Current work in the Bureau of Family Health (BFH) addresses child health and injury prevention through a variety of programs. The Child Death Review (CDR) program promotes the safety and well-being of children by reducing preventable childhood fatalities. This is accomplished through systemic, multi-agency reviews of the deaths of children up to the age of 21 years. All 67 Pennsylvania (Pa.) counties are represented on 62 local CDR teams. The CDR program through the BFH facilitates the review process, provides training and technical assistance to local teams, and ensures data quality. The CDR program is supported through a combination of Title V and other federal funds, with other federal funds being used to fund staff time and Title V funds being used to fund training and technical assistance efforts as well as prevention activities.

 

Of the 1,664 deaths occurring in 2020, 801 (48.1%) were reviewed and entered in the National Fatality Review-Case Reporting System (NCFRP-CRS) by local CDR teams. Many teams were unable to complete a review of all children’s deaths occurring in 2020 due to continued COVID-19 related efforts which impacted the teams’ ability to meet, and some key team members’ capability to devote time and resources to CDR. More than a third (39.2%) of all deaths reviewed were infant deaths. Children 18 through 21 years of age accounted for 34.3% of child deaths reviewed. Combined, these two age groups represented 74.0% of all child deaths reviewed in Pa. in 2020.

 

Deaths of Black/African American children, including infants, occur at a higher rate than those of other races. Both the national rate and the Pa. rate of Black/African American children’s deaths saw an increase from 2019 to 2020. In Pa., the rate increased from 91.7 per 100,000 population in 2019 to 105.0 per 100,000 population in 2020. Nationally, for the same time period, the rate increased for Black/African American children from 90.2 per 100,000 to 97.1 per 100,000. Black/African American children continue to die at a rate twice that of white children.

 

While the Pa. rate of death for white children saw a slight decrease in 2020, the national rate saw a slight increase. The Pa. rate was 44.8 per 100,000 population in 2019 compared to 43.9 per 100,000 population in 2020. In 2019, the national rate was 46.1 per 100,000 population and in 2020, the rate was 48.1 per 100,000 population.

 

The rate of death for Asian/Pacific Islander children residing in Pa. decreased from 31.0 per 100,000 population in 2019 to 28.7 per 100,000 population in 2020. The national rate decreased in 2019 from 31.9 per 100,000 population to 28.5 per 100,000 population in 2020.

 

Of the 94 reviews conducted on deaths occurring in children aged 1 through 9 years, the most frequent cause of death was cancer, which was identified in 10 cases (10.6%).  Of the 118 reviews conducted on deaths occurring in children aged 10 through 17 years, the most frequent cause of death was due to bodily force or weapon, identified in 42 cases (35.6%). Of the 275 reviews conducted on deaths of youth aged 18 through 21 years, the most frequently occurring cause of death was bodily force or weapon, identified in 121 cases (44.0%).

 

The purpose of the reviews conducted by local CDR teams is to gather and examine data regarding the circumstances surrounding child deaths. The examination of that data is used to promote prevention initiatives that reduce the incidence of child fatalities. Development and implementation of prevention measures vary according to the community and the findings of the local CDR Team. Prevention activities are led by the local CDR teams, local CDR team members, or through collaborations with other local entities, including, but not limited to, coroners, local health departments, hospitals, law enforcement, home visitation programs, children’s advocacy centers, and schools. Some of the prevention measures that have been implemented focus on motor vehicle safety, suicide prevention, safe sleep, prematurity, and farm safety.

 

Lead poisoning is a preventable environmental health hazard and, if not addressed, affects families regardless of race, ethnicity, or socioeconomic status. Nationally, among states with older housing stock, lead-based paint is a significant source of lead exposure in young children. According to the 2020 American Community Survey estimate, Pa. ranks fifth in the nation for the percentage of housing units identified as having been built before 1950, when lead was most prevalent. In Pa., lead exposure and lead poisoning disproportionally affect minority children and families whose incomes are below the federal poverty threshold. Of the children poisoned, Black/African American and Hispanic children are disproportionately represented because, due to inequities caused by systemic racism, they are more likely to be economically disadvantaged. The number of Black/African American children poisoned is over 2.5 times higher than the share of Black/African American children in the population and the number of Hispanic children poisoned is 1.2 times higher than the share of Hispanic children in the population. Further, the share of white children poisoned is nearly two times lower than the share of white children in the population.

 

In 2022, lead abatement or remediation efforts continued through the federally funded Lead Hazard Control Program (LHCP). The grant, through the Department of Housing and Urban Development (HUD), runs from September 15, 2020, through March 14, 2024. The total funding amount is $2.9 million with $2.5 million for lead hazard remediation and $400,000 for other healthy homes related services. The Department anticipates making 165 units lead safe with these funds and improving the health and lives of those families and their communities.

