1. Lead Poisoning in Milwaukee –
Effects of Home Lead Abatement
Kevin Smith, MPH
Joseph J. Zilber School of Public Health &
City of Milwaukee Health Department

2. Acknowledgements
• Amy Kalkbrenner – Joseph J. Zilber School of Public Health
• Elise Papke – Joseph J. Zilber School of Public Health
• Joyce Whitebsky – School of Architecture and Urban Design
• Lisa Lien – City of Milwaukee Health Department: Lead Poisoning Prevention
Program
• Robert Colla – City of Milwaukee Health Department: Lead Poisoning
Prevention Program
• Sanjib Bhattacharyya – City of Milwaukee Health Department: Public Health
Laboratories
• Steve Gradus - City of Milwaukee Health Department: Public Health
Laboratories
• Kristen Grimes – Children’s Health Alliance of Wisconsin
• Chuck Warzecha – Bureau of Environmental and Occupational Health
• Margie Coons – Wisconsin Childhood Lead Poisoning Prevention Program

3. Introduction to Lead Based Paint
• 24 million homes in USA have lead
paint (CDC, 2014)
• ~3 million metric tons of lead paint
in US homes (CDC, 1991)
• Nearly 4 million homes with
children living in them have lead
based paint (CDC, 2014)
• *Leaded Gasoline Emissions*
 5.5–6.7 million metric tons in soil
(CDC, 1991)
 75% remains

4. Introduction to Lead Based Paint
• 14.1% of pre-1940 housing
>1200 ppm
• 1% of post-1960 housing >1200
ppm
http://www.usgs.gov/blogs/features/usgs_top_story/getting-the-dirt-on-soil/

5. Introduction to Lead Based Paint
• Homes built before 1978 most likely to have lead based paint (HUD, 2011)

6. Introduction to Lead Based Paint
• 1940s: Manufacturers began to remove lead from paint voluntarily
• 1971: Lead Based Paint Poisoning Prevention Act
 Prohibited paint ≥ 1% lead by weight
 Allowable levels
 0.5% until 12/31/1974
 0.06% (600 ppm) after 12/31/1974
• 1978: Consumer Product Safety Commission
 Banned use of leaded paint in homes

7. Childhood Lead Poisoning
• Approximately 535,000 children currently have elevated blood lead
levels ≥ 5μg/dL (CDC, 2014)
 2012: Standard for lead poisoning was lowered
 Previously ≥ 10μg/dL
 Now ≥ 5μg/dL
• Children ages 1 – 6 years old are at highest risk for lead poisoning
(CDC, 2014)
• Children living in Renter occupied units are at greater risk for
significant exposure to lead based paint (HUD, 2011)
 Renter: 30% of homes
 Owner: 23% of homes

8. Childhood Lead Poisoning
• Learning Impairments
 4th grade standardized tests (Amato, 2012)
 Reading
 Mathematics
 Language Arts
 IQ Reductions (Nevin, 2012)

9. Childhood Lead Poisoning
• Learning Impairments
 4th grade standardized tests (Amato, 2012)
 Reading
 Mathematics
 Language Arts
 IQ Reductions (Nevin, 2012)
• Behavioral Impairments
 4th grade suspension rates (Amato, 2013)
 2.66 times more likely
 23% of the racial discipline gap
 Crime (Nevin, 2012)
 Violent Crime – 23 year lag time

10. Childhood Lead Poisoning
• Learning Impairments
 4th grade standardized tests (Amato, 2012)
 Reading
 Mathematics
 Language Arts
 IQ Reductions (Nevin, 2012)
• Behavioral Impairments
 4th grade suspension rates (Amato, 2013)
 2.66 times more likely
 23% of the racial discipline gap
 Crime (Nevin, 2012)
 Violent Crime – 23 year lag time
 Homicides – 21 year lag time

11. Childhood Lead Poisoning
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
%OFCHILDRENTESTED
YEAR
Percent Children Tested with Elevated BLLs (≥10 µg/dL )
U.S. Totals Wisconsin Milwaukee, WI
Data Sources: 1 Centers for Disease Control and Prevention: Childhood Lead Poisoning Data, Statistics, and Surveillance.
2 City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports

12. Objectives
• Identify risk of lead poisoning in:
1. Children that live in Unabated Pre-1940 Homes
 Age stratification
2. Families that live in Non-owner Occupied, unabated Pre-1940 Homes
3. Children living in Previously Abated Pre-1940 Homes
 Stratified by
 Age
 Time after abatement
 Type of abatement

13. Methods – Incidence (1996 – 2011)
• Systematic Tracking of Elevated Lead Levels and Remediation
(STELLAR)
 De-Identified 222,804 children
 Cases: ≥ 10μg/dL
 Non-Cases: < 10μg/dL
 Date first confirmed
 Address
 Age at test

14. Methods – Property Information
• City of Milwaukee Master Property Records (MPROP)
 Address
 Taxkey
 Year of Construction
 Pre-1940
 Post-1940
 Owner Occupancy
• Parcel Base - Property Map

15. Methods – Home Abatement (1996 – 2011)
• Lead Safe Housing Registry (LSHR) – City of Milwaukee
 Address of Abated Unit
 Date of Abatement
 Abatement Type
 Primary Prevention
 Secondary Prevention

16. Methods – Analysis and Mapping
• Addresses matched for each record at date first confirmed
• Geocoded with ArcGIS 10.2.2. software
 Cases: N = 21,317
 Non-Cases: N = 141,478
 Abated Homes: N = 16,886 units

17. Methods – Analysis
• Relative Risks calculated (1996 – 2011)
 15 year aggregate risk
 Year of Construction (Pre-1940 vs. Post-1940)
 Stratified by Age at test
 Owner vs. Non-owner occupied
 Date of Abatement
 Stratified by:
 Age at test
 Prevention Type
 Time After Abatement
 Annual risks
 Year of Construction
 Occupancy
 Abatement
 4 year aggregate risk
 Primary/Secondary Prevention

18. Results – Seasonal Variation of Incidences
Data Source: Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New cases occur most frequently
during summer months every year
Overall decrease in new cases from
1996 - 2011

19. Results – Annual Cases and Home Abatement
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
CUMULATIVE#OFUNITSABATED
CHILDRENWITHELEVATEDBLOODLEAD
YEAR
Elevated Blood Lead Levels and # of Units Abated
Pre-1940 Units Abated Total Units Abated Prevalance Incidence
Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee
Incidence and prevalence of cases
decrease each year as more pre-1940
units are abated

20. Results – Annual Cases and Home Abatement
• Each Year:
 Prevalence decreased 13.4% (R2 = 0.98)
 Incidence decreased 10.8% (R2 = 0.95)
 An estimated 984 homes were abated - 821 were Pre-1940 homes

21. Results – Cases and Home Abatement
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
0 2000 4000 6000 8000 10000 12000 14000
NUMBEROFCASESPERYEAR
TOTAL NUMBER OF ABATED UNITS
Case Reduction per Unit Abated (1996 - 2011)
Incidence Prevalence
Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee
Incidence decreases by 10.8% &
prevalence decreases by 13.5% for every
1,000 units abated

22. Results – Cases and Home Abatement
• Per 1,000 units abated:
 Prevalence decreased 13.5% (R2 = 0.97)
 Incidence decreased 10.8% (R2 =0.93)

23. Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New Cases = 21,317New cases from 1996 – 2011 spatially
correlate with pre-1940 homes

24. Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New Cases = 21,317Abated Units = 16,886
Prevention efforts successfully
targeted homes in high-risk areas

25. New Cases = 5,816
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
In 1996, 5,816 new cases were reported to
Milwaukee Health Department prior to
Childhood Lead Poisoning Prevention efforts

26. New Cases = 5,816
New Cases = 381
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
After 15 years of Childhood Lead Poisoning Prevention
Program targeted efforts, new cases were reduced 381 in 2011

27. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

28. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

29. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

30. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

31. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

32. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

33. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

34. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

35. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

36. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

37. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

38. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

39. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

40. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

41. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

42. As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year

43. Results –Relative Risk for Lead Poisoning
based on key factors

44. Results – Annual Risk in Unabated Units
y = 0.2076x - 409.99
R² = 0.4299
0
1
2
3
4
5
6
7
8
9
10
11
12
13
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
RelativeRiskRatio
Year
Unabated Pre-1940s Homes
Annual Risk 15 yr Aggregate Risk Annual Regression

