guidance for state and local public health officialschapter 2. a comprehensive approach to childhood...

Centers for Disease Control and PreventionNovember 1997

Screening Young Childrenfor Lead Poisoning:

Guidance for State and LocalPublic Health Officials

Screening Young Childrenfor Lead Poisoning:

Guidance for State and LocalPublic Health Officials

Centers for Disease Controland PreventionDavid Satcher, M.D., Ph.D., Director

National Center for Environmental HealthRichard J. Jackson, M.D., M.P.H., DirectorDivision of Environmental Hazards and Health EffectsHenry Falk, M.D., DirectorLead Poisoning Prevention BranchJerry Hershovitz, ChiefNancy Tips, Associate to the Chief for Planning and Evaluation

U.S. Department of Healthand Human Services, Public Health ServiceNovember 1997

Suggested reference:

Centers for Disease Control and Prevention. Screening YoungChildren for Lead Poisoning: Guidance for State and LocalPublic Health Officials. Atlanta: CDC, 1997.

iScreening Young Children for Lead Poisoning

Contents

Foreword..........................................................................................v

Preface..............................................................................................1

Advisory Committee on Childhood Lead PoisoningPrevention........................................................................................4

Executive Summary........................................................................9

Chapter 1. Childhood Lead Poisoning in theUnited States......................................................13

Chapter 2. A Comprehensive Approach to ChildhoodLead Poisoning Prevention..............................21

Chapter 3. The Statewide Plan for Childhood BloodLead Screening...................................................31

Chapter 4. Roles of Child Health-Care Providers inChildhood Lead Poisoning Prevention..........77

Chapter 5. CDC Resources and Information forImplementation of Guidance.......................111

Chapter 6. Childhood Lead Poisoning PreventionResearch Priorities..........................................115

Glossary......................................................................................117

ii Screening Young Children for Lead Poisoning

List of Tables and Figures

Table 1.1. Quantity and percentage of U.S. housing builtbefore 1950, by state ........................................15

Table 2.1. Assessing children�s exposure to lead.............22

Table 2.2. Childhood lead poisoning prevention activitiesand associated policies......................................25

Table 2.3. Examples of childhood lead poisoning preven-tion activities and collaboration.......................27

Table 3.1. Percentage of children ages 1-5 years withBLLs ≥10 µg/dL, by year house built, andgeometric mean BLL, by year house built, U.S.,1991-1994...........................................................39

Table 3.2. Percentage of children with BLLs ≥10 µg/dLby race/ethnicity and income, U.S., 1991-1994.....................................................................41

Table 3.3. Percentage of children ages 1-11 years withBLLs ≥10 µg/dL by age group, U.S., 1991-1994.....................................................................43

Table 3.4. Guidelines for choosing an appropriate screen-ing recommendation.........................................50

Table 4.1. Schedule for diagnostic testing of a child withan elevated BLL on a screening test...............92

iiiScreening Young Children for Lead Poisoning

Table 4.2. Clinical evaluation.............................................98

Table 4.3 Comprehensive follow-up services,according to diagnostic BLL.........................106

Figure 1.1. Geometric mean blood lead levels ofchildren ages 1-5 years in the U.S.:NHANES II and III...........................................17

Figure 3.1. Housing built before 1950 in SouthCarolina: geographic analysis at threedifferent levels�county, zip code, andcensus tract...........................................................59

vScreening Young Children for Lead Poisoning

Foreword

We find ourselves at a crossroads. On the one hand, bloodlead levels in the U.S. population continue to decline, offeringthe hope that lead poisoning can be eliminated in the not toodistant future. On the other hand, children, who are mostvulnerable to the harmful effects of lead, continue to beexposed to this toxicant at an unacceptable rate. Some890,000 U.S. children have lead levels high enough to causeadverse effects on their ability to learn, mainly because ofexposure to deteriorating lead-based paint in their homes. Tobetter protect our children, we must step up our efforts toidentify those with elevated blood lead levels so that they canreceive the care they need.

At present, too many children with elevated leadlevels are not being identified. More effective screen-ing is necessary and must be focused where children are mostlikely to benefit. The policy outlined in this document hastwo main purposes: to increase screening and follow-up careof children who most need these services, and to help com-munities pursue the most appropriate approach to the preven-tion of childhood lead poisoning. In some places, the level ofrisk for lead exposure may not justify the screening of allchildren. In many other places, more screening than is cur-rently being done will be necessary.

The process described in the pages that follow will succeedor fail to the extent that it is embraced by state and localhealth departments, Medicaid agencies, health-care providers,

vi Screening Young Children for Lead Poisoning

and other community members. Chapter 3 contains ourrecommendations for developing screening that is responsiveto community situations and needs. We believe that thecommunity should be involved in planning and carrying outscreening, and we have tried to outline a process that is easy tofollow, even though it involves complex decisions. TheCenters for Disease Control and Prevention (CDC) willcontinue to support state and local public health agencies asthey lead the development of statewide screening plans, andour agency stands ready to guide and encourage communitiesin all facets of lead poisoning prevention. In its effort tocombat lead poisoning among children, CDC works withother Federal agencies, especially the Department of Housingand Urban Development (HUD) and the EnvironmentalProtection Agency (EPA), through a combination of regula-tion, guidance, technical assistance, and funding support.

I want to thank the members of the CDC Advisory Commit-tee, our consultants, and all who have contributed their timeand talents to this guidance. I believe that the approachdescribed in these pages will move the nation closer to itsgoal of eliminating childhood lead poisoning. Certainly, thechildren of this nation deserve no less.

Richard J. Jackson, M.D., M.P.H.DirectorNational Center for Environmental Health

1Screening Young Children for Lead Poisoning

Preface

This guidance on childhood lead screening was devel-oped by CDC in consultation with the members andconsultants of the Advisory Committee on Childhood LeadPoisoning Prevention. The committee comprises non-Federal experts drawn from health departments, pediatricpractices, managed-care organizations, academia, andnon-governmental agencies working on affordable hous-ing and public lead poisoning prevention education. Theguidance was also reviewed by childhood lead poisoningprevention program managers and was available during a6-week period for public comment. The final document isfrom CDC and does not necessarily reflect the views of allmembers of the advisory committee.

In 1991, the U.S. Public Health Service (PHS) called for asociety-wide effort to eliminate childhood lead poisoningin 20 years (CDC, 1991), and in 1997, PHS remains com-mitted to this goal. Childhood lead screening should bepart of a comprehensive program to reach this goal.Chapter 3 of this document discusses the development ofstatewide plans for childhood blood lead screening. Thepurpose of these plans is to increase the screening andfollow-up care of children who most need these servicesand to ensure that screening is appropriate for localconditions.

The main intended audience for this guidance is state andlocal health officials; however, it may also be used by

2 Screening Young Children for Lead Poisoning

child health-care providers, managed-care organizations,and others.

Several topics are not covered or are considered onlybriefly in this document. Some of these topics havebeen recently considered by other groups:

� Health effects and sources and pathways of exposure(National Research Council, 1993).

� Chelation therapy (American Academy of Pediatrics,1995).

� Controlling lead hazards in the home (U.S. Department ofHousing and Urban Development, 1995).

� National policy for controlling lead hazards in housing(Lead-Based Paint Hazard Reduction and Financing TaskForce, 1995).

The continued expansion of knowledge about childhood leadpoisoning prevention will be reflected in future changes inCDC guidance.

References

American Academy of Pediatrics Committee on Drugs.Treatment guidelines for lead exposure in children. Pediatrics1995;96:155-60.


Centers for Disease Control. Strategic plan for theelimination of childhood lead poisoning. Atlanta:Department of Health and Human Services, 1991.

Lead-Based Paint Hazard Reduction and Financing TaskForce. Putting the pieces together: controlling leadhazards in the nation�s housing. Washington, D.C.: U.S.Department of Housing and Urban Development, 1995.

National Research Council. Measuring lead exposure ininfants, children, and other sensitive populations. Washing-ton, D.C.: National Academy Press, 1993.

U.S. Department of Housing and Urban Development(HUD). Guidelines for the evaluation and control oflead-based paint hazards in housing. Washington, D.C.:HUD, 1995.


Advisory Committee on Childhood LeadPoisoning Prevention

ChairpersonJ. Routt Reigart, II, MDProfessor of PediatricsMedical University of South Carolina171 Ashley AvenueCharleston, SC 29425

Executive SecretaryHenry Falk, MDDirector, Division of Environmental Hazards and Health EffectsNational Center for Environmental HealthCenters for Disease Control and PreventionAtlanta, GA 30341�3724

MembersIsabella J. Clemente, CPNPAssociate Director, Division of Environmental SciencesPediatric ClinicsMontefiore Medical CenterMoses 401111 East 210th StreetBronx, NY 10467

Cushing N. DolbeareConsultant on Housing and Public Policy215 Eighth Street, NEWashington, DC 20002�6105

Alvaro Garza, MD, MPHHealth Officer, Stanislaus County820 Scenic DriveModesto, CA 95350


Rita Marie GergelyDirector, Lead Poisoning Prevention ProgramsIowa Department of Public HealthLucas State Office BuildingDes Moines, IA 50319�0075

Andrew K. Goodman, MDAssistant Commissioner, Division of Community and Occupational HealthNew York City Department of Health125 Worth StreetNew York, NY 10013

Birt Harvey, MDPediatrician101 Alma Street, #1201Palo Alto, CA 94301�1011

Sanders Francis Hawkins, PhDDirector, Laboratory ServicesConnecticut Department of Public Health10 Clinton StreetHartford, CT 06106

Patricia L. McLaine, BSN, MPHAssistant Director for Program ManagementNational Center for Lead-Safe Housing10227 Wincopin CircleColumbia, MD 21044

Janet A. Phoenix, MD, MPHManager, Public Health ProgramsNational Safety CouncilNational Lead Information Center1019 19th Street, NWWashington, DC 20036�5105


Joel D. Schwartz, PhDAssociate Professor, Environmental EpidemiologyHarvard School of Public Health665 Huntington AvenueBoston, MA 02115

Roger F. Suchyta, MDAssociate Executive DirectorAmerican Academy of Pediatrics141 Northwest Point BoulevardElk Grove Village, IL 60009�0927

ConsultantsJ. Julian Chisolm, Jr., MDDirector, Lead Poisoning Prevention ProgramKennedy Kreiger Institute707 North BroadwayBaltimore, MD 21205

Charles G. CopleyDirector, Department of Community Health and the EnvironmentSt. Charles County Department of Community Health305 N. Kings HighwaySt. Charles, MO 63301

Andrew M. Davis, MD, MPHAssociate Medical Director, Rush Prudential Health Plans233 Wacker DriveSuite 3900Chicago, IL 60606

Dwala S. GriffinAdministrator, Division of Health ServicesLouisville-Jefferson County Health Department400 East Gray StreetLouisville, KY 40202


Philip J. Landrigan, MDChairman, Department of Community MedicineDirector, Division of Environment and Occupational MedicineMount Sinai Medical CenterNew York, NY 10029

Herbert L. Needleman, MDProfessor of Psychiatry and PediatricsWestern Psychiatric Institute and ClinicUniversity of Pittsburgh School of Medicine3600 Forbes AvenuePittsburgh, PA 15213�2593

Patrick Jeremy Parsons, PhDDirector, Lead Poisoning LaboratoryWadsworth Center for Laboratories and ResearchNew York State Department of HealthAlbany, NY 12201�0509

Sergio Piomelli, MDDirector, Division of Pediatric Hematology and OncologyColumbia University Babies Hospital3959 BroadwayNew York, NY 10032

Stephanie L. Pollack, JDConservation Law Foundation of New England62 Summer StreetBoston, MA 02110�1008

Lewis Bradford PrenneyDirector, Childhood Lead Poisoning Prevention ProgramMassachusetts Department of Public Health470 Atlantic AvenueBoston, MA 02110


Thomas L. Schlenker, MDExecutive DirectorSalt Lake City-County Health Department2001 South State Street, S�2500Salt Lake City, UT 84190�2150

Peter Simon, MD, MPHAssistant Medical DirectorDivision of Family HealthRhode Island Department of Health3 Capitol Hill, Room 302Providence, RI 02908


Executive Summary

Childhood lead poisoning is a major, preventable environ-mental health problem. Blood lead levels (BLLs) as low as10 µg/dL are associated with harmful effects on children�slearning and behavior. Very high BLLs (≥70 µg/dL) causedevastating health consequences, including seizures,coma, and death. It is currently estimated that some890,000 U.S. children have BLLs ≥10 µg/dL (CDC, 1997).Since the virtual elimination of lead from gasoline, lead-based paint hazards in homes are the most importantremaining source of lead exposure in U.S. children.

