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RESEARCH
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Prevention Measures ROLE OF HEALTH CARE SYSTEM Moderator: Dr. Susan K. Cummins; Panel members: Dr. Carol Pertowski, Dr. Xiaoming Shen, Dr. Victor John, Dr. A.F.A.Mascarenhas, Dr. Mahadeviah Introduction This panel represented very diverse public health programs and experiences. Dr. Cummins comes from a background of an established large public health program (California, which is the most populated state in America). Dr. Carol Pertowski is from the USA Center for Disease Control and Prevention which supports the necessary training of new research programs in developing countries: Egypt, Russia, India, China, etc. Drs. John, Mascarenhas, and Mahadeviah represent Indian institutions, which deal daily with public health issues and programs. Finally, Dr. Shen was instrumental in establishing a Lead program in Shanghai, China, and has done extensive work on Lead poisoning in an effort to raise awareness of this health problem in his country. This panel presented two detailed examples of how lead poisoning is addressed in public health programs: one from a developed country ( USA), and the other of a developing country ( India). Then the panel presented a good example of quality research conducted in a new program ( China). Finally, Dr. Pertowski presented the results of a lead poisoning research project in Egypt, which was in collaboration with the CDC. The experiences of the panel members, along with their recommendations, highlight the potential for establishing a successful program to address the problems of lead poisoning. They showed by example that through collaboration and cooperation, quality research can be used by committed health official to aid in establishing a program within the "health care system" which could result in lessening the public’s exposure to lead. USA Experience: Screening Young Children for Lead Poisoning in California Dr. S. Cummins About 15 years ago, the California Department of Health Services (DHS) conducted childhood lead poisoning surveys in three high-risk areas of the state. These studies found a varied prevalence of childhood lead poisoning, ranging from a low of 14 percent in Sacramento to a high of 67 percent in Oakland. These results caused the State legislature to pass enabling legislation that established California’s childhood lead poisoning prevention program. The program educates the public and health care providers about childhood lead poisoning, conducts surveillance of childhood lead poisoning and lead sources, provides care to lead poisoned children, and collaborates with others to establish an infrastructure of trained professionals to identify and manage lead paint hazards. Care of lead poisoned children is best provided at a local level, and requires collaboration between the medical care, public health, and environmental health sector. To accomplish this, the DHS provides financial resources, care standards and technical assistance to 51 local childhood lead poisoning prevention programs throughout California. Once a child with lead poisoning has been identified, the state office notifies the child’s local program, initiating a case investigation. Case investigation and management consist of a visit to the child’s home by a specially trained public health nurse and an environmental health specialist. The public health nurse takes a detailed history to identify possible sources of lead in the child’s environment, and other care needs. The public health nurse also educates the family about lead, and simple measures such as hand washing and wet mop cleaning that reduce lead dust in the home. The environmental specialist takes environmental samples from the child’s home and analyzes them for lead, and works with the family and others to remediate the sources of lead in the child’s environment. The child’s physician provides medical care and follow-up, including follow-up blood lead testing, evaluation for and treatment of nutritional deficiencies, and medical therapy such as chelation when the child’s blood lead level is high enough to require such care. The Experience of the Cairo Lead Survey, (Egypt) 1997- 1998,Collaboration with CDC Carol Pertowski, MD From 1997 - present, the Field Epidemiology Training Program of the Egyptian Ministry of Health and Population, in conjunction with the U.S. Centers for Disease Control and Prevention, has been conducting a population-based survey of blood lead levels and anemia among children ages 2 - 6 years in Cairo. Steps in planning the survey included obtaining clearances from appropriate government agencies, reviewing the literature and in-country experience to determine the likely sources of lead exposure, designing the sampling frame and selecting the study population, and assuring medical follow up of children identified with anemia and elevated blood lead levels. The survey involves collection of a blood sample from the child, a questionnaire for the parents on likely sources of lead exposure, and collection of dust, water, paint, and floor samples for lead analysis. Local health staff has been instrumental in planning the survey, arranging transportation, and assuring a high rate of participation among parents and children. Among the lessons learned from the study are the usefulness of population-based data for defining the extent of childhood lead poisoning and highlighting likely sources of exposure. However, the educational activities and vitamin supplements that can help reduce children’s exposure to lead will need to be carried out on a local level. Identification and referral of children with blood lead levels and anemia may exceed the capacity of local clinics and require supplementation of resources. The survey has also focused interest in development of educational materials for parents and health care providers and support of basic lead poisoning prevention efforts.