45. Results – Annual Risk in Rental Units
0
0.5
1
1.5
2
2.5
3
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
RelativeRiskRatio
Year
Renter Occupied Pre-1940 Units
Annual Risk 15 yr Aggregate Risk

46. Results – Annual Risk in Abated Units
y = 0.0049x - 8.6599
R² = 0.0049
0
0.5
1
1.5
2
2.5
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
RelativeRiskRatio
Year
Abated Pre-1940 Units
Annual Risk 15 yr Aggregate Risk Annual Regression

47. Summary – Risk for Lead Poisoning
• Pre-1940 homes were 5.8 times higher than Post-1940 homes
 Children 24 months or younger were 7.91 times higher in Pre-1940 homes
 Children older than 24 months were an average of 3.99 times higher in Pre-
1940 homes
• Children living in non-owner occupied homes were 2.02 times higher
risk for lead poisoning than in owner occupied homes
• Lead abatement in Pre-1940 homes reduced the risk to 0.69 times that
of an unabated Pre-1940 home
 Primary Prevention was 0.56 times lower than an unabated Pre-1940 home
 Secondary Prevention was 1.15 times higher than an unabated Pre-1940 home
 No difference in risk was present for 9 month cut off period
 Children older than 48 months may have greater reduced risk – small sample
• Prevalence reduced by 13% per 1,000 units abated
• Incidence reduced by 11% per 1,000 units abated

48. Future Directions – Risk Analysis & GIS
• Few studies have investigated home paint abatement and BLLs
 Most studies look at Secondary Prevention
 Primary Prevention are lacking
 Long term integrity of prevention efforts are lacking
• This investigation has one of the most complete data sets
 Lead Abatement records per home
 Blood Lead test results for every test taken
• Innovative data analysis and powerful risk calculations
• GIS data analysis and case surveillance
• Provides the ground work for future studies, education and policy
• Integration with soil remediation

49. References
• Center for Disease Control and Prevention (1991, October 1). Preventing Lead
Poisoning in Young Children: Chapter 3. Retrieved from:
http://www.cdc.gov/nceh/lead/Publications/books/plpyc/chapter3.htm
• Center for Disease Control and Prevention (2014, June 19). Lead – Home Page.
Retrieved from: http://www.cdc.gov/nceh/lead/
• Center for Disease Control and Prevention (2014, October 30). LCDC’s national
Surveillance Data (1997-2013). Retrieved from:
http://www.cdc.gov/nceh/lead/data/national.htm
• Center for Disease Control and Prevention (2014, October 30). LCDC’s national
Surveillance Data (1997-2013). Retrieved from:
http://www.cdc.gov/nceh/lead/data/national.htm
• City of Milwaukee Health Department (2014, September, 12). Lead Poisoning
Prevention Data and Reports. Received from: http://city.milwaukee.gov/Lead-
Poisoning-Prevention-Data#.VI88wqecteU
• Cox, D.C., Dewalt, G., O’Haver, R., and Salatino, B. American Health Homes Survey;
Lead and Arsenic Findings. U.S. Department of Housing and Urban Development:
Office of Healthy Homes and Lead Hazard Control, April, 2011.Mielke, 2010

