**Slide 1**

This module was developed to provide CDC\'s recommendations for
preventing and treating lead poisoning in newly arrived refugee
children.  The target audiences for this module are refugee
coordinators, refugee health coordinators, state and local health
departments, and additional organizations involved with the well-being
and resettlement of refugees.  For the purpose of simplifying this
module, all audiences above will be referred to as \"resettlement
workers.\"  The goal is to encourage resettlement workers to assist in
the identification and determination of possible lead hazards in the
homes of newly arrived refugee children, assure blood lead screening and
case management activities, and educate newly arrived refugee families
on lead poisoning prevention strategies.  This module looks at the
essential role resettlement workers play in putting CDC\'s
recommendations into action.

**Slide 2**

This module will focus on five areas:  

• Problem of lead poisoning,

• Effects of this problem on refugees,

• Sources of lead exposure,

• CDC\'s recommendations for preventing and treating lead poisoning in
newly arrived refugee children, and

• Helpful resources.  

Now, we will focus on \"What is the problem?\"

**Slide 3**

Childhood lead poisoning is one of the most common and preventable
childhood health problems we have in the United States today.  Elevated
blood lead levels (BLLs) in our children can be prevented because enough
is known about the sources and pathways of lead exposure and ways to
limit exposure.

.

Lead is found everywhere in our environment as a result of
industrialization. Man\'s use of lead dates back to at least 3500 B.C.
Lead is a heavy metal and does not break down or decompose. Because it
is durable and malleable, sheets of lead have been used to make water
pipes, pewter vessels, paint, and other commercial products.

.

The only accurate way to measure a child\'s exposure to lead is by
taking a blood sample and testing it for lead.  A BLL greater than or
equal to 10 micrograms per deciliter (≥10 µg/dL) is considered
\"elevated\" - a level at which harmful health effects are known to
occur.

**Slide 4**

Great strides have been taken through the years to reduce BLLs among
young children in the United States. Because of a reduction in lead
hazards (such as leaded gasoline) and improved screening practices and
policy initiatives, BLLs in children aged 1-5 years continue to decrease
in the United States as shown.  The chart displays data from the
National Health and Nutrition Examination Survey (NHANES).  From
1999-2002 data, the geometric mean BLL in the U.S. population for
children aged 1-5 years was 1.9µg/dL, and the national prevalence of
elevated BLLs was 1.6%.^1^

However, in many communities, the average BLL is higher than the
national average.  As many as 33.6% of children in one U.S. community
had elevated BLLs.^2^  In addition, the risk for elevated BLLs remains
high for certain populations.  In one study, as many as 27% of newly
arrived refugee children had elevated BLLs making refugees one of the
highest risk groups.^3^

^1^ CDC.  Blood lead levels \-\-- United States, 1999\--2002.  MMWR
2005;54(20):513-16.

^2^ Dignam TA, Evens A, Eduardo E, et al. High intensity targeted
screening for elevated blood lead levels among children in 2 inner-city
Chicago communities.  Am J Public Health. 2004;94(11):1945-51.

^3^Geltman PL, Brown MJ, Cochran J.  Lead poisoning among refugee
children resettled in Massachusetts, 1995 to 1999.  Pediatrics.
2001;50:457-59.

To learn more about childhood lead poisoning data in your state/local
jurisdiction, contact the Childhood Lead Poisoning Prevention Program in
your state.

**Slide 5**

Lead is a poison that affects almost every system in the body.  Shortly
after lead gets into the body, it travels in the blood to the \"soft
tissues\" (such as the liver, kidneys, and brain).  

It is particularly harmful to the developing brain and nervous system of
fetuses and young children.  

Children\'s unique physiology and behavior can influence the extent of
their exposure. Children are at higher risk for the adverse health
effects of lead exposure because:

• Children\'s nervous systems are still developing.

• Children have more hand-to-mouth activity.  As part of normal
development, young children often place their hands and toys into their
mouths.  This activity is the most frequent cause of lead ingestion.  If
lead contaminated dust is found on the floor or a child\'s toy, the
child\'s exposure is increased.