In 1991, the U.S. Department of Health and Human Servicescalled for elimination of childhood lead poisoning and in1997 retains its commitment to see this effort through. Bloodlead screening is an important element of a comprehensiveprogram to eliminate childhood lead poisoning. The goal ofsuch screening is to identify children who need individualinterventions to reduce their BLLs. The 1991 edition ofPreventing Lead Poisoning in Young Childr en called forvirtually universal screening of children 12�72 monthsof age. Nonetheless, a 1994 national survey showed thatonly about one-fourth of young children had beenscr eened and only about one-third of poor children, whoar e at higher risk of lead exposure than other children,had been scr eened.

Some populations of children are heavily exposed tolead while others are not. A recent national estimate


(CDC, 1997) showed that 21.9% of black children livingin housing built before 1946 had elevated BLLs (≥10µg/dL). Studies of other groups of children haveshown quite low prevalence of elevated BLLs. Forexample, a 1994 survey of 967 poor children in Alaskafound that none had a BLL above 11 µg/dL (Robin etal., 1997).

Many children, especially those living in older housingor who are poor, need screening and, if necessary,appropriate interventions to lower their BLLs. At thesame time, children living where risk for lead exposurehas been demonstrated to be extremely low do not allneed to be screened. The task for public health agen-cies, parents, and health-care providers is to identifythose children who will benefit from screening and toensure that they receive the services they need.

CDC Recommendations - Statewide Plan

State health officials should develop a statewide planfor childhood lead screening and convene an inclusiveplanning committee composed of child health-careproviders as well as representatives from local healthdepartments, managed-care organizations, Medicaid,private insurance organizations, and the community.

The plan should address:� Division of the state, if necessary, into areas with different

recommendations for screening.� Screening recommendations for each area. (A basic targeted-

screening recommendation is provided below as an example.)� Dissemination of screening recommendations for each area.

� Evaluation.


A Basic Targeted-Screening Recommendation

State health officials should use this basic recommenda-tion only as an interim measure. A recommendation thatis based on assessment of local data and an inclusiveplanning process is preferred.

Within the state or locale for which this recommendation ismade, child health-care providers should use a blood lead testto screen children at ages 1 and 2, and children 36-72 monthsof age who have not previously been screened, if they meetone of the following criteria:

� Child resides in one of these zip codes: [place here alist of all zip codes in the state or jurisdiction that have≥27% of housing built befor e 1950. This information isavailable from the U.S . Census Bureau.]

� Child receives services from public assistance programs forthe poor, such as Medicaid or the Supplemental FoodProgram for Women, Infants, and Children (WIC).

� Child�s parent or guardian answers �yes� or �don�t know� toany question in a basic personal-risk questionnaire consistingof these three questions:

-Does your child live in or regularly visit a house that wasbuilt before 1950? This question could apply to a facilitysuch as a home day-care center or the home of ababysitter or relative.-Does your child live in or regularly visit a house builtbefore 1978 with recent or ongoing renovations or re-modeling (within the last 6 months)?-Does your child have a sibling or playmate who has ordid have lead poisoning?


In the absence of a statewide plan or other formalguidance from health officials, universal screening forvirtually all young children, as called for in the 1991edition of Preventing Lead Poisoning in Young Children(CDC, 1991), should be carried out.

CDC provides funding and technical advice to assist states andlocales in all activities that are called for in this guidancedocument.

In this document, CDC also provides general guidelines aboutthe roles and responsibilities of child health-care providers inpreventing childhood lead poisoning, including anticipatoryguidance, screening and follow-up testing, clinical manage-ment, chelation therapy, family education about elevated BLLs,and participation in a follow-up team.

References

Centers for Disease Control and Prevention. Update: bloodlead levels�United States, 1991-1994. MMWR 1997;46:141-6.

Centers for Disease Control and Prevention. Erratum: vol. 46,no.7. MMWR 1997;46:607

Robin LF, Beller M, Middaugh JP. Statewide assessment oflead poisoning and exposure risk among children receivingMedicaid services in Alaska. Pediatrics 1997;99:E91-E96.


Chapter 1: Childhood Lead Poisoning

1 Childhood Lead Poisoning in the United States

The problem of childhood lead poisoning. Child-hood lead poisoning is a major, preventable environmentalhealth problem in the United States. Blood lead levels(BLLs) as low as 10 µg/dL are associated with harmfuleffects on children�s ability to learn. Very high BLLs (≥70µg/dL) can cause devastating health consequences, includingseizures, coma, and death. It is currently estimated that some890,000 U.S. children have BLLs ≥10 µg/dL (CDC, 1997).

Lead exposure. Children can be exposed to lead in manyways. Sources of exposure include lead-based paint andindustrial sites and smelters that use or produce lead-contain-ing materials. Lead-contaminated dust, soil, and water; lead-containing materials used in parental occupations or hobbies;and lead-containing ceramicware and traditional remedies allcontribute to childhood lead exposure. Lead-contaminatedhouse dust, ingested in the course of normal hand-to-mouthactivity, is of major significance. House dust is most oftencontaminated by lead-based paint in the home, when suchpaint is peeling, deteriorating, or scattered about during homerenovation or preparation of painted surfaces for repainting.

Housing with lead-based paint. Lead-based paint inhomes is the most important remaining source of lead expo-sure for U.S. children. Substantial progress has been made inreducing other environmental sources of lead exposure,especially from gasoline and food. But 83% of all homesbuilt in the United States before 1978 still contain some lead-



based paint at a concentration of at least one mg/cm2 (U.S.Environmental Protection Agency, 1995). The older thehouse, the more likely it is to contain lead-based paint and tohave a higher concentration of lead in the paint. Housingbuilt before 1950 poses the greatest risk of exposure tochildren. Such housing is present in every state. (Table 1.1.)Even states with low overall rates of older housing haveareas that contain predominately older housing.

Temporal trend of elevated BLLs in children. AverageBLLs for the population as a whole have declined dramati-cally since the 1970s. As shown in Figure 1.1., the geometricmean BLLs for children ages 1-5 years declined from 15.0µg/dL during 1976-1980 (Mahaffey et al., 1982) to 2.7µg/dL during 1991-1994 (CDC, 1997).



Table 1.1. Quantity and percentage of U.S. housing builtbefore 1950, by state

StateTotal Housin g

Un its

Housin gUn its Built

Befor e 1 950

BuiltBefor e

1 950 (%)

Alabama 1,670,379 298,303 17.9

Alaska 232,608 16,248 7.0

Arizona 1,659,430 110,746 6.7

Arkansas 1,000,667 176,662 17.7

California 11,182,882 2,211,243 19.8

Colorado 1,477,349 270,562 18.3

Connecticut 1,320,850 462,808 35.0

Delaware 289,919 64,704 22.3

Dist. of Columbia 278,489 155,194 55.7

Florida 6,100,262 472,481 7.7

Georgia 2,638,418 381,827 14.5

Hawaii 389,810 52,347 13.4

Idaho 413,327 100,738 24.4

Illinois 4,506,275 1,662,888 36.9

Indiana 2,246,046 756,843 33.7

Iowa 1,143,669 490,394 42.9

Kansas 1,044,112 345,564 33.1

Kentucky 1,506,845 364,678 24.2

Louisiana 1,716,241 333,965 19.5

Maine 587,045 242,858 41.1

Maryland 1,891,917 473,984 25.1

Massachusetts 2,472,711 1,157,737 46.8

Michigan 3,847,926 1,228,635 31.9

Minnesota 1,848,445 585,539 31.7

Mississippi 1,010,423 167,685 16.6

Missouri 2,199,129 629,868 28.6



Montana 361,155 108,805 30.1

Nebraska 660,621 249,631 37.8

Nevada 518,858 31,044 6.0

New Hampshire 503,904 162,201 32.2

New Jersey 3,075,310 1,082,081 35.2

New Mexico 632,058 97,750 15.5

New York 7,226,891 3,401,416 47.1

North Carolina 2,818,193 494,675 17.6

North Dakota 276,340 85,128 30.8

Ohio 4,371,945 1,561,695 35.7

Oklahoma 1,406,499 298,347 21.2

Oregon 1,193,567 316,648 26.5

Pennsylvania 4,938,140 2,213,386 44.8

Rhode Island 414,572 181,215 43.7

South Carolina 1,424,155 218,781 15.4

South Dakota 292,436 107,374 36.7

Tennessee 2,026,067 380,068 18.8

Texas 7,008,999 1,008,475 14.4

Utah 598,388 127,266 21.3

Vermont 271,214 109,780 40.5

Virginia 2,496,334 481,679 19.3

Washington 2,032,378 500,808 24.6

West Virginia 781,295 270,441 34.6

Wisconsin 2,055,774 757,204 36.8

Wyoming 203,411 48,254 23.7

Un ited States 1 02 ,263 ,678 27,508 ,653 26.9

StateTotal Housin g

Un its

Housin gUn its Built

Befor e 1 950

BuiltBefor e

1 950 (%)

Source: 1990 U.S. census

Table 1.1. (Continued)



1976-1980 1988-1991 1991-19940

2

4

6

8

10

12

14

16

NHANES II NHANES III

Geo

me

tric

mea

n b

loo

d le

ad

leve

l (ug

/dL

)

15.0

3.62.7

Figure 1.1. Geometric mean blood lead levels of childrenages 1-5 years in the United States: NHANES II and III



Distribution of elevated BLLs among children. Somepopulations of children are heavily exposed to lead whileothers are not. For example, a recent national estimate(CDC, 1997) showed that 21.9% of black children living inhousing built before 1946 had elevated BLLs (≥10 µg/dL).Studies of other groups of children have shown quite lowprevalence of elevated BLLs. For example, a 1994 survey of967 poor children in Alaska found that none had a BLLabove 11 µg/dL (Robin et al., 1997).