 

The Department worked with local partners across Pa. in areas with older housing stock, and in some instances, elevated blood lead levels, to identify and remove lead hazards in housing units occupied by families with children six years of age and under, whose incomes are below the federal poverty threshold. The goal of the LHCP is to protect Pa.’s children from the long-term effects of lead poisoning as well as evaluate the overall living conditions within the home to obtain healthier outcomes for Pa. families.

 

In 2022, the LHCP held a total of 45 events educating the public about lead exposure and lead poisoning as well as the LHCP and its benefits to families and the community. Thirty-five units were evaluated for LHCP services; of those evaluated, 11 homes have been remediated, making them lead safe.

 

The LHCP also participated with the Section 3 program. The Section 3 program requires that recipients of certain HUD financial assistance programs provide training, employment, contracting, and other economic opportunities to persons whose incomes are below the federal poverty threshold, especially recipients of government assistance for housing, and to businesses that provide economic opportunities to this population. Recipients of HUD financial assistance and their contractors and subcontractors are required to provide economic opportunities, to the greatest extent possible, consistent with existing federal, state, and local laws and regulations. As of today, LHCP partners have provided over 400 working hours of training and employment to persons eligible for the Section 3 program.

 

Furthermore, efforts to reduce lead exposure and lead poisoning in children continued through the Childhood Lead Poisoning Prevention Program (CLPPP). Using funds received from the Centers for Disease Control and Prevention (CDC) for a five-year grant (September 2021 through September 2026), the CLPPP partnered with local health departments to implement strategies and activities to ensure blood lead testing and reporting, enhance blood lead surveillance, and improve linkages of lead-exposed children to recommended services. On January 1, 2022, in response to the CDC’s updated blood lead reference value (BLRV) from 5 µg/dL to 3.5 µg/dL, the Department adopted the new lower BLRV and encouraged all county and municipal health departments (CMHDs), lead prevention partners, and health care providers to use the lowered BLRV to determine the blood lead level required for case management and environmental investigation. Additionally, ongoing efforts to support childhood blood lead poisoning prevention work continued with the passage of Act 150 of 2022 “the Childhood Blood Lead Test Act (act)” on November 3, 2022. Requirements of the act, which took effect on January 2, 2023, are anticipated to result in increased blood lead testing rates and reporting. The BFH continues to operate a toll-free Lead Information Line to provide information and resources on prevention, screening, abatement, and regulatory issues on lead for the citizens of Pa.

 

Bureau staff participate in the Pritzker Children’s Initiative subgroup related to lead poisoning prevention. This group consists of participants from state and local government, managed care organizations, housing authorities, hospitals, health systems, home visiting, and other social programs. The initiative aims to increase blood lead testing and referral rates, allocate state funding for remediation services, and engage the public to eliminate lead poisoning in children across the state. In the past year, the group has been committed to the development and implementation of several initiatives. In addition to the creation of a screening guide for Pa. primary care providers and a resource guide to help municipalities protect children from lead paint poisoning and improve property values, the Lead-Free Promise Project (LFPP), a coalition of more than 50 organizations, was established. The coalition’s goals are to have all children tested twice for lead at ages one and two and ensure all poisoned children are referred to Early Intervention Services. In the past year, the LFPP advocated for the passage of Senate bill 522 (Act 150 of 2022) which increases the availability and coverage of lead testing for Pa.’s children. Additionally, the LFPP secured 10 million in funds from the American Recovery Plan Act (ARPA) which will be used for lead hazard control, lead training and capacity building for lead programs in Pa.  

 

Additionally, using Title V funding, the BFH supports a variety of child health focused programs implemented by the 11 County Municipal Health Departments (CMHDs). Allegheny County Health Department uses the Healthy Families America (HFA) program to educate parents and families on the importance of well child visits, child development, safety, and nutrition. In 2022, the HFA program enrolled and served over 85 families. The Philadelphia Department of Public Health (PDPH) offers a clinic specifically designed for youth aimed toward improving their health and increasing their knowledge about health-related issues. Staff assess psychological and reproductive health needs and offer referrals to clinical, social, and behavioral health services as well as engage teens in reproductive life planning. In 2022, PDPH served 88 youth through this program.

 

Through the Preventive Health and Health Services (PHHS) Block Grant, the Bureau of Health Promotion and Risk Reduction (BHPRR) provided funds to the American Trauma Society of Pennsylvania (ATSPA) for the Safe Kids Pennsylvania statewide coalition as well as to nine CMHDs for Safe and Healthy Communities. This work is also indirectly supported by Title V, which partially funds a DOH position overseeing it.

