Choose Safe Places for Early Care and Education (CSPECE): Three-Year Report

What is APPLETREE?

ATSDR's Partnership to Promote Local Efforts to Reduce Environmental Exposure (APPLETREE) Program is a cooperative agreement. APPLETREE funds 28 state health departments. APPLETREE helps states increase their capacity to advance ATSDR's goal of keeping communities safe from harmful chemical exposures and related diseases.

In 2017, ATSDR expanded the scope of APPLETREE to include CSPECE.

Over the past three years (2017-2019), ATSDR's APPLETREE states developed and piloted new early care and education (ECE) interventions for CSPECE. All 28 APPLETREE states participated in the below CSPECE activities. These activities were customized by geographical intervention area, chemicals of most concern, and each state's ECE licensing program:

• Creating partnerships to build collaboration and sustinability
• Developing processes to screen for harmful environmental hazards
• Responding to identified potential hazards through education, recommended actions, and technical assistance
• Providing training and educational materials for ECE stakeholders
• Changing state licensing systems that increase environmental considerations for licensing ECEs.

Partnerships

During this period, APPLETREE states developed 216 unique partnerships to enhance collaboration and sustainability of their CSPECE programs. Partners supported development and delivery of programs in the following ways:

• Provided licensing policy/processing information to adapt program plans to state needs
• Planned screening, response, and education activities
• Developed and provided referrals for screening and educational materials, as well as provided screening checklists, outreach, education, and training
• Connected state programs to partners
• Integrated environmental considerations into systems-level processes
• Contributed to special projects on topics like radon, lead, and private wells
• Provided data and facilitated data sharing for screening and program data

Diverse Partnerships

APPLETREE states developed partnerships with diverse organizations and experts:

State and Local Childcare and Health

• State or local ECE licensing agencies
• State or local family or children's health and wellness agencies or organizations
• Head Start or community based child care programs
• Non-profits serving children or families
• Resource and referral agencies
• Local or tribal health authorities

Environmental Programs

• State environmental agencies
• Specific environmental programs (e.g. childhood lead poisoning prevention, radon)

Subject Matter Experts

• Universities
• Private consulting firms
• Planning and zoning authorities
• Data and tracking programs
• Cooperative Extension programs

Screening and Response

States developed several processes to screen for harmful environmental hazards at ECE locations. Processes included site visits, data analysis, screening questionnaires or checklists used by providers or inspectors, and screening protocols or manuals.

• 33 screening products developed
• 177 technical assists and Health Assessments documents completed
• 9,176 referrals received and screened materials

Over the three years, states received and screened 9,176 referrals. A screening process started when a partner (e.g., ECE provider, licensing inspector, or partner agency) submitted referrals or data. Some states started special screening activities for radon, asbestos, or other hazards. When a potential hazard was identified, states responded through providing education, technical assistance, and recommendations to reduce or prevent exposure.

Screening Models
In most states, programs marketed a screening tool to ECE providers. They then asked providers to opt in by completing and submitting the tool. A few states used a list of new ECE location data to screen when ECE providers applied for a license. Some states were able to establish a process with state licensing inspectors to obtain referrals for screening.

Screening Products
States developed 33 screening products that

• Show standard procedures for receiving referrals and screening for environmental hazards
• Help narrow the list of possible locations for ECE providers
• Prepare state health agencies and partners to respond to hazards

Examples of screening products include checklists, questionnaires, surveys, protocols and manuals, online tools, hazard assessments, notification letters or reports, and certificates.

States distributed screening materials through state licensing partners, other program partners, and directly through their own program. The chart below shows methods used by states for reaching and introducing ECE programs to the CSPECE program or for screening.