50. Appendix 1

51. Appendix 2
Year of Construction, Owner Occupancy and Prior Abatement Relative Risk Calculations with 95% Confidence Intervals for Aggregate and Annual Lead Poisoning Rates
Relative Risk (95% CI) 15 year Aggregate (1996 - 2011) 1996 1997 1998 1999 2000 2001 2002
Pre-1940 Unit 5.83 (5.57, 6.11) 3.64 (3.32, 3.98) 3.79 (3.42, 4.20) 5.68 (4.78, 6.75) 4.77 (4.04, 5.63) 4.55 (3.87, 5.36) 5.45 (4.51, 6.59) 5.43 (4.45, 6.64)
Non-Owner Occupied 2.01 (1.96, 2.08) 1.73 (1.65, 1.84) 1.76 (1.65, 1.88) 1.89 (1.71, 2.10) 1.85 (1.67, 2.05) 1.64 (1.47, 1.82) 1.77 (1.58, 1.99) 1.77 (1.57, 2.01)
Prior Abatement 0.6908 (0.66, 0.73) 1.01 (0.45, 2.25) 0.92 (0.60, 1.41) 1.06 (0.77, 1.47)
0.8792 (0.68,
1.13) 1.24 (1.04, 1.48) 1.58 (1.35, 1.85)
Case (≥ 10 μg/dL) 22769 5816 3696 1725 1657 1438 1396 1269
No Case (≤ 10 μg/dL) 163398 13709 11352 9534 7373 8123 9364 9908
Relative Risk (95% CI) 2003 2004 2005 2006 2007 2008 2009 2010 2011
Pre-1940 Unit 7.06 (5.51, 9.05) 8.22 (6.32, 10.69) 5.70 (4.48, 7.25) 7.47 (5.43, 10.26) 5.86 (4.37, 7.86) 8.32 (5.81, 11.92)
8.33 (5.81,
11.95) 5.98 (4.32, 8.29) 5.66 (4.01, 7.98)
Non-Owner Occupied 1.70 (1.48, 1.95) 2.02 (1.75, 2.24) 1.76 (1.51, 2.05) 1.85 (1.53, 2.23) 2.25 (1.85, 2.74) 1.56 (1.28, 1.91) 1.86 (1.49, 2.31) 1.57 (1.23, 1.99) 2.05 (1.56, 2.70)
Prior Abatement 1.89 (1.63, 2.19) 1.69 (1.44, 1.99) 1.59 (1.35, 1.87) 1.42 (1.15, 1.75) 1.22 (0.99, 1.51) 1.18 (0.95, 1.47) 1.08 (0.85, 1.37) 0.83 (0.63, 1.10) 1.21 (0.93, 1.55)
Case (≥ 10 μg/dL) 1046 936 838 589 600 520 461 401 381
No Case (≤ 10 μg/dL) 9514 9939 9296 8968 10296 10598 11122 12680 11622

52. Results –Risk by Abatement Type (4-Year Range)
Year Range Abatement
Record
Relative Risk 95% CI
1996 - 1999 Total Abated 0.78 (0.61, 1.00)
Primary 0.69 (0.53, 0.91)
Secondary 3.18 (3.13, 3.23)
1999 - 2003 Total Abated 1.38 (1.27, 1.50)
Primary 1.1 (0.98, 1.23)
Secondary 2.36 (2.1, 2.66)
2004 - 2007 Total Abated 1.45 (1.32, 1.58)
Primary 1.2 (1.07, 1.34)
Secondary 2.25 (1.97, 2.58)
2008 - 2011 Total Abated 1.06 (0.94, 1.20)
Primary 0.86 (0.74, 0.99)
Secondary 1.83 (1.52, 2.20) 0
0.5
1
1.5
2
2.5
3
3.5
1996-1999 2000-2003 2004-2007 2008-2011
RelativeRisk
Year Range
Abatement Type (4 Year Range)
Total Abatement Primary Prevention Secondary Prevention
Total 15 yr risk Primary 15 yr risk Secondary 15 yr risk

53. Appendix 3
Year Range Abatement
Record
Case
(≥ 10 μg/dL)
No Case
(< 10 μg/dL)
Total Relative Risk 95% CI
1996 - 1999 Total Abated 48 147 195 0.78 (0.61, 1.00)
Primary 41 147 188 0.69 (0.53, 0.91)
Secondary 7 0 7 3.18 (3.13, 3.23)
None 10,982 23,917 34,899
1999 - 2003 Total Abated 443 1,370 1,813 1.38 (1.27, 1.50)
Primary 274 1,135 1,409 1.1 (0.98, 1.23)
Secondary 169 235 404 2.36 (2.1, 2.66)
None 3,897 18,095 21,992
2004 - 2007 Total Abated 482 2,581 3,063 1.45 (1.32, 1.58)
Primary 305 2,036 2,341 1.2 (1.07, 1.34)
Secondary 177 545 722 2.25 (1.97, 2.58)
None 2,094 17,153 19,247
2008 - 2011 Total Abated 303 4,315 4,618 1.06 (0.94, 1.20)
Primary 192 3,441 3,633 0.86 (0.74, 0.99)
Secondary 111 874 985 1.83 (1.52, 2.20)
None 1,175 17,875 19,050