• Children absorb more lead than adults in their gastrointestinal (GI)
tract when exposed to lead.  Per unit body weight, children drink more
water, breathe more air, and consume more food than adults.  Children
absorb greater amounts of lead in food and beverages.  Children absorb
about 40% compared with adult\'s absorption of 5-15%.^4^

^4^ Ziegler EE, Edwards BB, Jensen RL, et al.  Absorption and retention
of lead by infants.  Pediatr Res. 1978;12:29-34.

**Slide 6**

Lead poisoning for the most part is silent. Therefore, the vast majority
of those exposed may go undiagnosed and untreated.  

Lead has no known physiologic value to the human body and no safe lead
level exists.

Lead affects children in various ways as you can see from this slide.
 Examples include:

• Reductions in IQ and attention span, leading to learning disabilities

• Behavioral problems (such as hyperactivity).  Also, associations have
been found between lead exposure and aggression and antisocial or
delinquent behaviors

• Impaired growth and hearing loss

• Severe neurological problems such as seizures, coma, and even death
caused by very high levels (higher than 70ug/dL)

**Slide 7**

We have discussed why children\'s exposure to lead is a concern. Now, we
will explore how these effects become more pronounced in the refugee
population.

**Slide 8**

From the mid-1970s until the mid-1990s at least three-quarters of
refugees coming to the United States were from the former Soviet Union
or Southeast Asia. Now refugees are admitted from some 60 locations
around the world. Specifically, the percentage of refugees from Europe
has decreased while the percentage of refugees from Africa has increased
from 9 to 35%.

For self study: To learn more about the refugee population in your
state/local jurisdiction, contact the State Refugee
Coordinators/Agencies and the State Refugee Health Coordinators.

For trainers: After this slide, you may want to insert one or two slide
depicting your state/local refugee population data.

**Slide 9**

Childhood lead poisoning is a problem worldwide. In other parts of the
world, predominant sources of lead are very different from those lead
sources in the United States.

• For example, leaded gasoline is still widely used in many countries
and contributes to elevated BLLs, especially in urban children.

• Poorly glazed pottery causes high lead levels in food, which can be
the most prominent source of lead in some areas, such as parts of Latin
America.

• Point industrial sources, such as smelters, may dramatically increase
lead levels in air and soil in parts of the world where environmental
controls have not been effectively implemented, such as in Eastern
Europe.

• Lead contamination from cottage industries that recycle lead (often in
backyards) is a problem in Central America and elsewhere.

• Additional sources of lead contamination include flour mills,
medications and cosmetics, and consumer products.  

Newly arrived refugee children are twice as likely as U.S. children to
have elevated BLLs.  Some sub-populations of refugee children are
12-14.5 times more likely to have elevated BLLs.^3^

Even though refugees may be exposed to lead prior to arriving into the
United States, data suggest that refugee children are also exposed to
lead in this country.  For some children, living in the United States
gives them their first exposure to lead.^5^

^3^Geltman PL, Brown MJ, Cochran J.  Lead poisoning among refugee
children resettled in Massachusetts, 1995 to 1999.  Pediatrics.
2001;50:457-59.
                                                                                                                                        

^5^CDC.  Elevated blood lead levels in refugee  children - New
Hampshire, 2003-2004.  MMWR.  2005;54(2);42-6.

**Slide 10**

Several risk factors exist for elevated BLLs in children; some factors
are more specific to the refugee population.

• The most common risk factor for ALL children is living in an older
home, specifically those homes that were built before 1950 and are in
disrepair.

• Also, a known risk factor is the visual presence of lead hazards such
as peeling and chipping paint on the housing exterior.

However, in the refugee population -

• Some cultural practices and behaviors could increase the chance of
ingesting lead (such as eating off the floor).  Traditional medicines
and cosmetics from the home country may also contain lead.

• An overall lack of awareness about the dangers of lead and the need to
protect children from known lead hazards makes the refugee population
more vulnerable.  