Blood-lead screening of children. If we are to elimi-nate childhood lead poisoning, a comprehensive approach isnecessary. (See Chapter 2.) Blood lead screening is animportant element of such an approach. The goal of screen-ing is to identify children who need individual interventionsto reduce their BLLs. The 1991 edition of Preventing LeadPoisoning in Young Children called for virtually universal screen-ing of children 12-72 months of age. Nonetheless, a 1994national survey showed that many children who are at riskfor lead exposure are not being screened (Binder et al., 1996).According to the survey, only about 24% of young childrenhad been screened; fewer than one-third of those at increasedrisk for lead exposure because of poverty or residence inolder housing had been screened.

Current situation. Many children, especially those livingin older housing or who are poor, are still being harmed bythe effects of lead exposure. These children need screeningand, if necessary, appropriate interventions to lower theirBLLs. At the same time, children in places with populationsthat are known to be at extremely low risk for lead exposuredo not all need to be screened. The task for public healthagencies, parents, and health-care providers is to identify



those children who will benefit from screening and to ensurethat they receive the services they need.

References

Binder S, Matte TD, Kresnow M, Houston B, Sacks JJ. Leadtesting of children and homes: results of a national telephonesurvey. Public Health Rep 1996;111:342-6.

Centers for Disease Control. Preventing lead poisoning inyoung children: a statement by the Centers for DiseaseControl, October 1991. Atlanta: Department of Health andHuman Services, 1991.

Centers for Disease Control and Prevention. Update: bloodlead levels�United States, 1991-1994. MMWR1997;46:141-6.

Centers for Disease Control and Prevention. Erratum: vol.46, no.7. MMWR 1997;46:607

Mahaffey KR, Annest JL, Roberts J, Murphy RS. Nationalestimates of blood lead levels: United States, 1976-1980. NEngl J Med 1982;307:573-9.

Robin LF, Beller M, Middaugh JP. Statewide assessment oflead poisoning and exposure risk among children receivingMedicaid services in Alaska. Pediatrics 1997;99:E91-E96.

Office of Pollution Prevention and Toxics (OPPT). Reporton the National Survey of Lead-Based Paint in Housing:base report. Washington, DC: US Environmental ProtectionAgency, OPPT; 1995. Report No.: EPA/747-R95-003.


Chapter 2: A Comprehensive Approach

2 A Comprehensive Approach to Childhood Lead Poisoning Prevention

Although lead poisoning among children is a bigger problemin some places than in others, there is potential for leadexposure in nearly all jurisdictions. Public health agenciesshould develop a comprehensive approach to preventingchildhood lead poisoning that is based on the three functionsdefined in The Future of Public Health: assessment, policydevelopment, and assurance (National Academy of Sciences,1988).

1. Assessing Children’s Exposure to Lead

Sources of data for assessment of children�s exposure to leadare summarized in Table 2.1. Sources include childhoodblood lead surveillance systems (complete data are currentlyunavailable in most places, but many such systems are beingdeveloped); the U.S. Census (widely available data on olderhousing and young children living in poverty); the ToxicRelease Inventory (TRI) from the EPA (widely available dataon local industrial sources of lead exposure); and localsurveys. Local surveys may be conducted to gather data onindustrial sources not included in the TRI; on drinking waterthat might be contaminated by lead; and on householdswhere lead may be present in traditional remedies,ceramicware, cosmetics, or materials used in hobbies.



Table 2.1. Assessing children’s exposure to lead

Ex posur e Sour ce orRisk Factor

Examples of Sources ofData for Assessment

Pre-1950 housing Census data, tax-assessor data

Demographic factors (e.g., poverty)

Census data, blood leadsurveillance data

Industrial sources, parentaloccupation (take-homeexposure)

Toxic Release Inventory, localsurveys, blood leadsurveillance data

Drinking waterLocal surveys, EPA, localutility companies

Hobbies, traditional remedies,ceramicware, cosmetics

Local surveys, blood leadsurveillance data



2 . Developing Policies for Childhood LeadPoisoning Prevention

Policies and activities are necessary in three major areas:primary prevention, secondary prevention, and monitoring(surveillance). Activities and associated policies are summa-rized in Table 2.2.

Primary prevention activities prevent children from being ex-posed to lead. Especially significant are actions to reduceresidential lead hazards before children are born, are suffi-ciently mobile to be at increased risk for exposure to house-hold lead, or before children move into a home with leadhazards. (Alliance to End Childhood Lead Poisoning, 1994.)

Secondary prevention activities reduce the harmful effects ofelevated BLLs after elevations have occurred. Activitiesinclude BLL screening and follow-up care.

�Universal� screening is the BLL screening of all children inan area; �targeted� screening is the BLL screening of childrenwho are selected on the basis of: 1) environmental assess-ment to determine where children are being exposed to leadhazards, or 2) individual risk assessment to identify childrenwho meet certain criteria, which may include place of resi-dence, membership in a high-risk group, or �yes� answers to apersonal-risk questionnaire. (See Chapter 3 for more detail onsecondary prevention activities.)

Monitoring (surveillance) activities provide information that formsthe basis for planning, evaluation, and public support ofpolicies and programs. Activities include development ofsystems to monitor children�s BLLs, sources of exposure,



reduction of lead hazards, and availability of lead-safehousing.

Of particular importance are childhood blood lead surveil-lance systems containing information on elevated and non-elevated BLL results, demographics, results of environmentalinvestigations, probable sources of exposure, and prescribedmedical treatments.



Table 2.2. Childhood lead poisoning prevention activitiesand associated policies

Activity Examples of Associated Policies

Primary Prevention

Evaluation and control ofresidential lead-based painthazards

Protective housing codes or statutes

Public lead education State- or area-wide plan calling forcommunity-wide lead education

Professional lead education andtraining

State certification for lead-abatement workers

Anticipatory guidance by childhealth-care providers

State Medicaid policies requiringanticipatory guidance

Identification and control ofsources of lead exposure otherthan lead-based paint

State- or area-wide plan to reduceexposures from industry anddrinking water

Secondary Prevention

Childhood blood lead screening State- or area-wide screening plan;state Medicaid policies andcontracts calling for screening;protocols and policies for providersand managed-care organizations

Follow-up care for children withelevated BLLs

Local policies to establish a follow-up care team; protocols for carecoordination, and for medical andenvironmental management;Medicaid policies and contractscalling for follow-up care

Monitoring (Surveillance)

Monitoring of children’s BLLs State policy requiring laboratories toreport all BLL test results ofresident children

Monitoring of targeted (older,deteriorating) housing stock,hazard-reduction activities, andlead-safe housing

State certification and licensingprocedures for monitoring safety oflead-hazard reduction activities andoccurrence of such activities inareas with targeted housing;procedures for tracking lead-safehousing



3 . Assuring the Performance of Activitiesto Prevent Childhood Lead Poisoning

Health departments should, at a minimum, support, oversee,and monitor the activities necessary to prevent childhoodlead poisoning.

In a comprehensive approach, there are roles for manydifferent collaborators in both the public and the privatesector. (See, for example, Alliance to End Childhood LeadPoisoning, 1996; and Lead-Based Paint Hazard Reduction andFinancing Task Force, 1995.) Examples of activities, collabo-rating groups, and health department roles are shown in Table2.3.



Activity Collabor ator sRoles of public h ealthdepar tm en ts

Primary prevention

Anticipatory guidance Health-care providers,medical groups,managed-careorganizations

Provide educationalmaterials; publicize,disseminate, and marketprevention information

Public education Health-care providers,medical groups,managed-careorganizations,community-basedorganizations, realtors,contractors, homeremodelers, homeinspectors, the press

Assess community needs;provide educational materials;convene planning groups;oversee, carry out, orevaluate campaigns; respondto consumer inquiries

Maintenance or improvementof older housing

Property owners,realtors, bankers,community-basedorganizations,remodelers, housingmaintenance staff

Convene policy-developmentgroups; maintain system formonitoring targeted (older,deteriorating) housing;provide training formaintenance staff andremodelers; providecontractor training andcertification

Lead hazard evaluationand control

Lead inspectors, riskassessors, lead abatementcontractors, trainers,community-basedorganizations, andlicensing agencies

Accredit training providers,certify lead professionals,provide advice and referralsto property owners

Table 2.3. Examples of childhood lead poisoningprevention activities and collaboration



Table 2.3. Examples of childhood lead poisoningprevention activities and collaboration (continued)

Activity CollaboratorsRoles of public healthdepar tments

Secondary prevention

Screening Health-care providers,medical groups,managed-careorganizations

Provide patient-educationmaterials and screeningprotocols; conduct screening

Follow-up care: medicalmanagement

Health-care providers,medical groups,managed-careorganizations

Provide referrals, protocols,and care coordination;provide medicalmanagement.

Follow-up care: environmentalinvestigation

Public and private-sectorenvironmental healthspecialists

Provide referrals;investigation services;training, licensing, andcertification of investigators;laboratory quality controls

Follow-up care: family leadeducation, home visiting

Visiting nurseassociations, community-based organizations

Provide referrals, training,and home-visiting services

Follow-up care: lead-hazardcontrol

Property-owners,bankers, realtors, policymakers, enforcementagencies

Convene policy-makinggroups; provide referrals,training, licensing, andcertification; provide hazard-reduction services



Table 2.3. Examples of childhood lead poisoningprevention activities and collaboration (continued)

Activity CollaboratorsRoles of public healthdepar tments

Monitoring (surveillance)

Using BLL information forprogram development

Health-care providers,medical groups,managed-careorganizations, clinicallaboratories

Conduct outreach and policydevelopment to encourageBLL reporting; providesystems to collect, manage,analyze, and disseminateresults

Using information on lead-hazard control activities tomonitor safety of theseactivities and lead-safe housing

Environmentalsanitarians, lead hazard-reduction contractors

Encourage reporting as partof training, licensing, andcertification programs;provide systems to collect,manage, analyze, anddisseminate results



References

Alliance to End Childhood Lead Poisoning (AECLP). Child-hood lead poisoning: developing prevention programs andmobilizing resources. Primary Prevention Strategies Hand-book. Vol 2. Washington, D.C.: AECLP, 1994.

Alliance to End Childhood Lead Poisoning (AECLP). Inno-vative financing sources for lead hazard control. Washington,D.C.: AECLP, 1996.

Lead-Based Paint Hazard Reduction and Financing TaskForce. Putting the pieces together: controlling lead hazardsin the nation�s housing. Washington, D.C.: U.S. Departmentof Housing and Urban Development, 1995.

National Academy of Sciences Committee for the Study ofthe Future of Public Health. The future of public health.Washington, D.C.: National Academy Press, 1988.


Chapter 3: The Statewide Plan

3 The Statewide Plan for Childhood Blood Lead Screening

State public health officials should develop a statewide planfor childhood blood lead screening.

The plan should address:� Division of the state, if necessary, into areas with different

recommendations for screening.� Screening recommendations for each area. (A basic

targeted-screening recommendation is provided below asan example.)

� Dissemination of screening recommendations for eacharea.

� Evaluation.

Screening policy should be based on data that is representa-tive of the entire population. Children should be screenedaccording to state policy.

In the absence of a statewide plan or other formal guidancefrom health officials, universal screening for virtually allyoung children, as called for in the 1991 edition of PreventingLead Poisoning in Young Children (CDC, 1991), should becarried out.



A Basic Targeted-Screening Recommendation

State health officials should use this basic recom-mendation only as an interim measure. A recom-mendation that is based on assessment of local dataand an inclusive planning process is preferred.