State Licensing Partners

• Mandatory or voluntary pre-licensing course
• Partner's pre-licensing or annual inspection process
• Informational licensing website
• Application packet
• Direct referral
• Email

Other Program Partners

Realtors, planning and zoning officials, resource and referral, nonprofits, local health authorities through

• Mailing lists
• Websites
• Direct distribution

Directly Through APPLETREE Program

• During education, outreach, and training opportunities
• CSPECE website
• Newsletters
• Statewide mailing
• Statewide distribution of educational/promotional materials

Response: States provided 177 occurrences of technical support (technical assists and public health assessment documents). A technical assist can be as simple as a record of a phone conversation. A technical assist does not contain public health conclusions but might offer recommendations. A health assessment document evaluates a site for hazardous substances, health outcomes, and community concerns.

Education

The goal of education is to increase knowledge about children’s environmental health. This help to ensure ECE sites are safely located away from potential environmental hazards. States provided direct educational training and created and distributed educational materials for many stakeholders.

• 73 educational products developed
• 4,584 ECE stakeholders directly provided educational training
• 555,683 ECE stakeholders reaches through indirect educational materials

States developed educational products including factsheets, websites, infographics, training materials, marketing materials, brochures, and videos. Audiences included providers, licensing staff, state health departments, environmental health professionals, parents, planning professionals, and other APPLETREE partners.

Twenty-one states delivered education either directly by an educator or indirectly through flyers, brochures, infographics, and other means. Trainings focused on the following:

• General introduction to CSPECE
• ECE and environmental hazard information: recognizing hazards, environmental health issues, and children's unique vulnerability
• Contaminant-specific information: safe drinking water, private wells, lead, radon, indoor air quality, integrated pest management, and green cleaning
• CSPECE program specifics: screening tool, screening process, mapping tool, and criteria for safe siting

System-Level Changes

Integrating changes into state licensing systems, that increase environmental considerations for licensing ECE and education programs, can have a major effect. The changes implemented by grantees reached all ECE providers in a state or intervention area. These changes laid a foundation to protect children from environmental exposure in ECEs. The 13 systems-level changes adopted during the three years of the program included the following:

• Adding voluntary screening questionnaire or checklist into licensing application materials
• Adding screening questionnaires, checklists, or safe siting considerations into the licensing process
• Including safe siting or Children's Environmental Health educational curriculum into state continuing education system for ECE providers
• Integrating safe siting training and screening into mandatory state licensing training for all new ECE providers
• Acknowledging through a statewide certificate program all ECE providers who participate in APPLETREE programs to assess environmental exposure
• Partnering with state licensing agencies to integrate CSPECE into the state's Health and Human Services (HHS) Child Care and Development Block Grant (learn more about block grants)

There are also systems-level changes in progress that states intend to adopt in the next grant cycle. One, adjusting city policies to protect ECEs from hazardous environmental exposures. Two, developing guidance to prioritize funding for facilities in areas with environmental health concerns.

Success Stories

California Child Care and Development Fund Block Grant Application Changes: Partnerships, Systems-Level Change

Summary: The California CSPECE Team ensured that CSPECE guidance language was added to California's application for the Child Care and Development Fund Block Grant (CCDF).

Full Story: After reaching out to ECE stakeholders and raising awareness of the issues addressed in CSPECE guidance, the California CSPECE team worked to determine where intervention could further benefit ECEs.

The team worked with the state licensing agency, the California Department of Social Services, and the California Department of Education (CDE). CDE is the lead agency for submitting the CCDF Block Grant application on behalf of all agencies and organizations that participate. CDE agreed to include language stating that the CDE will partner with the California Department of Public Health. The partnership will include outreach and education activities on harmful environmental exposures that affect children in ECE settings.

Idaho Property Checklist Screening for Environmental Hazards: Screening and Response, Education

Summary: After using the voluntary Property Checklist to evaluate a potential ECE location, a childcare provider in Idaho decided not to purchase the site, which was a former gas station.

Full Story: The Choose Safe Places Program in Idaho is a voluntary program that encourages providers to use the Property Checklist when considering a site. This Checklist outlines potential environmental exposures that the provider should consider when assessing a site. It provides specific resources for where to obtain more information about each type of hazard. In the current pilot program, Idaho STARS Child Care Consultants assist providers in using the Property Checklist.

