contact Karen Garbarino, Children’s Environmental Health Chief, at the Vermont Department of Health, PO Box 70, Burlington, VT 05402 (802) 863-7206.
Vermont Selected Reportable Diseases
January 1998- December 1998*
RECOMMENDED CHILDHOOD IMMUNIZATION SCHEDULE
JANUARY - DECEMBER 1999
Please replace your 1998 Childhood Immunization Schedule with this issue’s insert. Additional copies are available at the district office when you pick up vaccines. Changes to this year’s schedule are:
- Rotavirus Vaccine – recommended for all children that can start the series before 6 months of age. This live oral vaccine is given at 2, 4 and 6 months simultaneously with other recommended vaccines. Dose 1 should not be given after 6 months of age, and late starters should not receive subsequent doses after their first birthday. We anticipate supplying this vaccine, on a limited basis, when federal contracts are established this spring.
- Polio Vaccines – the sequential schedule of 2 doses of IPV followed by 2 doses of OPV is now recommended except in special circumstances as described in the schedule footnotes.
LYME DISEASE VACCINE
The FDA has approved LYMErix (SmithKline Beecham), a Lyme disease vaccine. LYMErix is approved for people between the ages of 15 and 70 and should be administered intramuscularly in the deltoid muscle at intervals of 0, 1, and 12 months. To obtain maximum protection, it should be given in the mid-winter months, before the tick season. In randomized studies, the vaccine showed 50% efficacy after 2 doses (95% CI=14%-71%), and 78% efficacy after 3 doses (95%CI=59%-88%). The duration of immunity following the three dose vaccination series is unknown, and the need for booster doses has not been determined.
An estimated 85% of persons with symptomatic Lyme disease have the characteristic rash, erythema migrans. Untreated infection can cause arthritis or neurologic symptoms. At any stage, the disease can usually be successfully treated with standard antibiotic regimens.
Lyme disease can be acquired in Ver-mont though the number of reported indigenous cases remains low. In 1997 and 1998 there were a total of 5 indigenous cases reported from the following counties: Lamoille, Bennington, Addison and Rutland. Most Vermont residents that acquire Lyme disease have visited a highly endemic area. The Advisory Committee on Immunization Practices (ACIP) is drafting Lyme disease vaccine recommendations. Preliminary information suggests that Ver-mont may be classified as a moderate risk state for acquiring Lyme disease along with other New England states. This risk status is based on the total incidence of Lyme cases reported, including both in-state and out-of-state exposures.
Personal protection from Lyme disease (e.g., wearing protective clothing, using tick repellant, removing attached ticks promptly) is important for everyone and should not be neglected even if one is vaccinated.
Vaccination should be considered based on a person’s risk for exposure to infected vector ticks. Vaccination of persons with frequent or prolonged exposure to ticks in areas endemic for Lyme disease is likely to be an important preventive strategy. For persons with only brief or intermittent exposure to tick habitat in areas where Lyme disease is endemic, the public health benefits of vaccination, compared with early diagnosis and treatment of Lyme disease, are not clear.
LYMErix is not recommended for women who are pregnant or considering pregnancy in the immediate future. The most common side effect is soreness at the site of injection.
For further information: Please contact the Vermont Department of Health at (802)863-7240.
CDC. Availability of Lyme Disease Vaccine. MMWR 1999;48:35-36,43.
REPORT DISEASE : VERMONT TOLL-FREE
1-800-640-4374 OR 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Jan K. Carney, MD, MPH