Within the state or locale for which this recommendation ismade, child health-care providers should use a blood lead testto screen children at ages 1 and 2, and children 36-72 monthsof age who have not previously been screened, if they meetone of the following criteria:

� Child resides in one of these zip codes: [place here a list ofall zip codes in the state or jurisdiction that have ≥ 27% of housingbuilt before 1950. This information is available from the U.S.Census Bureau.]

� Child receives services from public assistance programs forthe poor, such as Medicaid or the Supplemental FoodProgram for Women, Infants, and Children (WIC).

� Child�s parent or guardian answers �yes� or �don�t know�to any question in a basic personal-risk questionnaireconsisting of these three questions:

-Does your child live in or regularly visit a house that was builtbefore 1950? This question could apply to a facility such as a homeday-care center or the home of a babysitter or relative.-Does your child live in or regularly visit a house built before 1978with recent or ongoing renovations or remodeling (within the last 6months)?-Does your child have a sibling or playmate who has or did havelead poisoning?



discussion of those steps on the facing right hand pages.

There are six steps to developing andimplementing the statewide screeningplan.

1. Form an advisory committee.

2. Assess lead exposure and screening capacity.

3. Determine the boundaries of recommendation areas.

4. Decide on appropriate screening.

5. Write screening recommendations for areas with universalscreening and for those with targeted screening.

6. Implement the statewide plan.

Editor�s Note: In the rest of this chapter, we outline (on theleft hand pages) the step-by-step process for developing andimplementing a statewide screening plan and provide a



1. Form an advisory committee.

State health officials should form an advisory committee todevelop the statewide plan. The committee should includechild health-care providers as well as representatives fromlocal health departments, managed-care organizations, Medi-caid, private insurance organizations, and the community.

The Advisory Committee



The advisory committee

The statewide plan for childhood blood lead screeningdeveloped by the health department should, at a minimum,have the input of child health-care providers, insurers, andparents.

Involvement of health-care providers, their organizations,and managed-care organizations throughout the process willimprove acceptance of screening recommendations. Theimportance of community collaboration in public healthdecision-making is underscored by community health re-search (e.g., Green and Kreuter, 1991). Studies (e.g., Grecoand Eisenberg, 1993) also indicate that health-care providersrespond well to information and recommendations that comefrom peers and from their organizations.

Working with insurers, especially the state Medicaid agency,will help ensure that screening is included, as appropriate, incontracts and policies.

The Advisory Committee



2 . Assess lead exposure andscreening capacity.

2.1. Examine information on children�srisk for lead exposure.

2.1.1. Examine BLL data.Exercise caution in using BLL data to assess risk for leadexposure, because these data may not reflect the risk of theentire population. If BLL data are not thought to be reliable,other data should be used (see following sections) untilimproved BLL data are available.

Use the following criteria to evaluate BLL data. Data shouldmeet all of these criteria. If they do not, they are probably notan adequate basis for screening decisions.

Criteria for evaluating BLL data1. Laboratory data are available for children who have been

screened.2. Laboratory data are of good quality.3. Laboratory data are available for individual children.4. Demographic, socioeconomic, and geographic data are

available for individual children.5. Screening data are representative of the pediatric popula-

tion of the jurisdiction.6. Screening data are available for a sample that is large

enough to allow for a valid estimate of prevalence to bemade.

Assessment



Evaluating BLL data, additional consider-ations

� Labs reporting data should be successful participants in anapproved proficiency-testing program.

� BLL test results should be maintained in a way that allowsidentification of duplicate and sequential tests on a singlechild. It must be possible to distinguish between numberof children tested and number of tests performed.

� The results of all tests, regardless of BLL, should beavailable, so that calculation of rates of elevated BLLsamong screened children can take place.

� The data should be representative, i.e., the demographic,socioeconomic, and geographic distribution of childrenscreened should be similar to that of all children in thejurisdiction.

� Screening data that are not representative of the entirepopulation, although not ideal, may be useful. For ex-ample, data showing low prevalence among those athighest risk would tend to support a targeted-screeningrecommendation; data showing high prevalence amongthose at lowest risk would tend to support a universal-screening recommendation (see Step 5).

Assessment



2.1.2. Examine data on housing.

These data are widely available from the U.S. census and canbe used to estimate potential lead-exposure risk in an area. Ifadequate BLL data are unavailable, housing data can be usedalone. Data are available for states, counties, zip codes,census tracts, and census block groups.

The focus should be on housing built before 1950 because itposes the greatest risk for lead exposure.

Assessment



Age of housing

Housing built before 1950 poses the greatest risk for leadexposure because it is much more likely to contain lead-basedpaint than is newer housing.

� Paint manufactured before 1950 has more lead than paintmanufactured after that year (Lead-Based Paint HazardReduction and Financing Task Force, 1995).

� 27% of U.S. housing was built before 1950. Percentagesof pre-1950 housing vary widely among states and coun-ties.

� Data from the most recent National Health and NutritionExamination Survey (NHANES III, Phase 2) confirm therelationship between housing age and BLLs (CDC, 1997).

Table 3.1. Percentage of children ages 1-5 years with BLLs≥10 µg/dL, by year house built, and geometric mean BLL, byyear house built, U.S., 1991-1994

Year housebuilt

% withBLLs

>10 µg/dL

Geometric meanBLL (µg/dL)

Before 1946 8.6 3.8

1946-1973 4.6 2.8

1973 onward 1.6 2.0

Assessment



2.1.3. Examine data on demographic char-acteristics of children.

The focus should be on poor children and children of racial/ethnic minority groups because generally they are at higherrisk than other children.

Demographic data on children are widely available from theU.S. census and can be used to identify places with highproportions of children who may be at higher than averagerisk for lead exposure.

Assessment



Data on demographic characteristics ofchildren: race/ethnicity and income

Data from NHANES III, Phase 2, show strong relationshipsbetween BLL and race/ethnicity and between BLL andincome.

Table 3.2. Percentage of children with BLLs ≥10 µg/dL byrace/ethnicity and income, U.S., 1991-1994

Assessment

Characteristic% children, ages 1-5 with

BLLs >10 µg/dL

Race/Ethnicity

Black, non-Hispanic 11.2%

Mexican-American 4.0%

White, non-Hispanic 2.3%

Income

Low 8.0%

Middle 1.9%

High 1.0%

All children 4.4%



2.1.3. Examine data on demographic char-acteristics of children (continued).

The focus should be on children between the ages of 12 and36 months (1- and 2-year-old children) because BLLs tend tobe highest in this age group, and more children in this agegroup have BLLs ≥10 µg/dL.

Examine census and local information to determine whetherthere are places with high percentages of young children.Estimates generated since the last U.S. census (conducted in1990) are available to help identify these areas.

Assessment



Data on demographic characteristics ofchildren: age

Focus on children at ages 1 and 2.One- and 2-year-old children are at greatest risk for elevatedBLLs because of:� Increasing mobility during the second year of life, resulting

in more access to lead hazards.� Normal hand-to-mouth activity.

In addition, the developing nervous systems of young chil-dren are more susceptible to the adverse effects of lead.

Data from NHANES III, Phase 2, reinforce the associationbetween children�s age and their risk for elevated BLLs.

Table 3.3. Percentage of children ages 1-11 years withBLLs ≥10 µg/dL by age group, U.S., 1991-1994

Age group(years)

% with BLLs>10 µg/dL

1-2 5.9%

3-5 3.5%

6-11 2.0%

Assessment



2.1.4. Examine data on the presence ofother sources of lead.

Examine data from within the state on other sources of leadexposure, such as pottery, traditional remedies and cosmetics,operating or abandoned industrial sources, waste-disposalsites, occupational and take-home exposure, and drinkingwater. (See National Research Council, 1993, for a compre-hensive discussion of sources and pathways of lead expo-sure.)

Data from local surveys may supply additional informationabout local sources of lead exposure. BLL surveillance datamay also reveal the presence of unusual sources.

Assessment



Other sources and pathways of leadexposure

Industries, work sites, occupations, and associatedmaterialsSecondary smelting and refining of nonferrous metalsBrass/copper foundriesFiring rangesAutomotive repair shopsBridge, tunnel, and elevated highway constructionMotor vehicle parts and accessoriesStorage batteries (lead batteries)Valve and pipe fittingsPlumbing fixture fittings and trimPotteryChemical and chemical preparationsIndustrial machinery and equipmentInorganic pigmentsPrimary batteries, dry and wet

Hobbies and home activitiesRecreational use of firing rangesHome repairs, repainting, or remodelingFurniture refinishingStained glass makingCasting ammunitionMaking fishing weights or sinkers, or toy soldiersUsing lead solder (e.g., for electronics)Using lead-containing artists� paints or ceramic glazesBurning lead-painted woodCar or boat repair

Assessment



2.2. Assess the capacity of local publichealth systems within the state to overseeand provide lead screening.

This assessment will be one basis for deciding whether todivide the state into areas with different recommendedscreening.

Examine local information about:� Health department organization and capacity to oversee

screening.� Current screening activity.� Capacity to collect and analyze screening data.� Child health-care delivery systems and patterns.� Enrollment of children in Medicaid managed care.� Health department capacity to support private providers

of screening.� Health department capacity to provide screening for

children without other access to care.

Assessment



Information on local health systems

Some locales have long-standing, comprehensive childhoodlead poisoning prevention programs with ties to managed-care organizations and support from providers. Other placeshave less experience, fewer allocated resources, and lessprovider involvement.

Information about local activities should be used to developa plan that is responsive to local needs and respectful of localcapacities.

Assessment



3 . Determine the boundaries ofrecommendation areas.

If necessary, subdivide the state into recommendation areas.A recommendation area is a geographic area for which ascreening recommendation can be reasonably made.

Efforts should be made to draw boundaries so thatrecommendation areas are reasonably homogeneous both inmagnitude of risk and in health-system capacity to providescreening.

Recommendation Areas



Boundaries of recommendation areas

Some states have relatively widespread and homogeneousrisk, while others have less risk or scattered pockets of risk.States also differ with regard to the capacity of local healthsystems to oversee and provide screening.

Universal screening is appropriate in areas with widespreadrisk. A state with widespread risk may comprise a singlerecommendation area with universal screening. Other stateswith less risk or scattered pockets of risk may be divided intodifferent areas, some with universal screening and others withtargeted screening.

Example: A state is divided into two recommendation areas:1) a large city, designated as a universal-screening areabecause of its high percentage of older housing, and 2) therest of the state, throughout which older housing is scattered,which is designated as a targeted-screening area. The largecity’s health department, with its experienced lead program,will oversee screening in the city; the state health departmentwill oversee screening in the rest of the state.

Recommendation Areas



4. Decide on appropriate screening.

Choose universal or targeted screening for each recommenda-tion area. Use the following table to guide decision making.

Table 3.4. Guidelines for choosing an appropriate screeningrecommendation

Appropriate Screening

% children, ages12-36 months, withBLLs >10 µg/dL

% housing builtbefore 1950

Recommendedscreening

>12% ---- universal

<12% >27%universal (ortargeted--seediscussion)

3-12% <27% targeted

<3% <27% see discussion

unknown >27% universal

unknown <27% targeted



Cut-off pointsThese should be used as guides to decision making andshould not inhibit, for example, universal screening atprevalences of elevated BLLs or older housing that areslightly lower.