• A compromised nutritional status - the evidence of chronic and acute
malnutrition - is a risk factor.  

Malnutrition is common in refugee populations.^6^ Anemia can enhance
lead absorption and thus can increase risk for elevated BLLs, even in
housing with minimal lead exposure hazards.

It is important to note:  Children who mouth or eat non-food items,
especially soil, which is common among certain refugee populations, are
at risk for lead poisoning, regardless of the age of their housing.

^6^United Nations System/Standing Committee on Nutrition.  Nutrition
information in crisis situations.

Geneva, Switzerland: Secretariat of the UNS/SCN; May 2004.  Report no.
2.

**Slide 11**

We have already mentioned international sources of lead exposure.  Now,
we will give further details on sources of lead exposure in the United
States.

**Slide 12**

Because the primary risk factor for lead poisoning in the United States
is older housing, most lead hazards come from lead paint chips that have
been ground into tiny bits.  These tiny bits of lead become part of the
dust and soil in and around homes.  

Although children may be exposed to lead from paint directly by
ingesting paint chips, they are more commonly exposed by ingesting house
dust or soil contaminated by leaded paint as part of normal
hand-to-mouth behavior.

Lead contamination of dust or soil occurs when leaded paint deteriorates
or is subject to friction or abrasion (as on window sashes). In
addition, lead can be dispersed when paint is disturbed during
demolition, remodeling, paint removal, or preparation of painted
surfaces for repainting.

Lead was used widely in paint through the 1940s.  Although lead use
declined during the 1950s and 1960s, and lead was banned from
residential house paint in 1978, lead remains a hazard in homes built
before the ban, especially in homes built before 1950.

**Slide 13**

According to the U.S. Department of Housing and Urban Development,
nearly 38 million housing units contain lead-based paint.  Of the 38
million, 24 million housing units (25% of the nation\'s housing) have
significant lead-based paint hazards (such as deteriorating lead paint
or lead-contaminated dust).

In addition, 1.2 million homes with significant lead-based paint hazards
housed low-income families with children younger than 6 years of age.

Refugee families are often resettled into older housing because of the
affordability of these units.

To learn more about housing data in your state/local jurisdiction,
contact the Housing Agency in your state.

**Slide 14**

A child\'s environment is full of lead. We have already discussed lead
in paint and how this dust may get on toys.  It may also get on pets as
well.  

Contamination of soil and exterior dust has been linked to sources, such
as lead smelters, fall-out from past use of leaded gasoline, and
weathering of exterior leaded paint. Soil located next to dwellings
typically has higher lead content than soil sampled from other locations
in a yard.  Potentially hazardous levels of lead in soil are not
uncommon.

Although lead in tap water contributes to children\'s lead body burden,
it is seldom the sole cause of elevated BLLs.  Lead in tap water usually
is from the corrosion of lead-containing materials found in water
distribution systems and household plumbing. Exposure to lead in tap
water has been reduced by measures taken during the last two decades
under the requirements of the 1986 and 1996 amendments to the Safe
Drinking Water Act and a subsequent U.S. EPA regulation (the Lead and
Copper Rule).

Except near the area of point sources, such as smelters and battery
manufacturing plants, inhalation of airborne lead is now a minor
exposure pathway for individual children in the United States.

During the 1980s, the quantity of lead in the U.S. diet decreased
markedly due to restricted use of lead-soldered side-seam cans and the
phasing out of lead as an additive in gasoline. Lead in foods comes from
several additional sources:

• soil in which the plant is grown;

• air and rain;

• food processing (including lead leaching from some types of metal cans
described above);

• contact with lead solder or ceramic vessels used to store the food;
and

• contact with lead dusts in the home.

Additional isolated sources of lead exposure are a concern.  For
additional information on other exposure sources, please visit
http://www.cdc.gov/nceh/lead.   

**Slide 15**

Now, we will discuss the CDC\'s recommendations for lead poisoning
prevention for newly arrived refugee children.