A provider used the Property Checklist for a potential childcare site formerly used as a gas station. When filling out the Checklist, the provider discovered that the former gas station had not been remediated. The Property Checklist helped the provider ask critical questions about environmental health risks when considering the site. The provider ultimately decided not to open their business in this location. The provider continues to look for a suitable site for their business and is using the Checklist to evaluate each location.

Massachusetts Evaluation of Potential Soil Contamination: Screening and Response

Summary: The Massachusetts Department of Public Health (MDPH) Choose Safe Places Program assisted in evaluating potential exposure to contaminated soil at a childcare program.

Full Story: Massachusetts Department of Early Education and Care (EEC) contacted the MDPH Choose Safe Places Program after learning about contaminated soil at a childcare program. The program is in an area undergoing investigation for years of dumping.

As part of the investigation, the Massachusetts Department of Environmental Protection (MassDEP) tested surface soil at the childcare facility. Some soil samples exceeded MassDEP standards for arsenic, lead, polychlorinated biphenyls, and polycyclic aromatic hydrocarbons.

To assist EEC, the Choose Safe Places Program reviewed soil sampling data and discussed concerns with MassDEP. Following discussions with MassDEP, the Program reassured EEC that there are no current exposure and no health risks for children and staff as they were in areas that are not accessible.

However, the Choose Safe Places Program made several recommendations:

• Children should not be allowed to dig through pea gravel and wood chips in the play yard
• People should obey posted signs to stay off the front yard
• The owner should prevent exposure by ensuring proper maintenance of the pea gravel and wood chips
• The owner should have children wash hands after being outside

The Choose Safe Places Program offered to explain these recommendations to the owner and answer health questions from staff or parents. EEC thanked the Choose Safe Places Program for the technical assistance and expressed relief that children are being protected.

Wisconsin Building Child Care Licensing Partnerships: Partnerships, Education

Summary: To reach childcare provider applicants before they commit to a location by purchase or lease, Wisconsin's Choose Safe Places for Early Care and Education (CSP) initiative is working with the Department of Children and Families (DCF) and Supporting Families Together Association (SFTA).

Full Story: In Wisconsin, most applicants for a childcare license have a site already under contract by the time they meet with SFTA, which regulates facilities. To ensure that locations are environmentally safe, Wisconsin CSP needs to intervene before applicants choose a location. There are currently 4,234 licensed facilities with capacity for 176,915 children, and about 200 facilities are newly licensed per year in the state.

Through meetings, Wisconsin CSP has successfully convinced partners to add the property questionnaire to the official DCF inquiry packet for new applicants. Several meetings have strengthened the partnerships, and partners have committed to providing feedback on the pilot property questionnaire. Partners are reviewing the questionnaire and will give Wisconsin CSP feedback to ensure applicants will fill out the questionnaire.

Missouri Screening Children for Lead Exposure: Screening and Response, Partnerships

Summary: In Missouri, there was a concern of potential exposure to children at a Head Start site located within a Superfund Site.

Full Story: A Missouri Head Start is located within the Newton County Mine Tailings Superfund Site. Head Start directors requested that all enrolled children receive a capillary lead test.

The Missouri Department of Health and Senior Services and the County Health Department performed finger sticks for children with their parent's approval. Test results on 26 children enrolled showed 25 results below five (5.0) micrograms per deciliter (ug/dl). One child, who tested at 5.0 ug/dl, was referred for further testing.

DHHS, ATSDR, the Environmental Protection Agency (EPA), the County Health Department, Missouri Department of Natural Resources, Head Start directors, and the Administration for Children and Families held a meeting on next steps. Afterward, EPA conducted soil sampling and dust wipe sampling. All samples collected were submitted to and analyzed by the State Public Health Laboratory. The dust wipe results all came back below the established standard of 40 micrograms per square foot (ug/ft2), which met the EPAs and the Department of Housing and Urban Development standard. Three of the soil samples showed elevated lead in the soil. Soil from below the sand in the sand box area and below the jungle gym area tested high for lead. Soil remediation of the Head Start site is anticipated in 2020.