12% prevalence: The vast majority of children in recom-mendation areas where less than 12% of children have BLLs≥10 µg/dL will have BLLs below 20 µg/dL, the level requir-ing medical and environmental intervention. The membersof CDC�s advisory committee reached substantial, althoughnot unanimous, agreement on the 12% cut-off, which is alsosupported by a cost-benefit analysis.

27% pre-1950 housing: Housing data can be used as aproxy for BLL data; 27% of U.S. housing was built before1950. (Bureau of the Census, 1992)

≥27% of housing pre-1950, but prevalence <12%:� Universal screening should be recommended unless preva-

lence data are reliable and representative.� If targeted screening is recommended, the condition of

older housing stock should be monitored. Decline inhousing conditions should trigger universal screening.

<3% prevalence: Where reliable BLL prevalence estimatesare extremely low and exposure sources are demonstrablylacking, methods other than routine screening should beused. Examples of alternatives are periodic focused surveys,routine review of BLL lab data, and public health alertsabout newly identified sources of lead exposure.Note: Whenever a parent or a health-care provider suspectsthat a child is at risk for lead exposure, a BLL test should beperformed regardless of health-department recommenda-tion.

Appropriate Screening



5 . Write screening recommenda-tions for areas with universalscreening, and for those withtargeted screening.

5.1. Write a universal-screening recom-mendation.

A sample:

Using a blood lead test, screen all children at ages 1and 2, and screen all children from 36-72 monthsof age who have not been screened previously.

Implementation of universal screening is discussed in Step 6.

Writing Recommendations



The universal-screening recommendation

In many places, universal screening will be the policy ofchoice.

In practice, universal screening has often been difficult toachieve. Barriers to screening and how to overcome them arediscussed in Step 6.




5.2. Write a targeted-screening recommen-dation.

A sample:

Using a blood lead test, screen children at ages 1and 2, and screen children from 36-72 months ofage who have not been screened previously if theymeet at least one of the health-department criteria.

Usual health-department criteria:

� Residence in a geographic area (e.g., a specified zip code)where there is risk for lead exposure. (See 5.2.1.)

� Membership in a group (e.g., Medicaid recipients) at riskfor lead exposure. (See 5.2.2.)

� Parent/guardian answers �yes� or �don�t know� to anyquestion in a personal-risk questionnaire. (See 5.2.3.)




The importance of targeted-screeningcriteria

The criteria established by the health department and itsadvisors will make it possible for child health-care providersand parents to identify children who need screening. Thesecriteria must be crafted to enable identification of as many at-risk children as possible. The criteria must be tailored tolocal conditions and easy to use.

Development of these criteria is discussed in detail on thefollowing pages.




5.2.1. Criterion: residence in a geographicarea.

This criterion makes it possible to identify children within arecommendation area who live in places where likelihood oflead exposure is increased (e.g., places with older housing).




Effectiveness of screening on the basis ofplace of residence

An analysis was performed on a state�s BLL surveillance datain order to test the effectiveness of screening that is based onresidence in zip codes and census tracts with high propor-tions of older housing.

An analysis of Rhode Island surveillance data - 1995

Rhode Island is a state that requires universal screening andhas BLL data on a relatively high proportion of its children.Analysis of 1995 Rhode Island surveillance data shows that:

If, contrary to fact, the state of Rhode Island were tocomprise a recommendation area with targeted screening:

� Using the criterion �screen all in zip codes with ≥27% pre-1950 housing� would result in identifying 92% of childrenwith BLLs ≥10 µg/dL.

� Using the criterion �screen all in census tracts with ≥27%pre-1950 housing� would result in identifying 93% ofchildren with BLLs ≥10 µg/dL.




5.2.1. Criterion: residence in a geographicarea (continued).

Within a larger recommendation area, smaller places wherelead exposure is likely should be pinpointed. Residence insuch a place constitutes a screening criterion.

The use of relatively small units of analysis (e.g., censustract, census block group) may reveal �pockets of risk� thatwould be invisible within a larger unit (e.g., county, zip code).However, small analytic units whose boundaries are notwidely recognized will not be useful as screening criteria in aclinical setting, where providers and parents must be easilyable to identify children for screening. For example, mostpeople cannot readily identify the census tract in which theylive.

Another possible criterion might be residence in a widelyrecognized neighborhood whose boundaries approximatethose of a relatively small analytic unit, such as a censustract, in which increased risk is identified.




Geographic analysis

Computerized mapping software and U.S. census data filesmake it easy to search recommendation areas for smallerareas with older housing or with high-risk groups. For ex-ample, the maps of South Carolina (Map 1), and ofGreenville County, S.C. (Maps 2 and 3), below show areas ofolder housing (shaded areas) for counties (Map 1), zipcodes (Map 2), and census tracts (Map 3). The use ofsmaller units of analysis (zip code or census tract) revealsareas of older housing that are obscured when the larger unit(county) is used. (Note that zip code boundaries do notnecessarily coincide with county boundaries.)

Figure 3.1. Housing built before 1950 in South Carolina:geographic analysis at three different levels�county, zip code,and census tract. (Shading indicates ≥ 27% of housing builtbefore 1950.)


Map 2: Zip codes inGreenville County, S.C.with ≥≥≥≥≥27% of housingbuilt before 1950

Map 3: Census tractsin GreenvilleCounty, S.C. with ≥≥≥≥≥27% of housingbuilt before 1950

Map 1: Counties in S.C. with ≥≥≥≥≥ 27%of housing builtbefore 1950



5.2.2. Criterion: membership in a high-risk group.

This criterion should make it possible to identify childrenwho may be at risk for reasons other than place of residence.

The focus should be on children who 1) are poor; 2) aremembers of racial/ethnic minority groups, including blackchildren and some groups of Hispanic and Asian-Americanchildren; 3) have occupationally exposed parents; or 4) havesome other significant group characteristic that puts them athigh risk.

Current (1997) Medicaid policy reflects the assumption thatall child beneficiaries are at risk for lead poisoning andrequires lead screening for all children who receive Medicaidbenefits. Anticipated changes in this policy may give statesthe responsibility of deciding whether all Medicaid-recipientchildren should be screened. In general, children who receiveMedicaid benefits should be screened unless there are reliable, represen-tative BLL data that demonstrate the absence of lead exposure in thispopulation.




Screening among children in a high-riskgroup

Ways to increase screening of poor children:� Screen all children who receive Medicaid benefits or

vouchers from the Supplemental Food Program forWomen, Infants, and Children (WIC).

� Add questions to the personal-risk questionnaire that elicitthe poverty status of respondents.

� Increase screening in geographic areas with high percent-ages of children in poverty.

� Screen in public clinics that serve poor children.� Improve access to health care for uninsured children.

The importance of membership in a high-risk group: Datafrom NHANES (CDC, 1997) and other studies (e.g.,Rothenberg et al., 1996) demonstrate that children who arepoor, are members of racial-ethnic minority groups, or whohave occupationally exposed parents are at higher risk of leadexposure than are other children. Membership in a minoritygroup does not predict risk in every community, and childrenin minority groups who are not exposed to lead do not haveelevated BLLs. Traditional remedies and lead-glazed cookingpots and ceramicware used by some Mexican-American andother (e.g., Southeast Asian) families may cause BLL eleva-tions. Children may also be exposed to lead brought home onclothes or persons, or in the car from adults� worksites.Occupations likely to be associated with �take-home� expo-sures include primary or secondary lead and copper smelting,battery manufacturing, battery recycling, painting and repairof older housing, construction and demolition, pottery work,stained-glass making, radiator repair, electronic componentsmanufacturing, work in gold-assay labs, and gold and silverrecovery.




5.2.3. Criterion: response to a personal-risk questionnaire.

This criterion makes it possible to identify children who maybe at risk but who do not meet other criteria. CDC recom-mends a basic three-question questionnaire as a startingpoint.

A basic personal-risk questionnaire:

1. Does your child live in or regularly visit a house that wasbuilt before 1950? This question could apply to a facilitysuch as a home day-care center or the home of ababysitter or relative.

2. Does your child live in or regularly visit a house builtbefore 1978 with recent or ongoing renovations or re-modeling (within the last 6 months)?

3. Does your child have a sibling or playmate who has or didhave lead poisoning?

Screen all children whose parent/guardian responds �yes� or�don�t know� to any question.




The personal-risk questionnairee personal-risk questionnairee personal-risk questionnairee personal-risk questionnairee personal-risk questionnaire

Educational value of questionnaires.A personal-risk questionnaire stimulates dialogue betweenthe health-care provider and parent about whether or not anindividual child should be screened and gives health-careproviders the opportunity to educate families about leadhazards.

Predictive value of recommended questions.Many, but not all, studies * have associated increased risk forelevated BLLs with positive answers to the first twoquestions. The third question is unlikely to cause a largeamount of unnecessary screening, and it may be important inindividual situations.

Sensitivity in predicting markedly elevated BLLs.Results of some studies have suggested that the questionnaireis more sensitive for identifying children with more severeBLL elevations, e.g., ≥15 µg/dL or ≥20 µg/dL, than foridentifying children with BLLs in the range of 10-14 µg/dL.

Cut-off date, 1978.The cut-off date, 1978, is recommended in question 2because there was some lead in residential paint until thistime. Renovations have been shown in many studies to beassociated with children�s increased risk for elevated BLLs.Lead hazards from unsafe renovations could occur in housingbefore 1978.

* For a list of studies of personal-risk questionnaires, see Chapter 5,List of Additional Information Available from CDC.




5.2.3. Criterion: response to a personal-risk questionnaire (continued).

Other questions. State health officials and their advisorsshould tailor the questionnaire to include questions aboutlocal sources of exposure in addition to housing, which iscovered by the recommended basic three-question question-naire.

In recommendation areas where exposure to lead from olderhousing is unlikely, the personal-risk questionnaire couldcontain questions about other risk factors such as parentaloccupation or the use of lead-containing ceramicware ortraditional remedies.




Examples of additional questions

Personal or family history.� Have you ever been told that your child has lead poison-

ing?Occupational, industrial, or hobby-related expo-sure.� Does your child live with an adult whose job or hobby

involves exposure to lead?� Does your child live near an active lead smelter, battery

recycling plant, or other industry likely to release lead intothe environment?

Other sources.� Does your child live within one block of a major highway

or busy street?� Do you use hot tap water for cooking or drinking?Cultural exposures.� Has your child ever been given home remedies (e.g.,

azarcon, greta, pay looah)?� Has your child been to Latin America?� Has your child ever lived outside the U.S.?� Does your family use pottery or ceramicware for cooking,

eating, or drinking?Poverty.� Does your family receive medical assistance?� Do you rent your home?� Do you or the child�s parents perform migrant farm work?� Have you recently moved?Behavior.� Have you seen your child eating paint chips?� Have you seen your child eat soil or dirt?Associated medical problems.� Have you been told that your child has low iron?




6. Implement the statewide plan.

It is up to state health officials and their advisors to ensurethat:

1) Staff members of state and local public health agenciesunderstand their roles as established by the statewide plan.

2) Health-care providers, medical groups, managed-careorganizations, and parents know what type of screening isrecommended for their communities.

3) Other parties affected by the plan, including the stateMedicaid agency, private insurers, and policy makers, areinvolved in the implementation process.

4) The plan is monitored, evaluated, and revised as appropri-ate.

Implementation



Implementation

Health-care provider groups and parent groups should edu-cate their members about recommended screening throughtheir newsletters and meetings. Maps of areas of likelyexposure are helpful in showing areas of risk.

