Environmental Lead Centre
Working Group
November 1995
Use the Links under contents to move quickly to the part of the document of interest.
3. Short Term Strategy and Achievements
4. Proposed Long Term Strategy
1.0 Introduction and Summary Back to contents
The purpose of this Discussion Paper is to outline the long term strategies which will form the basis of a submission to the NSW Cabinet, to be developed by the end of 1995. That submission, in the form of a Cabinet Minute, will seek both Government endorsement of a five year strategic program and the approval of the funding necessary to ensure its successful implementation.
The strategies contained in this Paper have been developed and refined through a process combining evaluation of the short term strategies implemented to date and consultation with the Broken Hill community and other key stakeholders. A critical part of this process was the development of a discussion document which examined Environmental Lead Centre activities under five broad program headings - Monitoring and Detection of Cases, Public Education, Public Lands Remediation, Research and Development, and Case Management. This document contained suggestions as to which short term strategies should be continued and what new, long term strategies may be required.
The document also formed the working papers for a 1½ day Lead Working Group Workshop held at the Centre on November 2 and 3, 1995. This provided an invaluable opportunity to incorporate ideas and proposals from community representatives, Council officers, industry representatives and centre employees.
Proposed long term strategies, based on the achievements and successes of the Short Term Strategy, were discussed and refined, amended, supported or rejected at the Workshop. Those passing this "test" were then further investigated and costed and appear as Section 4 of this Paper. The strategies are consistent with the recommendations of the Interdepartmental Lead Taskforce NSW Lead Action Plan (November 1994), the Report of the Parliamentary Select Committee upon Lead Pollution (December 1994) and the Review of the Broken Hill Environmental Lead Centre (October 1995).
Excessive absorption of lead from the environment has been shown to adversely affect the mental development of young children. Lead contamination in Broken Hill is widespread as a result of naturally occurring lead and previous smelting and mining activities. The arid environment in Broken Hill is also a contributing factor to the distribution and absorption of lead containing dusts. International experience has shown that successful programs to minimise lead hazards in contaminated communities must address a broad range of issues which include:
(2) "Case management" to lower blood lead levels of individuals with high blood lead levels
(3) "Public land remediation" work to reduce lead exposure and contain fugitive emissions at high risk sites
(4) "Public education" to inform the community about lead hazards and ways of preventing exposure to lead
(5) "Program management" to efficiently administer these activities.
This paper proposes the implementation of such a program in Broken Hill for a cost of $9,912,000 over five years.
This Discussion Paper will allow a further round of consultation prior to the Working Group meeting on 13 December 1995.
Key Direction Changes within the Long Term Strategy:
The magnitude of the reduction in blood lead levels achieved during the Short Term Strategy were unprecedented, with strong reductions in blood lead levels across all categories. The most significant falls have been found to be correlated with those children group’s which were a focus of the Short Term Strategy. Despite these reductions, blood lead levels amongst Broken Hill children are approximately double the estimate for the national average and are still significantly above the guidelines set by the national health authorities.
Ongoing work undertaken by the Broken Hill Environmental Lead Centre must ensure that any improvements made to the health status of children are sustainable. The Centre and the associated agencies must be cognisant of the potential for blood lead levels to return to previous high levels after initial improvements have been made. This problem has been observed in similar national and international lead remediation projects and is attributed largely to complacency within the community and to recontamination of previously remediated areas. There is likely to be a number of sources contributing to recontamination, one of which is dust originating from contamination hotspots across the city not yet addressed by the remediation program.
Assessing the effectiveness of remediation as a management tool has been a priority of the Short Term Strategy. Although the impact of remediation on reducing blood lead levels can not be fully evaluated until remediation works are completed in 1996, preliminary results strongly suggest that remediation has been successful for managing high blood lead levels. (In the Broken Hill program, high blood levels are considered to be over 20 micrograms per decilitre). However at lower blood lead levels, strong correlation was not observed between the effect of remediation and subsequent reductions in blood lead levels. Accordingly, at this stage it is not proposed to continue high cost remediation of home environments of children with lower blood lead levels (<20 m g/dL) except where the intervention is a component of early intervention program or in response to earlier commitments.
The strategies outlined in this community submission build on the achievements and foundation work undertaken in the Short Term Strategy. The community based Working Group, Steering Committee, staff and agencies involved in the implementation and review of the current strategy believe that the following new activities should be included as key issues in the Long Term Strategy:
2.0 Background and History Back to contents
The Western NSW Public Health Unit began studying high blood levels in Broken Hill’s children in 1991. This identified individual cases of child lead poisoning which required hospitalisation for lead poisoning therapy.