New York Assessment of Radon Exposure Concern: Screening and Response, Education

Summary: The New York State Department of Health (DOH) and Office of Children and Family Services (OCFS) assessed a potential exposure concern at a daycare.

Full Story: NYS DOH is providing outreach to promote safe siting of early care and education centers. The outreach resulted in experts in environmental radiation protection contacting CSPECE project coordinators about a daycare facility. The experts found the facility to be near a property where radium is a contaminant of concern. Because radon is a radioactive decay product of radium, the experts asked if radon testing had been completed at the facility. Given the concern for potential exposure at the daycare facility, the project coordinators immediately notified OCFS.

OCFS notified the facility's provider of a concern for potential radon exposure and recommended that radon sampling be conducted. The provider conducted radon testing within the daycare facility and shared the results with OCFS and DOH.

The results were well below the EPA's action level and did not show a concern for radon exposures at the daycare facility. The CSPECE project facilitated the ability to quickly rule out radon exposures as a concern for this daycare facility.

Connecticut Evaluation of Contaminated Groundwater Concern: Screening and Response

Summary: Connecticut's Childcare SAFER Program identified a new childcare facility located close to a potentially contaminated site and identified risk of contaminated groundwater vapor intrusion.

Full Story: The CT Childcare SAFER process, using a property history questionnaire, identified a childcare facility that was close to a potentially contaminated site. Follow-up work involved consultation with the Department of Energy and Environmental Protection and a review of existing environmental reports. This work revealed that groundwater contamination posed a potential vapor intrusion exposure concern for the facility.

CT Childcare SAFER recommended that the property owner or childcare operator conduct soil gas sampling to rule out the potential for vapor intrusion. Depending on the results, a depressurization system might be needed. The childcare facility wanted to open as soon as possible, and the property owner elected to install the system immediately. As a result of the SAFER Program, potential exposures to children from contaminants in groundwater will be permanently prevented by the installed system.

Montana Education on Indoor Environmental Hazards: Education

Summary: A school in Montana was at risk of potential hazardous exposures. Montana CSPECE shared information on potential exposures and methods to address those exposures with the building owner.

Full Story: Because a beauty school planned to rent part of the same building, a Montana school was at risk of potential hazardous chemical exposures. After learning about the situation, the Child Care Licensing Office called the State Toxicologist to discuss concerns.

The Montana CSPECE shared information about potential public health issues and listed some requirements from other states. Montana CSPECE listed the possible hazardous chemicals from hair salons, including ammonia, formaldehyde, polyethylene glycols, as well as synthetic fragrances and dyes. Additional nail salon chemicals include acetone, acetonitrile, butyl acetate, dibutyl phthalate, ethyl acetate, ethyl methacrylate, and toluene. This information was shared with the building owners, and the beauty school will not be opening in that building.

Texas City of Austin Permitting Pilot Project: Systems-Level Change, Partnerships

Summary: The Texas Department of State Health Services (DSHS) developed a pilot project with the City of Austin to address environmental health issues in early childcare. This included changes in the city's permitting processes to help keep children safe from environmental contamination.

Full Story: A goal of the DSHS Safe Siting program is to develop a method for cities to manage Safe Siting activities on their own. DSHS program staff met with the City of Austin employees, including members of Development Services, Environmental Health, and Brownfield Remediation sections. DSHS provided information and resources for children's environmental health and the City shared the processes for environmental inspections.

DSHS has developed a strong relationship with Austin's Development Services. The City of Austin Development Services assists business owners when they build, remodel or perform any type of construction. Austin is in the process of adjusting its policies to protect daycares from hazardous environmental exposures. These proposed changes will help ensure that future childcare facilities are screened against the Safe Siting map that DSHS created. DSHS is also receiving feedback from the City of Austin employees to improve the pilot program. DSHS will provide the City of Austin with future training sessions.