 

Nineteen Safe Kids PA Coalitions and Partners have continued to conduct childhood injury prevention activities through education, collaboration, and advocacy throughout Pa. Safe Kids PA provides statewide technical assistance activities to local Safe Kids coalitions and partners through a multi-faceted approach of public awareness, education, public policy, community activities, and safety supplies distribution.

The BPHHR continued to leverage funds from the PHHS Block Grant with nine CMHDs to utilize the following strategies to prevent childhood injuries:

• Implemented local health policies and/or sustainable environmental changes to reduce the prevalence of unintentional injuries.
• Implemented evidence-based motor vehicle injury prevention activities focusing on reducing motor vehicle related injuries and deaths.
• Implemented policy, systems, or environmental changes supported by evidence-based educational and outreach activities to reduce the prevalence of Adverse Childhood Experiences.
• Implemented policy, systems, or environmental changes supported by evidence-based educational and outreach activities to decrease suicide within the community.

 

Children in Pa. are also increasingly experiencing trauma and adverse childhood experiences (ACES) early in life. As of 2019-2020, 20.8% of children in Pa. had experienced at least one ACE and ACES were most reported among racial and ethnic minority children and among CSHCN. In 2019, Governor Wolf established the Office of Advocacy and Reform (OAR), which was tasked with the protection of disproportionately affected populations in Pa., including children. Since then, the OAR launched a think tank that developed a plan to make Pa. a trauma-informed, healing-centered state with the following priorities: building a network to connect and support community-based, grassroots movements across the commonwealth, prioritizing changes at the state level to affect culture, policy, and practice, healing from the trauma of a major disaster like the COVID-19 pandemic, and healing the damage of racism, communal, and historical trauma. OAR was dissolved in 2023, following the start of a new administration. Governor Shapiro has advocated for increased access to mental health services, especially for youth, but what that may look like in practice is forthcoming.

 

Priority: Improve mental health, behavioral health and developmental outcomes for children and youth with and without special health care needs

 

NPM 11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home

 

Strategy: Community Health Nurses will provide information about available medical homes to all families without a provider or insurance and that have children, ages 0-17 during visits to the State Health Center (SHC)

 

Objective: Ensure that all SHCs are documenting and reporting all referrals of children ages 0-17, who do not have a provider or insurance, made to medical home within six months

 

ESM: Percentage of children without a provider or insurance referred to medical homes

 

This ESM sought to establish a baseline of children without a medical provider or insurance seen by Community Health Nurses at SHCs across the state, as well as the number of those children referred to a medical home within six months. From June 2022 through December 2022, a total of 1,439 infants and children ages 0-17 seen in the SHCs were identified as not having a medical home. The Community Health Nurses made medical home referrals for 434 infants under the age of one year and 959 children aged 1-17. Referrals were made for 96.8% of infants and children identified as not having a medical home.

 

Priority: Reduce rates of child mortality and injury, especially where there is inequity

 

NPM 7.1: Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9

 

Strategy: Use Child Death Review data to inform child safety programming

 

Objective: Annually increase the number of recommendations from CDR teams related to preventing child death that are reviewed for feasibility and implemented each year

 

ESM: Number of recommendations from CDR teams that are implemented (child health)

 

The State CDR Team implemented a new prevention recommendation framework. The framework process consists of three steps: assessment; development; and evaluation. Assessment includes review of data (CDR data and other relevant data), current prevention strategies occurring in Pa. and other jurisdictions and best practices. This work will culminate in the development of a white paper for each type of death examined through the prevention framework. The white papers will serve as vehicles for sharing prevention strategies with partners that are positioned to act. The first type of death the team agreed to examine was Motor Vehicle Accidents. The State CDR Team reviewed death data and other injury data, discussed prevention practices currently in place within the state and identified potential partnerships to focus on these types of deaths and injuries. Feedback on the white paper for Motor Vehicle Accidents was sought from the State CDR Team during the June 2022 meeting.

 

In 2022, there were no state-level recommendations from the CDR teams for Title V staff to review for implementation related to child health. While the CDR teams continued to move forward with death reviews, they did not result in actionable recommendations at the state level.

 

The BFH contracts with the Philadelphia Medical Examiner’s Office (MEO) to conduct the Sudden Death in the Young (SDY) case registry. The MEO is responsible for identifying cases in Philadelphia, reviewing the deaths via its Child Death Review Team and Advanced Review Team, and entering the data learned from the reviews into the National Case Reporting System. The review teams’ meetings serve to identify underlying causes and risk factors associated with the sudden and unexpected deaths in children birth to age 20 years and to use that information to address infant and child mortality through prevention efforts. The families of the deceased are given an opportunity to consent to have the child’s deoxyribonucleic acid (DNA) samples used for research or DNA banking which are stored at the SDY Biorepository. Of the 59 identified cases in 2022, 6 families (10.2%) provided consent. The MEO has had more success in obtaining consents from families than all other jurisdictions participating in the SDY case registry due to the work of the bereavement counselors. The opportunity for further research enhances prevention efforts at the local level and has the potential to reduce mortality rates for these deaths on a national level. BFH is anticipating receiving recommendations resulting from the SDY reviews.