**Slide 16**

Resettlement workers are on the front-line aiding refugees as they
transition into life in the United States.  As such, we realize the need
to partner to assure that newly arrived refugee children receive the
best possible prevention and education regarding lead poisoning.
 Ideally, all children would live in lead-safe housing, especially those
whose nutritional status and lack of knowledge about the dangers of lead
place them at greatest risk.  However, until a reservoir of lead-safe
housing is developed, CDC and its partners recommend that three standard
strategies be implemented by resettlement workers to reduce the risk of
lead exposure in refugee children, they include:

1\) conducting an environmental assessment of the property

2\) assuring comprehensive medical interventions

3\) providing adequate education for this at risk population.

**Slide 17**

Why is it important to conduct an environmental assessment?

Many housing defects impact the health and safety of children.  For
example, lead-based paint and dust may contribute to lead poisoning in
children; water leakage and mold may contribute to asthma episodes;
improper use and storage of pesticides may result in unintentional
poisoning; and lack of working smoke and carbon monoxide alarms may
cause serious injury or death. This environmental assessment focuses
specifically on lead poisoning hazards.  For additional information on
the hazards mentioned above, please link to the federal Healthy Housing
Reference Manual.

The only way to know if a property contains lead hazards is to conduct a
thorough environmental assessment using field instruments to quantify
the amount of lead or laboratory analysis of collected samples.

Due to the time constraints of moving a refugee family into a home, an
assessment may not always seem feasible.

However, CDC has developed a quick environmental assessment tool that
can be used to evaluate the potential for lead hazards in a property.
(See Resources)

The environmental assessment strategy consists of 4 components.  All of
these components coordinate with the environmental assessment tool.

These four components are:

• pre-assessment,

• visual interior assessment,

• visual exterior assessment, and

• summary assessment.

A visit to the property is needed to conduct the complete assessment.

**Slide 18**

The purpose of the property pre-assessment is to evaluate the property
for possible lead hazards.  The pre-assessment has two questions that
may be used to determine the possibility of a lead hazard.

1\.  Was the property built before 1978?

As was mentioned previously, lead was banned from use in residential
house paint in 1978.  So, if the property was built before 1978, it most
likely contains lead based paint.

The property owner should be able to provide information on the property
including when the property was built.  Information on property age and
other specifications may also be obtained from the local tax assessor\'s
office.

If the answer is no (built after 1978), the assessment is complete and
the property can be assumed to be lead free.

If the answer is yes (built before 1978), proceed to the next question.

2\. Can the property owner provide a current certification that the
property is lead safe or lead free?  

If the property owner is able to provide a certificate of compliance you
may determine that the property is lead safe.  The agency that issued
the certificate may also be contacted for further validation.  If the
property is Section 8, certification of lead compliance is required by
law.

A certificate of compliance may be in the form of a certificate and/or
inspection report from a government agency or a licensed risk
assessor/inspector.  To find out more information about certifications
and licensed lead inspectors in your state or local jurisdiction,
contact the Childhood Lead Poisoning Prevention Program in your area.

**Slide 19**

The visual assessment of the interior structure is designed to assist in
the determination of possible lead hazards with the interior of the
property.

The assessment requires one to observe the interior condition of the
property for obvious chipping or peeling paint on walls or other signs
of deterioration of the interior structure. The assumption is that in
collaboration with the age of a property, the structural condition of
the property is a good indicator of its potential as a lead hazard.

Specifically, the resettlement worker should observe the condition of
the interior walls, windows, and steps.  The worker should look for:

• chipping or peeling paint on walls or interior window seals,

• noticeable cracks, holes, or missing or broken components on major
interior structures, such as steps or railings, requiring repairs more
than routine painting.

**Slide 20**

The visual assessment of the exterior structure is designed to assist in
the determination of possible lead hazards with the exterior structure
of the property. The assessment requires one to observe the exterior
condition of major structural components of the property that have been
identified as primary contributors to elevated BLLs in children.

To conduct the exterior assessment, all sides of the property have to be
observed for deterioration on each of the primary structure components.
 