These studies showed that Broken Hill children under 5 years of age had lead levels higher than those in children elsewhere in NSW. In 1991, almost 60% of Broken Hill’s children exceeded the current National Health and Medical Research Council’s level of concern for lead in children.
As a result of these concerns, the NSW Government (through the Environment Protection Authority) allocated $400,000 to study sources and pathways of lead contamination. In addition, NSW Health allocated $540,000 to monitor blood lead levels over three years. The results of these investigations led to the NSW Environment Protection Authority and NSW Health presenting a joint proposal to Government seeking funding to undertake a short term program to address the immediate concerns for children at risk from excessive lead levels.
The program called for:
Cabinet endorsed the proposal (known as the Short Term Strategy) and funding was made available in March 1994, to be administered by NSW Health.
Initial program objectives were to respond to the health needs of children with serious blood lead levels and to determine which strategies were effective in managing a broad range of blood levels. Evaluation of the success of individual strategies was to be used to form the basis of the Long Term Strategy, to be submitted to Cabinet in March, 1996. The nature of the strategy was short term because, at the time of its development, it was recognised that not enough was known to propose definitive and effective measures to deal with the Broken Hill lead contamination problem.
The Environmental Lead Centre has addressed these objectives and a summary of achievements to date appears in the following section. While the accompanying graphs demonstrate impressive declines in blood lead levels, a significant number of Broken Hill’s children still exceed National goals and averages. Lead in Broken Hill’s children remains a very significant problem. Proper management of the problem requires a dedicated effort over the next five years at least, if the children of Broken Hill are to share the same quality of health status available to children in other parts of NSW.
3.0 Short Term Strategy and Achievements
3.1 Short Term Strategy
The Short Term Strategy had two key objectives: to intervene in critical cases and to assess the success of a range of interventions.
To achieve these, the Environmental Lead Centre was set up in July 1994 with funding to June 1996 of $3.4 million. The Centre has responsibility for strategy implementation, including:
3.2 Improvements in Blood Lead Levels in Broken Hill Children
Blood lead levels in Broken Hill children have fallen steadily since the introduction of blood lead monitoring and education activities implemented by the community nurses in 1993. However, preliminary results from the Short Term Strategy (June 1994 to June 1996) indicate a dramatic decline in blood lead levels particularly in the higher blood lead categories.
The following graphs indicate the magnitude of this change. The first shows the reduction of high concentrations of lead in children’s blood from 1991 to 1995. The second shows that the rate of decline in blood lead levels has increased since the initiation of the Short Term Strategy. The third, most importantly, indicates that despite these improvements, Broken Hill’s children are still above the National Health and Medical Research Council’s level of concern for lead in children and well above the National average.
3.3 Achievements of the Short Term Strategy
The Centre has introduced a range of programs and services.
3.3.3 Public lands:
3.3.4 Public education:
This crucial program area has raised community awareness and acceptance of lead as an issue in Broken Hill and imparted information on how to reduce exposure. Activities have included:
3.3.5 Program management:
To support these activities, the Environmental Lead Centre was opened in July 1994. Since this time, 12 multi-disciplinary staff had to be recruited and trained, policies developed, strategies designed and trialed, equipment obtained and data bases established. Community and specialist committees and working groups had also to be established. Administrative procedures have also been developed to ensure appropriate reporting and recording mechanisms are undertaken in areas such as environmental audit reporting, blood lead level recording and remediation work documentation.
3.4 The Way Ahead
The adoption of a Long Term Strategy is now required to maintain the trend and bring levels down further towards those seen in the rest of NSW. The five year time frame will allow a high level of certainty to be developed about effective interventions, based on the successes of the Short Term Strategy.
The five year time frame is considered essential to allow the benefits of programs with delayed-time returns to be implemented and their impacts assessed. Some long term programs include:
4.0 Proposed Long Term Strategy Back to contents
In the Introduction to this paper, it was noted that initial proposed long term strategies were contained in a discussion document under five broad headings. Reconsidering those strategies in conjunction with new proposals generated at the Lead Working Group Workshop, it became clear that some adjustment would be necessary to present proposals in the format required for Cabinet consideration.