Health-care provider groups should be made aware of howscreening will be monitored and of the importance of theirparticipation in evaluating recommendations.

Providers should receive supportive materials. (For aprototypic provider handbook, see list of additional resourcesavailable from CDC in Chapter 5.) These materials includeinformation on background, screening, parent education,referrals, and local sources of lead exposure.

It is important that health departments, Medicaid, and man-aged-care organizations work closely together to bring aboutscreening of Medicaid enrollees, as recommended. Contractsbetween the state Medicaid agency and managed-care organi-zations should include screening, follow-up, and reportingrequirements. (For samples of contract language, see list ofadditional resources available from CDC in Chapter 5.)

Implementation



6.1. Special considerations in the imple-mentation of a universal-screening recom-mendation.

The recommendation for universal screening is straightfor-ward, but implementation of such a recommendation hasoften been inadequate.

Health officials should not assume that making and commu-nicating a universal-screening recommendation are sufficientto bring about such screening. It is critical to involve health-care providers, medical groups, managed-care organizations,Medicaid agencies, and community members in the decisionto recommend universal screening and to use the decision-making process to educate these groups about preventinglead poisoning.

In areas where universal screening is recommended, healthdepartments should monitor the effectiveness of the recom-mendation to ensure that screening rates are high.

Implementation



Universal screening

Since 1991, when CDC recommended virtually universalscreening of U.S. children, barriers to such screening havebeen identified.

The two most important are:

� Many providers and parents do not believe that leadexposure is a problem in their community.

� Some children who are at high risk for lead exposurebecause of poverty and residence in deteriorating housingdo not receive routine well-child care and thus are notscreened for lead.

To address these barriers, health departments have steppedup outreach and lead education for parents and providers andhave worked with other agencies and communities to in-crease rates of well-child care.

Monitoring of screening activity is necessary so that effortsto improve screening rates can be directed to areas wherescreening is inadequate. See discussion in 6.2.

Implementation



6.2. Steps to take in implementing recom-mendations.

Screening recommendations should be based on data. Ofparticular interest are BLL data. These data should be usedto explain and support the recommendations to those whomust carry them out, especially child health-care providers,medical groups, managed-care organizations, insurers, andparents. Ongoing collection and dissemination of data arenecessary. Public health officials should:

� Collect BLL information.

� Determine the number and location of children withelevated BLLs.

� Determine where screening is taking place and where it isnot.

� Compare information about screening activity and BLLs.(Graphics that display both screening and case informationare helpful in this comparison.)

� Target education and outreach to areas where more screen-ing is indicated.

Implementation



Importance of feedback

Research, as well as common sense, suggests that health-careproviders are more compliant with clinical practice guidelineswhen they receive feedback about the effectiveness, impor-tance, and relevance of what they are being asked to do(Elrodt, et al., 1995). Every effort should be made to supplyproviders with screening data showing BLLs among childrenin the areas where they practice.

Sources of BLL information

Childhood blood lead surveillance systems that collect resultsof all BLL tests from all laboratories that serve residents ofthe area are preferred. Such systems make possible theanalysis of screening and case data so that rates of elevatedBLLs among screened children can be calculated, trends inBLLs and in service delivery can be detected, and appropri-ate improvements made.

Alternatively, other monitoring methods can be used, such asserial BLL surveys; surveys of knowledge, attitudes, andbehaviors of health-care providers and parents in targetedcommunities; and studies performed by providers and pro-vider groups using chart-review or other methods to ascertainscreening practices.

Public health agencies, Medicaid agencies, and managed-careorganizations have a mutual interest in monitoring screeningdelivered under Medicaid and can share data to achieve thisgoal.

Implementation



6.3. Revise screening recommendations asbetter data become available.

As time passes, screening recommendations may becomeobsolete. Health officials should periodically evaluate therecommendations and revise them as appropriate.

Pediatric health-care providers, medical groups, managed-care organizations, Medicaid agencies, local health depart-ments, and parents may want to vary from recommendationsthat have been made. Health officials should develop areview process to explore background and supporting evi-dence, and to consider the reasons both for retaining and forchanging current recommendations.

Implementation



Revising screening recommendations

Changes in the risk for lead exposure.Change in the condition of older housing stock in a recom-mendation area is a reason to revisit a screening recommen-dation. Such housing may deteriorate or improve, creating achange in the potential risk for exposure to lead.

Additional information for making decisions.Additional BLL data may become available, making it pos-sible to generate better estimates of elevated BLL prevalenceand to use these estimates to refine recommendations,including the recommended personal-risk questionnaire.Better tools for analyzing and presenting data will also bedeveloped, allowing better prediction of risks for lead expo-sure.

Local input.Local medical groups and managed-care organizations mayperform blood lead surveys of their patient populations.Data from such surveys should be carefully evaluated, sincethese data can enhance the local decision-making process.



References

Centers for Disease Control. Preventing lead poisoning inyoung children: a statement by the Centers for DiseaseControl. Atlanta: Department of Health and Human Ser-vices, 1991.

Centers for Disease Control and Prevention. Update: bloodlead levels�United States, 1991-1994. MMWR1997;46:141-6.

Centers for Disease Control and Prevention. Erratum: Vol.46, no.7. MMWR 1997;46:607

Bureau of the Census. 1990 Census of population andhousing. Washington, D.C.: U.S. Department of Commerce,1992.

Elrodt AG, Conner L, Riedinger M, Weingarten S. Measuringand improving physician compliance with clinical practiceguidelines: a controlled interventional trial. Ann Intern Med1995;122:277-82.

Greco PJ, Eisenberg JM. Changing physicians� practices.Pediatrics 1993;329:1271-4.

Green LW, Kreuter MW. Health promotion planning: aneducational and environmental approach. 2nd ed. Toronto:Mayfield Publishing Company, 1991.

References



Lead-Based Paint Hazard Reduction and Financing TaskForce. Putting the pieces together: controlling lead hazardsin the nation�s housing. Washington, D.C.: U.S. Departmentof Housing and Urban Development, 1995.

National Research Council. Measuring lead exposure ininfants, children, and other sensitive populations. Washing-ton, D.C.: National Academy Press, 1993.

Rothenberg SJ, Williams FA Jr, Delrahim S, et al. Blood leadlevels in children in South Central Los Angeles. ArchEnviron Health 1996:51:383-8.

References

7 7Sc r e en in g Young Ch i l d r en f o r Lead Po i s on in g

Chapter 4: Roles of Child Health-Care Providers

4 Roles of Child Health-CareProviders in ChildhoodLead Poisoning Prevention

Roles of Child Health-Care Providers

1. Use and disseminate information from state and localpublic health agencies.

2. Give anticipatory guidance.

3. Perform routine blood lead screening, as recommended.

4. Provide family lead education.

5. Provide diagnostic and follow-up testing for children withelevated BLLs.

6. Provide clinical management for children when appro-priate.

7. Participate in a follow-up team.

8. Collaborate with public health agencies.

7 8 Sc r e en in g Young Ch i l d r en f o r Lead Po i s on in g


In addition to routine screening and follow-upcare, child health-care providers should per-form blood lead testing when children haveunexplained symptoms or signs that are con-sistent with lead poisoning.

Children with lead poisoning can present withseizures, other neurological symptoms, abdomi-nal pain, developmental delay, attention deficit,hyperactivity, other behavior disorders, schoolproblems, hearing loss, or anemia.



Editor�s Note: In the following discussion of the roles ofthe child health-care provider, we provide the roles onleft hand pages, and discussion on the facing right handpages.



1 . Use and disseminate informa-tion from state and local publichealth agencies.

Utilize information supplied by public health agen-cies on:

� Recommended screening.

� Educating families about lead.

� Follow-up care.

� Referral sources.



Information from public health agencies

Public health agencies will make recommendations aboutscreening. These recommendations will be based on localrisk for exposure to lead.

Screening policy should be based on data that are representa-tive of the entire population, and not limited to a providerpractice. Children should be screened according to state andlocal policy.

In the absence of a statewide plan or other formal guidancefrom health officials, universal screening for virtually allyoung children, as called for in the 1991 edition of Prev en t ingLead Poisoning in Young Children (CDC, 1991), should becarried out.

Public health agencies will supply:� Lead-education materials that reflect local policies and

exposure sources.

� Protocols for follow-up care for children with elevatedBLLs. Comprehensive follow-up includes in-home assess-ment, education, environmental investigation, and reduc-tion of lead exposure; supports clinical management; andis discussed in detail in Section 7.

� Referrals to local experts in the treatment of lead-poisoned children, and referrals to additional support-ive services for families.



2. Give anticipatory guidance.

During prenatal care and during preventive care at3-6 months and again at 12 months, provide infor-mation about:

� Hazards of deteriorating lead-based paint in olderhousing.

� Methods of controlling lead hazards safely.

� Hazards associated with repainting and renova-tion of homes built prior to 1978.

� Other exposure sources, such as traditionalremedies.



Anticipatory guidance

Anticipatory guidance should be provided prenatally, whenchildren are 3-6 months of age, and again when they are 12months of age, because parental guidance at these timesmight prevent some lead exposure and the resulting increasein BLLs that often occurs during a child�s second year of life.

When children are 1-2 years of age, parental guidanceshould be provided at well-child visits and when thepersonal-risk questionnaire is administered. (See Section3.3 below.)



3. Perform routine blood lead screen-ing as recommended.

3.1. Sampling method.Screening should be done by a blood lead measurement ofeither a venous or capillary (fingerstick) blood specimen.

3.2 Recommended screening.Follow health-department recommendations on screening. Inthe absence of recommendations from the health depart-ment, screen all children at ages 1 and 2 and children36-72 months of age who have not been previouslyscreened.



Choice of sample collection methodThe choice of a sample-collection method (venipunctureor fingerstick) should be determined by the accuracy oftest results, the availability of trained personnel, conve-nience, and cost. If children�s fingers are cleaned care-fully, capillary (fingerstick) sampling can perform well asa screening tool.

Screening recommendationsUni v e r s a l s c r e e n i n g will be recommended where therisk for lead exposure is widespread.

A sample universal screening recommendation:Using a b l ood l ead t e s t , s c r e en a l l ch i ld r en a t ag e s 1 and2 and a l l c h i l d r en 36 -72 mon th s o f a g e who hav e no tb e e n p r e v i o u s l y s c r e e n e d .

Ta r g e t e d s c r e e n i n g will be recommended where risk isless or is confined to specific geographic areas or tocertain subpopulations.

A sample targeted-screening recommendation:Using a b l ood l ead t e s t , s c r e en ch i ld r en a t ag e s 1 and 2 ,and c h i l d r en 36 -72 mon th s o f a g e who ha v e n o t p r e v i -ou s l y b e en s c r e e n ed , i f t h e y me e t on e o f t h e f o l l ow in gh e a l t h - d e pa r tmen t c r i t e r i a :� Res i d en c e i n a g e o g raph i c a r e a ( e . g . , a s p e c i f i e d z i p

c o d e ) .� Member sh ip in a h i gh - r i sk g roup ( e . g . , Medi ca id

r e c i p i e n t s ) .� Answer s t o a p e r s ona l - r i sk que s t i onna i r e ind i ca t ing risk.



3.3. The personal-risk questionnaire.

In places w i t h t a r g e t e d s c r e e n i n g , the health departmentmay recommend routine use of a questionnaire to helpidentify children who should receive BLL screening.