 

Specifically, the resettlement worker is to observe the condition of
the:

• exterior windows and doors;  

• porch and/or steps;

• roof, gutters and downspouts.

For the exterior windows and doors, the worker should observe for

• chipping or peeling paint on the window sash or mullions (a vertical
piece of stone or wood dividing a window or other opening)

• two or more windows or doors broken, missing, or boarded up

For the porch and/or steps, the worker should observe for

• two or more major elements (such as a porch railing or support column)
broken or missing

For the roof, gutters, and downspouts, the worker should observe for

• the roof missing parts (such as shingles), weathering surfaces, or
extensive holes or cracks

• gutters or downspouts broken or missing

**Slide 21**

The summary assessment is where the high risk status of the property
will be determined. For the purpose of this assessment, a high risk
property is one that has been found to contain possible lead hazards on
significant structural components (such as windows or porches) and
warrants further environmental analyses.

A property would be considered HIGH RISK and a health risk for young
children if the property has undergone an environmental assessment and
the interior observation is identified as a \"Yes\" and two out of the
three exterior observations are identified as a \"Yes\".  Another
property should be chosen to house the family.  The resettlement worker
should seek assistance for additional resources by contacting the

Childhood Lead Poisoning Prevention Program in your state or
jurisdiction.

Even though the properties may not have been assessed as high risk, if
they were built before 1978 the family should be educated on lead
poisoning prevention procedures.

**Slide 22**

The second strategy to reduce the risk of lead exposure in refugee
children is assuring that three necessary medical interventions take
place.  They are the:

• nutritional evaluation,

• initial blood lead screening, and

• repeat blood lead screening.

We will talk more about the nutritional portion in later slides.  First,
let\'s discuss blood lead screenings.

**Slide 23**

Federal standards state that a refugee medical screening take place
within 90 days after a refugee\'s arrival in the United States.  The
contents of the screening vary from state to state.  Most do not have a
BLL screening protocol for refugee children.  Assuring that a child has
an initial blood lead test within the 90 days of arrival into the United
States is essential to begin providing treatment for that child if
necessary.  

A repeat blood lead test should be performed 3 to 6 months after refugee
children are placed in their permanent residence.  The repeat blood lead
test should be considered a \"medical necessity\" regardless of result
from the first test.

The repeat blood lead test is extremely important in identifying
elevated BLLs in newly resettled refugee children.  Scientific evidence
demonstrated that although some children had elevated BLLs when they
arrived in the United States, the majority of the children did not.
 Thus the lead exposure occurred in the United States.^3,5^

^3^Geltman PL, Brown MJ, Cochran J.  Lead poisoning among refugee
children resettled in Massachusetts, 1995 to 1999.  Pediatrics.
2001;50:457-59.
                                                                                                                                            

^5^CDC.  Elevated blood lead levels in refugee  children - New
Hampshire, 2003-2004.  MMWR.  2005;54(2);42-6.

**Slide 24**

What is case management?  Case management involves coordinating,
providing, and overseeing the services required to reduce a child\'s BLL
below 10µg/dL.

The case definition that initiates case management varies by state.
 Some states begin when a child\'s BLL is 10µg/dL and others begin when
a child\'s BLL reaches 15µg/dL or 20µg/dL.  Contact the Childhood Lead
Poisoning Prevention Program in your state or jurisdiction.

A case manager works to decrease the child\'s BLL and to identify and
eliminate lead hazards in the child\'s environment.

Ninety percent of case management activities are conducted by a nurse or
social worker.  The case manager is usually a member of the local health
department staff.  Resettlement workers should work with the assigned
case manager to help facilitate and assure case management activities
are being conducted.

More detailed information about case management of children with
elevated BLLs may be found at www.cdc.gov/nceh/lead.    

**Slide 25**

Upon U.S. arrival, all refugee children should have nutritional
evaluations performed and should be provided with appropriate
nutritional and vitamin supplements as indicated. This should be
performed by a health professional.  A nutritional evaluation will not
only help identify needed supplements for lead poisoning prevention -
but for the overall health and well-being of the child.  Additionally,
receiving nutritional benefits through the Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC) should be part
of this activity.    