Childhood Lead poisoning Prevention Program in Shanghai, China Dr.Xioming Shen My research found that 38% of children (3-6 years) in Shanghai have blood lead levels greater than 10 micrograms per deciliter, which necessitated the prevention program. The specific reasons for this included a population of 14 million people, a proportionate number of vehicles, lead-based industries in urban areas and traditional medicines. Those involved in the program included officials of Shanghai Bureau of Public Health, District Health workers and workers of 75 community based clinics. Preventive measures included parental education, complete media coverage and promoting the use unleaded gasoline. Research societies were initiated and clinical services were started outside Shanghai. Perspective of the Small Scale Private Medical Sector in India Dr. A. F. A. Mascarenhas The health care system in India is largely divided into two major groups: the government and the private sector. In both these systems, there is a tier-structured hierarchy. The government sector follows the pattern of the central government right on top, succeeded by the state/district level, and goes right down to the community/primary health care level. This is a rigid structure with fixed norms of operation. There is no payment expected for services, though service is subject to availability of health care officials and infrastructure and the level of corruption within the local level systems. A similar pattern is not evident in the private sector. There is a variety extending from a) large medical universities that offer both health care services and academic training, b) corporate hospitals that cater to the upper middle class executive cadre, c) nursing homes and polyclinics at various neighborhoods, and d) the private physician’s clinic. There are no defined systems of operation at any level. The most standardized level, perhaps, would be the medical university level, which has to follow a nation-wide model prescribed by the government. Representing the level that would encompass the private nursing homes and polyclinics, I would like to elaborate a little more on the delivery of health care through these systems in India. These institutions are privately owned by corporate, voluntary agencies, trusts or even individuals. Catering largely to the middle class income group, they provide a range of facilities. On an average, the services provided include clinical diagnosis, routine laboratory diagnosis including x-ray and ultrasound facilities, operation theatres for surgery and rooms for in-patient care. The larger institutions may have more specialized diagnostic and critical care services, while at the other end of the spectrum, the individual physician’s clinic is limited to basic clinical diagnosis, management and referral of complicated cases. The standard polyclinic offers a variety of health services under one roof. It has a panel of consultants in basic specialties like general medicine, general surgery, obstetrics and gynecology, pediatrics, dermatology, orthopedics, ENT and eye services. It has also an array of consultants in super-specialties who are available on call. After a thorough clinical examination, the consultant asks for investigations like laboratory tests, x-rays, sonography etc. to pinpoint his/her diagnosis and then prescribes a line of treatment. Serious illnesses are admitted in the inpatient section for further monitoring and management. Surgery, both outpatient and inpatient, are conducted regularly. Emergency services are provided round the clock, with resident doctors and concerned specialists. The system of registration and appointments without elaborate bureaucratic hurdles facilitates patient services and flow. Some polyclinics offer "package" health check ups, which are becoming increasingly popular, as also health insurance plans. Being situated in their neighborhood, patients find these private polyclinics convenient and efficient. Based on a system of fee for services, these clinics also cater to a certain extent to the economically deprived persons. By keeping a close liaison with the family physicians functioning in the area, the polyclinic is thus able to network into a system that delivers the goods. With this background in mind, let us now focus on the problem of lead poisoning, and how these private sector polyclinics can contribute to its prevention and control. The health care provider in our country has a major role to play in providing health care services at all levels. Since lead poisoning is most dangerous in children, the pediatrician and the public health agencies are the most important stakeholders in the health care delivery system of lead prevention and control. There are many strategies, some which are generic to all the private care levels, whether it is the medical college hospital or the private physician, and some that are specific to the polyclinic/ nursing home level. General strategies These strategies cut across all types of health care systems, private or government. Some of the important points to keep in mind are that they:
The most commonly used strategy worldwide that is also relevant to our subcontinent is:
Specific Recommendations for Nursing Homes/ Polyclinics: A comprehensive, multifaceted approach to preventing childhood lead poisoning would include screening and surveillance, risk identification, primary prevention activities, interagency coordination, and services for poisoned children. 1. Patient awareness programs: in patient / out patient This is a critical component of any prevention program, and both practical and feasible in a nursing home. This can be done using mass media such as video clips or posters, and leaflets, or through group interactions with patients who are admitted in the hospital. 2. Special awareness programs for parents of child patients. Specific programs can be targeted for parents of children who come to the nursing home for consultation, investigations or treatment. Using a variety of techniques, the problem of lead poisoning and the role of the parents in its prevention in children should be emphasized. Pediatric health-care providers, working as part of the health team, must play a critical role in the prevention and management of childhood lead poisoning. Their roles should:
3. Anticipatory Guidance Means Teaching parents about major sources of lead and how to prevent poisoning. Tailoring guidance to likely hazards in the community may take the following forms:
4. Scientific seminars and discussions for medical personnel Medical science is always changing with new advances and technologies overtaking the old ones. Scientific sessions are commonly held for physicians as part of their continuing medical education. Lead poisoning and prevention can be one such topic for all the medical personnel attached to the polyclinic. Demonstrations of laboratory tests and therapies will enable the health practitioners to acquire skills in this area. 5. Training of laboratory and other personnel on testing Training programs for laboratory and other medical personnel of the polyclinic and other institutions is a role that nursing homes can play. Lead testing and screening is done using simple laboratory techniques that all polyclinics can offer. Special testing using package deals can be offered to educational institutions, daycare centers, and corporate firms. 7. Focussed efforts on prevention education of parents through general physicians, schools and other networks. Most nursing homes and polyclinics work in close association with the general physicians operating in the neighborhood. Capacity building programs aimed at ensuring awareness education of parents and increasing testing services are efforts that these nursing homes can offer the physicians. In a similar fashion, awareness programs for teachers, educators and voluntary agencies can be conducted regularly through established networks already in place. 8. Education and testing packages for educational institutions. Along with testing, awareness programs for lead prevention can be designed and implemented for neighborhood schools and colleges.9. Networking with other medical institutions to develop advocacy strategies to influence government action on prevention An important area is the change or the development of government policies towards environmental protection and lead screening and prevention of toxicity. Medical personnel can play a major role through the existing networks available. Various medical associations and public health agencies can lobby for change in existing laws or initiation of efforts in promoting lead prevention activities on a public scale. The public health agency could: * Ensure that necessary screening services are provided. * Analyze surveillance and other data to identify exposure patterns and high-risk populations. * Develop and implement a primary prevention plan that focuses on the highest risk sources and populations. * Coordinate prevention activities with other pertinent health, housing, and environmental agencies. * Ensure that medical and environmental follow-up services for poisoned children are provided. Primary Prevention One of the most important themes of this conference is the need to identify and remove sources of exposure to lead before children are harmed, that is, the need for primary prevention. Public and private health agencies must take a leading role in designing and implementing primary prevention programs. One important activity for our health systems is to use the data collected from screening and surveillance to develop a primary prevention plan designed to target resources to the most pervasive sources and the highest risk populations.
A few examples of handbills or posters that can be distributed to all parents will include the following: WHAT EVERY PARENT SHOULD KNOW WHAT IS LEAD POISONING? • A DISEASE CAUSED BY SWALLOWING OR INHALING LEAD. • LEAD POISONING CAN CAUSE ANEMIA AND DAMAGE TO THE BRAIN, KIDNEYS, AND NERVOUS SYTEM OF YOUNG CHILDREN. • LOW LEVELS CAN CAUSE LEARNING, SPEECH AND BEHAVIORAL PROBLEMS. • VERY HIGH LEVELS CAN CAUSE RETARDATION, CONVULSIONS, AND COMA. HOW DO CHILDREN BECOME LEAD POISONED?•LEAD DUST AND LEAD PAINT IN OLDER HOMES. • LEAD DUST COMES FROM REPAIRS TO AREAS WITH LEAD PAINT, OPENING/CLOSING WINDOWS, NORMAL WEAR AND TEAR OF LEAD PAINTED AREAS. • LEAD DUST SETTLES TO THE FLOOR, GETTING ONTO CHILDREN'S HANDS AND TOYS, IT ENTERS THE BODY WHEN THE CHILDREN PUT THEIR HANDS OR TOYS INTO THEIR MOUTHS. • EATING, CHEWING OR SUCKING ON LEAD BASED SURFACES: WINDOWSILLS, RAILINGS, and PAINTED SURFACES). WHO SHOULD BE TESTED FOR LEAD AND HOW OFTEN? • EVERY CHILD UNDER THE AGE OF FOUR MUST BE TESTED FOR LEAD EACH YEAR. WHAT IS A LEAD TEST? • A SMALL AMOUNT OF BLOOD IS TAKEN FROM YOUR CHILD'S FINGER OR ARM AND TESTED FOR LEAD. WHAT ARE THE HOUSEHOLD SOURCES? PAINTED AREAS:
WATER: LEAD PIPES AND SOLDER FOOD: GROWN IN SOIL WITH LEAD SOIL: STORED IN LEAD GLAZED POTTERY NEAR OLD LEAD PAINTED BUILDINGS (ESPECIALLY IF THEY HAVE BEEN SCRAPED, SANDBLASTED OR HAVE PEELING PAINT)NEAR BUSY ROADS WHAT ARE THE STEPS TO PROTECT YOUR FAMILY FROM LEAD HAZARDS?
HEALTHY.
MAKE SURE CHILDREN EAT HEALTHY, LOW-FAT FOODS.
Dr. John and Dr. Mahadeviah were in agreement about the necessity of an educational campaign by the health systems to raise mass awareness throughout India. All district hospitals should have at least one equipment to screen for lead poisoning and anemia. Medical schools should undertake outreach programs to inform the public about the problem. The railways, armed forces, insurance sectors, and voluntary health organizations should also be a part of the campaign. Both stressed the removal of cynical attitude of the doctors and urged to continue the momentum of preventive measures. The entire panel agreed that those children with anemia and malnutrition should be given special attention. The program should identify lead sources and allot specialized educational materials to target the children and communities exposed to excessive levels of lead. |