Such a questionnaire should also be used at times otherthan the routine screening schedule if it is suspected thata child faces increased risk for lead exposure (e.g.,because the family has moved to an older house).



The personal-risk questionnaire

A basic personal-risk questionnaire:

1. Does your child live in or regularly visit a house that wasbuilt before 1950? This question could apply to a facilitysuch as a home day-care center or the home of ababysitter or relative.

2. Does your child live in or regularly visit a house builtbefore 1978 with recent or ongoing renovations or re-modeling (within the last 6 months)?

3. Does your child have a sibling or playmate who has or didhave lead poisoning?

The health department may recommend additional ordifferent questions for soliciting information about localsources of exposure.



3.4. Additional BLL screening.

In addition to recommended routine screening, BLL screen-ing is also indicated when:

� A child�s likelihood of exposure has increased.

� An older child has excessive mouthing behavior or anexposure to lead.

� Parents have knowledge of a child�s lead exposure andrequest screening.



Indications for additional screening

Increased likelihood of exposure. Children�s risk forlead exposure may increase, for example, because the familyhas moved to older housing or to a geographic area with ahigher prevalence of older housing, or because the child livesin an older home that has recently been repaired or reno-vated.

Parental request. Parents may express concern about theirchildren�s potential lead exposure because of residence inolder housing, nearby construction or renovation, an elevatedBLL in a neighbor�s child, or unusual household exposures.Such information may be valuable in highlighting poten-tial exposure. A BLL test should be performed if there isreason to suspect that lead exposure has occurred.



4. Provide family lead education.

Provide families of children with capillary or venous BLLs≥10 µg/dL with prompt and individualized education aboutthe following:

� Their child�s BLL, and what it means.

� Potential adverse health effects of the elevated BLL.

� Sources of lead exposure and suggestions on how toreduce exposure.

� Importance of wet cleaning to remove lead dust on floors,window sills, and other surfaces; the ineffectiveness of drymethods of cleaning, such as sweeping.

� Importance of good nutrition in reducing the absorptionand effects of lead. If there are poor nutritional patterns,discuss adequate intake of calcium and iron and encourageregular meals.

� Need for follow-up BLL testing to monitor the child�sBLL, as appropriate.

� Results of environmental inspection, if applicable.

� Hazards of improper removal of lead-based paint. Particu-larly hazardous are open-flame burning, power sanding,water blasting, methylene chloride-based stripping, and drysanding and scraping.



Family lead education

Education should be reinforced during follow-up visits, asneeded.

Health departments can often furnish educational mate-rials to the health-care provider, including print materialsin various languages.



5. Provide diagnostic and follow-uptesting for children with elevatedBLLs.

5.1 Diagnostic testing.The following schedule is recommended.

Table 4.1. Schedule for diagnostic testing of a child withan elevated BLL on a screening test

* The higher the screening BLL, the more urgent the need for a diagnos-tic test.

fotluserfItsetgnineercs

(µ :si)Ld/g

tsetcitsongaidmrofrePnihtiwdoolbsuonevno :

91-01 shtnom3

44-02 *keew1-htnom1

95-54 sruoh84

96-06 sruoh42

rehgihro07nasayletaidemmItsetbalycnegreme



Diagnostic testing

A diagnostic test is the first venous BLL test performedwithin 6 months on a child with a previously elevated BLLon a screening test. If the diagnostic test is not performedwithin 6 months, the next test is considered a new screeningtest, and decisions about follow-up testing should be madeon the basis of the new test, and not on the basis of theoriginal screening test.

It is relatively common for children to have slightly elevatedscreening test results that do not persist on additional testing.For this reason, it is preferable to base interventions on theresults of diagnostic testing.

Exception to the recommended schedule

If a child with an elevated screening test result is lessthan 12 months old, or if there is reason to believe that achild�s BLL may be increasing rapidly, consider perform-ing the diagnostic test sooner than indicated in theaccompanying schedule.



5.2. Follow-up testing for children with elevateddiagnostic BLLs.

� Children with diagnostic BLLs of 10-14 µg/dL shouldhave at least one follow-up test within 3 months.

� Children with diagnostic BLL tests of 15-19 µg/dL shouldhave a follow-up test within 2 months.

� If the result of follow-up testing is ≥20 µg/dL, or if thechild has had two or more venous BLLs of 15-19 µg/dL atleast 3 months apart, the child should receive clinicalmanagement (see next section).

� Children with diagnostic BLLs ≥20 µg/dL should receiveclinical management, which includes additionalfollow-up testing (see next section).



Follow-up testing

A follow-up test is a venous BLL test used to monitor thestatus of a child with an elevated diagnostic BLL test.

Regular measurement of the BLL of a child with an elevateddiagnostic test result is important because the BLL maycontinue to rise. Rising BLLs are especially likely inchildren 6 months to 2 years of age because this is theage group in which mouthing behavior is most frequent.



6. Provide clinical management forchildren when appropriate.

Clinical management includes:

6.1. Clinical evaluation for complications of leadpoisoning.

6.2. Family lead education and referrals.

6.3. Chelation therapy, if appropriate.

6.4. Follow-up testing at appropriate intervals.



Clinical management

Clinical management is part of comprehensive follow-up careand is defined as the care that is usually given by a health-care provider to a child with an elevated BLL.

Office visits for clinical management should be comple-mented by activities that take place in the child�s home, suchas home visits by a nurse, social worker, or community healthworker; environmental investigation; and control of leadhazards identified in the child�s environment.

See Table 4.3. for a summary of comprehensive follow-upcare.

Note: The accompanying recommendations aboutclinical management are based on the experience ofclinicians who have treated lead-poisoned children.They should not be seen as rigid rules and should beused to guide clinical decisions.



6.1 Perform a clinical evaluation.

Table 4.2. Clinical evaluationMedical history.Ask about:� Symptoms.� Developmental history.� Mouthing activities.� Pica.� Previous BLL measurements.� Family history of lead poisoning.Environmental history.Ask about:� Age, condition, and ongoing remodeling or repainting of

primary residence and other places that the child spendstime (including secondary homes and day-care centers).Determine whether the child may be exposed to lead-basedpaint hazards at any or all of these places.

� Occupational and hobby histories of adults with whom thechild spends time. Determine whether the child is beingexposed to lead from an adult�s workplace or hobby.

� Other local sources of potential lead exposure.Nutritional history.� Take a dietary history.� Evaluate the child�s iron status using appropriate labora-

tory tests.� Ask about history of food stamps or WIC participation.Physical examination.Pay particular attention to the neurologic examination andto the child�s psychosocial and language development.



Clinical evaluation

Medical history. Developmental progress should bemonitored carefully. If there are delays or lags, the childshould be referred to an early intervention program forfurther assessment.

Environmental history. State and local health depart-ments may provide additional questions about local exposuresources.

Nutritional status. Identified nutritional problems shouldbe corrected.

� Deficiencies of calcium and iron may increase lead absorp-tion or toxicity.

� A diet high in fat may result in increased lead absorption.

� Because more absorption of lead may be increased whenthe stomach is empty, the scheduling of smaller and morefrequent meals may be helpful.

Physical examination. Findings of language delay orother neurobehavioral or cognitive problems shouldprompt referral to appropriate programs. Children mayneed early intervention programs and further examina-tions during the early school years to facilitate entry intoan appropriate educational program.

1 0 0 Sc r e en in g Young Ch i l d r en f o r Lead Po i s on in g


6.2. Provide family lead education andreferrals.

See Section 4 for topics that should be covered as part offamily lead education.

Refer children for appropriate social services if problemssuch as inadequate housing, lack of routine health care, orneed for early intervention educational services are discov-ered.

1 0 1Sc r e en in g Young Ch i l d r en f o r Lead Po i s on in g


Family lead education and referrals

The first opportunity to educate families about the causesand consequences of a child�s elevated BLL usually occurs inthe health-care provider�s office. Health-care providersshould discuss both short-term repercussions of elevatedBLLs (e.g., the need for follow-up testing and treatment, theneed to control lead hazards in the child�s environment) andlong-term repercussions (e.g., the potential for future learningproblems, the availability of early-intervention services).

Health departments may provide printed materials,flipcharts, and videos that can assist in the family-educa-tion process.

The health department may also provide referral sources,such as social-service agencies, parent-support groups, andhousing services.



6.3. Provide appropriate chelation therapy.

A child with a BLL ≥45 µg/dL should be treated promptlywith appropriate chelating agents and be removed fromsources of lead exposure.

BLL testing for children undergoing chelation.Before chelation therapy is initiated, a child with a BLL <70µg/dL should have a second BLL test, performed on avenous specimen, to ensure that therapy is based on the mostrecent and reliable information possible. Children withscreening BLLs of 60-69 µg/dL should have a venous BLLtest within 24 hours.

Children with BLLs ≥70 µg/dL should have an urgent repeatBLL test, but chelation therapy should begin immedi-ately, and not be delayed until the test result is available.

A child who is receiving chelation therapy should be tested atleast once a month. When chelation is terminated, BLLsshould be monitored frequently until sources of lead expo-sure have been identified and addressed.



Chelation therapy

Chelation therapy should be initiated immediately for allchildren with an initial screening-test result that is ≥70µg/dL. If such an elevated BLL is obtained on a fingersticksample, the health-care provider should order an immediatediagnostic test and consider initiating chelation while thattest is being performed, i f th e r e i s r eason to be l i e v e tha tth e r e su l t s o f th e s c r e en ing t e s t a r e a c cura t e ( e . g . , i f i twa s ob ta in ed b y a sk i l l e d ph l e bo t omi s t und e r c on t r o l l e dc o n d i t i o n s ) .



6.4. Provide follow-up BLL testing atappropriate intervals.

Children who are receiving clinical management should betested at 1- to 2-month intervals until these three conditionsare met:

1) The BLL has remained <15 µg/dL for at least 6 months,and

2) Lead hazards, e.g., chipping, peeling, lead-based paint,traditional remedies, etc., have been removed, and

3) There are no new exposures.

When these conditions are met, children should be testedapproximately every 3 months.

Children for whom these three conditions are met and whohave reached 36 months of age no longer need to receivefollow-up testing.



Follow-up testing

A follow-up test is a venous BLL test used to monitor thestatus of a child with an elevated BLL on a diagnostictest.

Children who are receiving clinical management shouldreceive follow-up testing to monitor the effectiveness ofservices they receive (e.g., lead education, home visitationand environmental investigation, lead-hazard control, chela-tion therapy).



7. Participate in a follow-up team.

Table 4.3. Comprehensive follow-up services, accordingto diagnostic* BLL

* A diagnostic BLL is the first venous BLL obtained within 6 months of an elevated screening BLL.

LLB(µ )Ld/g

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91-51

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.yrassecenfi,secivreslaicosrofrefeRtaegnarsihtnisLLBsuonev2,.e.i(tsisrepsLLBfI

otgnidroccadeecorp,nesrowro)trapashtnom3tsael.44-02sLLBrofsnoitca

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.noitagitsevnilatnemnorivneedivorP.lortnocdrazah-daeledivorP

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,)txetnidebircsed(tnemeganamlacinilc,)tnemeganam.lortnocdrazahdaeldna,noitagitsevnilatnemnorivne

07 rorehgih

tnemtaertlacidemnigebdnadlihcezilatipsoHesac(eracfonoitanidroocnigeB.yletaidemmi

,)txetnidebircsed(tnemeganamlacinilc,)tnemeganamlortnocdrazah-daeldna,noitagitsevnilatnemnorivne

.yletaidemmi



The follow-up team and comprehensive follow-up services

Comprehensive services are best provided by a team thatincludes the health-care provider, care coordinator, com-munity-health nurse or health advisor, environmentalspecialist, social services liaison, and housing specialist.Coordination of care, environmental services (i.e., identi-fying and controlling sources of lead exposure) and reloca-tion to safe housing are typically provided or coordinatedby the health department.