Studies have shown that good nutrition can reduce the amount of lead
absorbed in the body.  A diet deficient in iron and calcium may enhance
the amount of lead absorbed. Children should have a diet high in iron,
calcium, and vitamin C and low in fat.

Because each red blood cell has space that iron or lead can fill, an
iron-rich diet will help reduce the amount of lead in red blood cells.
 Good sources of iron include:

• red meats, fish and chicken,

• iron fortified cereals, and  

• dried fruits (raisins, prunes).

Also, research has shown that iron is absorbed better when vitamin C
rich food or drinks are part of the same meal or snack.  Good sources of
vitamin C include fruits, vegetables, and juice such as:

• oranges, orange juice,

• tomatoes, tomato juice, and

• green peppers.

Eating calcium is also important.  Calcium and lead compete for storage
space in the bones.  If the body does not have sufficient amounts of
calcium to fill storage space in bones, lead will take its place.  Also,
lead stored in bones may possibly get re-released into the blood later
in life. To get enough calcium in the diet, children should eat five
servings of calcium rich foods each day.  Good sources of calcium
include:

• milk,

• yogurt,

• cheese, and

• green leafy vegetables (e.g., spinach, kale, collard greens).

**Slide 26**

The final strategy to reduce the risk of lead exposure in refugee
children consists of providing lead poisoning prevention education to
refugee families.

Lead poisoning prevention education is directed at helping parents
prevent and/or reduce residential lead exposure in children and other
sources of lead.  Lead poisoning prevention education should be provided
to families educating them on routine medical care, proper nutrition,
and house cleaning strategies.

The race and ethnicity of refugee populations will vary based on
locality and world events.  CDC has developed a health education
resource database that links users up to health education materials from
across the nation.  For example, users may search the database for lead
poisoning prevention materials in a specific language.  Please visit
http://www.cdc.gov/nceh/lead to view the latest version of the health
education database.   

In the Resources Section of the toolkit we have provided a technical
fact sheet for health care providers and other health professional staff
as needed.

**Slide 27**

This module ends with a list of resources that are available to help you
implement CDC\'s recommendations.

**Slide 28**

We have listed important resources that may help you implement CDC\'s
recommendations. A full list of these and other resources may be found
in the Resources Section of the tool kit.   

State and local childhood lead poisoning prevention programs

Provides comprehensive childhood lead poisoning prevention efforts in 40
state and local jurisdictions, funded by CDC.  

CDC\'s Lead Poisoning Prevention Program

Provides leadership to state and local health departments in developing
comprehensive programs to combat childhood lead poisoning.

Division of Global Migration and Quarantine

The Division of Global Migration and Quarantine has statutory
responsibility to make and enforce regulations necessary to prevent the
introduction, transmission, or spread of communicable diseases from
foreign countries into the United States.  

Office of Global Health Affairs

Provides policy guidance and coordination on refugee health policy
issues, in collaboration with Public Health Service Operating Divisions,
the Office of Refugee Resettlement, the Department of State, and others.

Office of Refugee Resettlement

Plans, develops, and directs implementation of a comprehensive program
for domestic refugee and entrant resettlement assistance. The Office
monitors and evaluates the performance of states and other public and
private agencies in administering these programs and supports actions to
improve them.

Bureau of Population, Refugees, and Migration

Has the primary responsiblility for formulating plicies on population,
refugees, and migration, and for administering U.S. refugee assistance
and admissions programs.

**Slide 29**

Additional resources include:

The U.S. Department of Housing and Urban Development (HUD) provides
information about HUD programs that address lead-based paint in housing.
 This site also provides guidelines on controlling lead-based paint
hazards, a list of helpful documents for property owners, and contacts
to local housing agencies.

The U.S. Environmental Protection Agency provides information about lead
regulations and policies and training and resource materials.