Strategies are now grouped under five program areas:
(2) Case management
(3) Public lands
(4) Public education
(5) Program management
Area (1) contains strategies appearing in "Monitoring and detection of cases" and "Research and development" in the original workshop papers.
4.1 Monitoring and Research Back to contents
The purpose of monitoring is threefold:
The information collected through monitoring also forms the basis for designing the best approaches and solutions to both individual cases and public land areas where there is a high degree of exposure for children.
The monitoring program is divided into four main areas of activity.
The monitoring and research program is essential for enabling key responsibilities of the Environmental Lead Centre to be undertaken. These include:
Over the next 5 years it will be necessary to continue to monitor and evaluate the effects of home remediation. Monitoring activities proposed for the long term will assess the impact of early intervention strategies on very young children and quantify the extent to which public land acts as a source or pathway of lead exposure.
Key strategies incorporated into the ongoing monitoring and research program are:
4.1.1 Blood Sampling/Monitoring
ii) Maintain and enhance child testing registration, recording and recall procedures.
4.1.2 Environmental Monitoring and Assessment
ii) Continue and expand the air monitoring network.
iii) Continue home assessments where blood lead level results indicate concern.
iv) Continue internal dust studies.
v) Continue high quality analytical program.
vi) Where required, conduct premise assessments for other care givers (eg. Grandparents’ homes, day care houses).
vii) Continue monitoring remediation work.
viii) Monitor day care establishments, early child care centres and infant schools on a regular basis.
ix) Use Council’s Geographic Information System to map the spatial distribution of lead parameters to isolate lead hotspots or contamination trends.
4.1.3. Public Land Auditing
ii) Continue monitoring public land remediation initiatives as part of the ongoing evaluation program.
4.1.4. Auditing of Government Authority Houses
4.1.5 Continued Remediation Monitoring
4.1.6 Special Projects
4.1.7 Extension of Existing Activities
ii) Continue register and recall procedures to follow up on hospital births.
iii) Continue to assess case management activities in order to improve and modify programs.
iv) Evaluate non-specific case management and education programs.
4.2 Case Management Back to contents
High blood lead levels are harmful to children. The health effects of lead are most pronounced at very high levels in excess of 50 m g/dL. Children so affected may experience marked confusion and disturbance of brain function with fitting, and serious impairment of other organs such as the kidneys. While the range and severity of health effects are less pronounced at lower blood lead levels, important effects still occur in children with levels between 10-24 m g/dL at which point a child’s development may be adversely affected.
In 1993, 40% of local children under five (about 500 Broken Hill children) had blood lead levels greater than 15 m g/dL. In response to this problem, over the past two years the Environmental Lead Centre has focused on working with these children and their families to minimise the impact lead has on their health and wellbeing. The anticipated number of children above 15 m g/dL in 1995 is 20% or about 220 children.
Children identified through the monitoring program enter a case management program. Case management starts with the identification of the likely causes of the high blood lead level. Based on these assessments a treatment plan, tailored to meet each child’s specific needs, is implemented. Ongoing assessment of each child’s response to case management activities is undertaken to ensure that blood lead levels drop in response to the treatment and advice offered.
While the overall efforts of the Environmental Lead Centre since 1994 have been very successful in reducing the health impact of the lead, the ubiquitous nature of lead in Broken Hill means that at least some local children will continue to be put at risk of developing high blood lead levels for the foreseeable future. Therefore the ongoing availability of case management services is essential if the next generation of Broken Hill children are to be protected against this hazard.
Key strategies incorporated into the ongoing case management program are:
ii) Continue case specific home based counselling and education activities for all children under 5 years with blood levels over 15 m g/dL (approximately 1,500 nurse visits per year) and extend to all infants under 18 months to identify and deal with potential hazards in the home (approximately 600 nurse visits per year).
iii) Continue level 1 house remediation and commence level 2 and 3 remediation in specific risk categories (1 being full remediation, 2 provision of labour and materials and 3 materials only - an early intervention strategy) and continue family liaison. The following are approximate figures only:
Level 2 remediation: 55 in year 1 (155 over 5 years)
Level 3 remediation: 50 in year 1 (225 over 5 years)
Under the current strategy, 108 level 1 remediations are anticipated. Developing appropriate low cost interventions has enabled the number of families to be incorporated into case management programs over a two year period to be increased from 108 to 300, whilst the corresponding budget has increased from $1.5 million to only $1.8 million. The impact of low cost remediations will be continually evaluated in the ongoing program.
iv) Continue to maintain and provide operational costs for six alternate accommodation houses.
v) Supply loan remediation equipment (special vacuum cleaners) to caregivers of children participating in the program.
vi) Extend house remediation to control groups used in Short Term Strategy in line with recommendations on the ethics of use of control groups in studies (approximately 22 families).