Because childhood lead exposure is likely to beassociated with poor and deteriorating communities,children with elevated BLLs may also have problemssuch as inadequate housing, lack of routine medicalcare, and poor nutrition. Children may also neededucational services, and the team may be instrumen-tal in ensuring that children with a history of elevatedBLLs receives early intervention or special educationservices for which they are eligible.



8. Collaborate with public healthagencies.

Health departments and child health-care providers shouldinteract in a number of ways:

� They should exchange information on local exposures tolead.

� Providers should put complete information on laboratoryBLL test-requisition slips and should report childrenwith elevated BLLs to the health department, as re-quired.

� Health departments should collect lab data, analyze it, andprepare reports for providers and the public.

� Providers should encourage health departments to reviewdata and to adjust screening recommendations as neces-sary.



Working with the health department

Some states require that laboratories report the results of allchildren�s BLL tests, along with demographic and addressinformation. These reports are the foundation of BLLsurveillance systems and depend on complete and accurateinformation being placed on the lab slip by the provider.

On the basis of surveillance information and other informa-tion from health-care providers, state and local health depart-ments will be able to review and improve screening recom-mendations so that they are as effective as possible.


Chapter 5: Resources

5CDC Resources and Information for Implemen- tation of Guidance

The guidance in this document calls upon state and localhealth departments to use data and an inclusive process todevelop screening recommendations. Some health depart-ments are already carrying out this process. Others will needsupport for additional efforts. CDC provides resources andsupport to health departments to ensure that this guidance isimplemented in an effective and timely way.

Statewide plan. CDC gives technical assistance to healthdepartments in the statewide planning process and in thedissemination of screening recommendations.

Census data. U.S. census data are available from manysources. CDC offers assistance in analyzing and displayingthese data, and, with other Federal agencies, has future plansto make appropriate parts of the census data files available onthe Internet to support lead poisoning preventionactivities.

Grant program. CDC provides funding to states andlocalities through the State and Community-Based ChildhoodLead Poisoning Prevention Program grants for screening, forensuring that follow-up care takes place, and for lead educa-tion and monitoring and surveillance activities. In the future,CDC will support grantees in developing and disseminatingscreening recommendations.



Blood lead surveillance data. CDC assists state andlocal lead programs in collecting, managing, analyzing, anddisseminating surveillance data, and in evaluating the useful-ness of these data for statewide planning.

Outreach and communication. CDC provides materi-als and technical assistance to health departments to aidthem in communications with other agencies, child health-care providers, managed-care organizations, and the public.For example, CDC provides a prototype for a handbook forhealth-care providers. (See Section A)

List of additional information available from CDC.

A. Support for child health-care providers: aprototypic handbook for providers. For use byhealth departments in preparing materials for health-careproviders, this template includes background informationand space for additional state and local materials such asstate policies, screening recommendations, patient-education brochures, and local referral sources.

B. Developing a statewide plan: materials forexamining and analyzing data and makingscreening recommendations. For use by state andlocal health officials and epidemiologists, and their advi-sors in decision making, these materials provide importantbackground.

B.1 Update: Blood Lead Levels�United States, 1991-1994. Morbid-ity and Mortality Weekly Report, February 21, 1997. MMWRarticle containing data from Phase 2 of the Third Na-tional Health and Nutrition Examination Survey



(NHANES III), from 1991 to 1994.

B.2 Brody DJ, Pirkle JL, Kramer RA, et al. Blood lead levels inthe U.S. population: phase 1 of the Third National Health andNutrition Examination Survey (NHANES III, 1988 to 1991).JAMA 1994;272:277�83.

B.3 Pirkle JL, Brody DJ, Gunter EW, et al. The decline in bloodlead levels in the United States: the National Health and Nutri-tion Examination Surveys (NHANES). JAMA1994;272:284�91.

B.4 Costs and benefits of a universal screening program for elevatedblood lead levels in 1-year-old children. Cost-benefit analysisperformed by scientists within and outside CDC.

B.5 Relationship between prevalence of BLLs >10 µg/dL andprevalences above other cut-off levels. Table of expectedproportions of children with BLLs higher than selectedthresholds, given different prevalences of elevated BLLs.

B.6 Exact confidence intervals for some hypothetical estimates ofprevalence of BLLs >10 µg/dL, by number of children screened.

B.7 Conditions required for a source of lead to be a lead hazard.

B.8 Samples of Medicaid contract language on childhood blood leadscreening.

B.9 List of studies of effectiveness of personal-risk questionnaires forselecting children for blood lead screening.



C.C.C.C.C. Materials for Laboratorians Materials for Laboratorians Materials for Laboratorians Materials for Laboratorians Materials for Laboratorians

C.1 The lead laboratory. A summary of laboratory issues,including quality assurance and accreditation.

C.2 Capillary blood sampling protocol.

C.3 Proficiency testing and quality control.

Table A: Proficiency Testing Programs for LeadLaboratories

Table B: Quality Control Materials for Use inBlood Lead Testing

Table C: Quality Control Materials for Use inUrine Lead Testing

Table D: Quality Control Materials forErythrocyte Protoporphyrin Tests


Chapter 6: Research Priorities

6Childhood Lead PoisoningPrevention ResearchPriorities

If we are to improve lead poisoning prevention strategies, weneed additional research in the following areas:

1) Effectiveness of interventions aimed at preventing orreducing elevated BLLs and their adverse health effectsamong children, including studies of:

� The effectiveness and cost effectiveness of interven-tions to control lead hazards in housing.

� The effectiveness of family education about leadpoisoning prevention in preventing BLLelevations or in reducing already elevated BLLs.

� The effectiveness of chelation therapy in preventing orreducing neurobehavioral effects of elevated BLLs,especially among children with modestly elevatedBLLs.

2) Barriers to screening and other lead poisoning preventionactivities, especially in places with high prevalences ofelevated BLLs.


Chapter 6: Research Priorities

3) Prediction of places with high and low prevalences ofelevated BLLs. Such information could be used to allocateresources and target efforts.

4) Methods of identifying individual children with BLLs≥20 µg/dL including research on the use of the personal-risk questionnaire.

5) The impact of new laboratory methods, including hand-held and clinic-based BLL analyzers, on preventionprograms and BLL monitoring.

6) The contribution to elevated BLLs in children of nonpaintsources of lead exposure, including studies of exposure tolead taken home from workplaces of adults.


Glossary

Specific to this document

Anticipatory guidance is theeducation provided to parents orcaretakers during a routineprenatal or pediatric visit toprevent or reduce the risk thattheir fetuses or children willdevelop lead poisoning.

In general, anticipatory guidancefor lead should include informa-tion about the dangers ofdeteriorating lead-based paint inhomes and of improper renova-tion or remodeling that disturbslead-based paint.

A blood lead level (BLL) is theconcentration of lead in a sampleof blood. This concentration isusually expressed in microgramsper deciliter (µg/dL) or micromoles per liter (µmol/L). One µg/dL is equal to 0.048 µmol/L.

General

Anticipatory guidance is theeducation provided to parents orcaretakers during a routineprenatal or pediatric visit toprevent or reduce the risk thattheir fetuses or children willdevelop a particular healthproblem.

Assessment is the process,usually carried out or coordinatedby a public health agency, ofdetermining the nature and extentof hazards and health problemswithin a jurisdiction.

GlossaryIncluded below are two sets of definitions. One set is generallyused in public health, child health care, and preventive medi-cine. The second set is specific to this document.


Glossary

Care coordination is the formalcoordination of the care of a childwith a BLL that exceeds a specificvalue—as determined by local orstate officials—and the assurancethat services needed by that childare provided.

Clinical management is thecare of a child with an elevatedBLL that is usually performed by achild health-care provider. Itincludes 1) clinical evaluation forcomplications of lead poisoning; 2)family lead education and referrals;3) chelation therapy, if appropriate;4) follow-up testing at appropriateintervals.

A diagnostic test is the firstvenous blood lead test performedwithin 6 months on a child who haspreviously had an elevated BLL ona screening test.

A follow-up test refers to ablood lead test used to monitor thestatus of a child with a previouslyelevated diagnostic test for lead.

A diagnostic test is a laboratorytest used to determine whether aperson has a particular healthproblem.

A follow-up test is a laboratorytest for the purpose of monitoringthe care of a person with aparticular health problem.

Specific to this documentGeneral


Glossary

A jurisdiction is the geographicarea over which a state or localgovernment has political authority.Counties and incorporated places,such as cities, boroughs, towns, andvillages, are examples ofjurisdictions. One jurisdiction maylie partially or totally within another,such as a county within a state.

A place is any geographic area.

Prevalence is the percentage of apopulation with a particularcharacteristic.

Primary prevention is theprevention of an adverse healtheffect in an individual orpopulation. One method ofaccomplishing this is reducing oreliminating a hazard in theenvironment to which an individualor population is exposed.

A lead poisoning preventionprogram is an organized set ofactivities, including primary andsecondary prevention activities, toprevent childhood lead poisoning.

A personal-risk questionnaireis administered by a child health-care provider to the parents orguardians of a young child to helpdetermine whether that child is atincreased risk of having an elevatedBLL. The personal-riskquestionnaire is one component ofan individual risk evaluation.

General Specific to this document

Prevalence is the percentageof a population with an elevatedBLL.


Glossary

A recommendation area is aplace for which a public healthagency makes a recommendation onhow to screen resident children forlead poisoning. A recommendationarea can be a country, state, county,city, or other place.

BLL screening for lead poisoningis the routine measurement of BLLsin asymptomatic children.

A screening program for leadpoisoning is BLL screening, thediagnostic evaluation of childrenwith elevated BLLs, and theprovision of educational,environmental, medical, and otherservices to children found to haveelevated BLLs. A screeningprogram is one component of achildhood lead poisoningprevention program.

Screening is a method, usuallyinvolving a physical examination ora laboratory test, to identifyasymptomatic individuals as likely,or unlikely, to have a particularhealth problem.

A screening program consistsof screening for a health problem, adiagnostic evaluation for those withpositive screening-test results, andtreatment for those in whom thehealth problem is diagnosed.

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Glossary

A screening test is a laboratorytest to identify asymptomaticindividuals as likely or unlikely tohave a particular health problem.

Secondary prevention is theprevention or slowing of theprogression of a health problem inaffected individuals.

A screening test for leadpoisoning is a laboratory test forlead that is performed on the bloodof an asymptomatic child todetermine whether the child has anelevated BLL.

Secondary prevention is theidentification of children withelevated BLLs and the preventionor reduction of further exposure ofthose children to lead.

Targeted screening is the BLLscreening of some, but not all,children in a recommendation area.The selection of children to bescreened is based on the presenceof a factor that places these childrenat increased risk for lead exposure.

Universal screening is the BLLscreening of all children at ages 1and 2 in a recommendation area.

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guidance for state and local public health officialschapter 2. a comprehensive approach to childhood...

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