 

Strategy: Reduce head injury amongst participants in school and non-school related sports

 

Objective: Annually increase the number of ConcussionWise trainings provided by the Safety and Youth Sports Program to athletic personnel by two per year 

 

ESM: Number of ConcussionWise trainings to athletic personnel

 

The BFH aims to prevent childhood injury through concussion prevention and management training and protocols in youth sports. The goal of the Safety in Youth Sports Program (SYSP) is to educate and train personnel involved in youth sports, both school-based and club-based, regarding general traumatic brain injury (TBI) knowledge, concussion prevention, concussion identification, and concussion management. To achieve this goal, the SYSP uses the Sports Safety International’s ConcussionWise Training curriculum. Each training is delivered by a certified ConcussionWise Instructor. Target personnel included medical providers, school and club coaches, school nurses, parents, athletes, and students.

 

In 2022, the program’s grantee, The Pennsylvania Athletic Trainers’ Society (PATS), had difficulty recruiting and retaining ConcussionWise Instructors. They responded to that difficulty by ensuring that the athletic trainers recruited would dedicate the time necessary to schedule and complete trainings to become ConcussionWise Instructors. A total of 36 trainings, exceeding the goal of 32, were conducted for athletic personnel. The trained athletic personnel then conducted 118 trainings for diverse populations reaching 2,514 individuals. PATS partnered with youth sports organizations and school districts in urban and rural areas when scheduling trainings to help address areas of health inequity.

 

Strategy: Provide comprehensive in-home child safety education visits

 

Strategy: Provide home-safety interventions performed as a result of needs identified during comprehensive in-home child safety education visits

 

Objective: Increase the number of eligible households that receive a home child safety education visit or intervention by 3% by June 30, 2024

 

ESM: Number of comprehensive in-home child safety education visits completed

 

ESM: Number of home safety interventions performed as a result of needs identified through comprehensive in-home child safety education visits

 

In July 2021, the BFH began the Prevent Injuries in Children (PIC) program. The PIC program is a primary prevention program that combines comprehensive in-home child safety education visits and home safety interventions to increase child safety practices including the use of home safety equipment. The PIC program differs from prior in‑home child safety programs, more narrowly focusing on child injury prevention than a broader healthy home perspective. While local organizations have lamented the loss of the broader healthy homes services, BFH strives to provide targeted and evidence-based or evidence-informed strategies to improve child health.

 

The PIC program is provided in association with other home visiting programs as an additional and separate component that provides education and interventions to families. PIC providers are required to complete Motivational Interviewing training to better engage with families as well as training on child injury hazards, prevention, and appropriate interventions. Low-cost interventions are provided at no-charge to participating families based on their specific child safety needs.

 

The PIC program was designed to provide services in counties with the greatest health disparities in child injury and address health equity and serve those most in need without additional work or efforts at the local level. Counties were ranked for priority based on injury, death, race and ethnicity, and emergency department visits using both rates and numbers. Eight categories were used to establish the county prioritization with data calculated for the combined 0-9 age group and all given equal weight in the ranking and prioritization process.

 

The PIC program was anticipated to operate in 10 counties; however, suitable vendors were only found for four counties. While two of the four counties are meeting expectations the other two are having substantial challenges enrolling participants leading to overall suboptimal outcomes.

 

In 2022, BFH anticipated completing 180 comprehensive in-home child safety education visits and performing 900 home safety interventions as a result of needs identified through the comprehensive in-home child safety education visits. BFH estimated that each comprehensive in-home child safety education visit would result in five home safety interventions being performed. While the PIC program only produced 73 comprehensive in-home child safety education visits, 713 home safety interventions were performed, or nearly 10 home safety interventions performed per comprehensive in-home child safety education visit.

 

While the PIC program is not reaching as many children and families as anticipated, it is reaching those most in need. The nearly double rate of home safety interventions performed per comprehensive in-home child safety education visit is a sign of success in the goal of child injury prevention. Another unintended benefit of not achieving the anticipated number of comprehensive in-home child safety education visits is that there is not a wait for families interested in the PIC program to receive services. The BFH would like to serve a greater number of families, however, the families served to date have received prompt and highly needed services.

 

The BFH continues to serve as a statewide resource on healthy homes providing information and referrals to appropriate organizations.