4.3 Public Lands Back to contents
Control of lead exposure pathways is complex. Remediation of public lands will be an important aspect of the ongoing strategy. Public land is defined as vacant land, either freehold or leasehold, other Crown lands (eg. regeneration reserve), and land administered by the Broken Hill City Council (playgrounds, footpaths, etc.).
Given the ubiquitous nature of lead in the Broken Hill environment, it will be necessary to address the remediation of high-exposure-risk open spaces in addition to remediating home environments in order to minimise the potential for lead contamination to be a continued exposure hazard to Broken Hill children. As Broken Hill is located in the semi arid region of NSW, exposed areas with high soil lead content have the potential to recontaminate previously remediated areas during windy or storm conditions.
To achieve a reduction in the lead loading of Broken Hill there must be a commitment to constantly chip away at all sources of lead contamination in the city until exposure from these sources is significantly reduced. Public land remediation must be implemented systematically and constantly and prioritised on the basis of risk.
Key strategies incorporated into the ongoing Public Lands management program are:
4.3.1 Greening Programs
4.3.2 Co-operative Public Works with Broken Hill City Council
4.3.3 Program Co-ordination and Development
4.3.4 Remediation and Evaluation Work
4.3.5 Enhancing Community Participation
ii) Develop and provide information on appropriate planting and maintenance for nature strips and gardens to maximise water efficiency and ground cover.
4.4 Public Education Back to contents
Community information and education strategies are essential for the success of intervention programs.
Lead has always been, and for many years to come will continue to be, a major influence on the social and economic wellbeing of Broken Hill, as well as having the potential to impact adversely on the health of local children. Lead in Broken Hill is ubiquitous - it can be found throughout the town; around and in houses, in the streets, in public places, on the line of lode, and on private lands.
Management of the Broken Hill lead problem requires a mix of community-based education programs developed by the Short Term Strategy. These programs focus on: keeping the local community informed about the lead issue and what can be done to minimise its impact on health; the provision of a monitoring program targeting the environment and blood lead levels in children: the provision of a monitoring program targeting the environment and blood lead levels in children; effective case management for children with high blood lead levels; efforts to create safer public lands and ongoing research and development. These activities aim to continuously enhance the ability of the Broken Hill community to deal with this issue and minimise the risk of young children developing high blood lead levels.
Public education plays its part and provides appropriately targeted messages about the lead issue in Broken Hill. Its continuation is essential to the overall success of future lead control initiatives. In particular there is a need to inform each new group of parents, grandparents and carers (Broken Hill has around 350 births a year) why lead is an important health issue, how and where children get exposed to lead, things carers and children can do to minimise lead ingestion, about the availability and use of blood lead screening and other related services, and the overall impact of lead control strategies on the community’s health.
Key strategies incorporated into the ongoing education program are:
ii) Further develop interactive sessions with schools and pre schools.
iii) Continue to piggyback off significant environmental dates and local dates of interest (world environment day, show day, Agfair and so on).
iv) Continue to promote awareness and understanding of issues, and increase knowledge, through talks and media interviews.
v) Continue to develop information and resource materials, guidelines and other publications.
vi) Develop specific teaching aids, resource kits, programs and curriculum material aimed at educators, aboriginal and community health workers, general practitioners, midwives, nurses and Council workers.
vii) Maintain and develop new interactive programs and inducements aimed at children (clinic attendance inducements and activities).
viii) Develop material for use at conferences and seminars.
4.5 Program Management Back to contents
For the preceding operational programs to work, there must be a small number of support staff and infrastructure to support implementation.
This section outlines the requirements in these areas to ensure that programs are run and managed effectively.
ii) Provide for necessary staff related expenses; training, travel, transport. It is proposed to maintain current expenditure rates in this area.
iii) Maintain the Environmental Lead Centre as an operational base; rent, utilities, office maintenance, stationery.
iv) Maintain data and computing services. The budget reflects some software and hardware upgrading which will be necessary in 1997 to properly manage and manipulate the increasing data base and analytical requirements.
January 9, 2003 9:15 AM
|
|
|
|
|
|
|
|
|
|
|
|