sening Young Children )r Lead Poisoning: Guidance for State and Loca Public Health Officials Centers for Disease Control and Prevention November 1997 CDC CENTERS FOR DISEASE CONTROL AND PREVENTION Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials Centers for Disease Control and Prevention David Satcher, M.D., Ph.D., Director National Center for Environmental Health Richard J. Jackson, M.D., Director Division of Environmental Hazards and Health Effects Henry Falk, M.D., Director Lead Poisoning Prevention Branch Jerry Hershovitz, Chief Nancy Tips, Associate to the Chief for Planning and Evaluation U.S. Department of Health and Human Services, Public Health Service November 1997 Suggested reference: Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Atlanta; CDC, 1997. Contents Foreword v Preface 1 Advisory Committee on Childhood Lead Poisoning Prevention 4 Executive Summary 9 Chapter 1. Childhood Lead Poisoning in the United States 13 Chapter 2. A Comprehensive Approach to Childhood Lead Poisoning Prevention 21 Chapter 3. The Statewide Plan for Childhood Blood Lead Screening 31 Chapter 4. Roles of Child Health-Care Providers in Childhood Lead Poisoning Prevention 77 Chapter 5. CDC Resources and Information for Implementation of Guidance Ill Chapter 6. Childhood Lead Poisoning Prevention Research Priorities 115 Glossary 117 Screening Young Children for Lead Poisoning i List of Tables and Figures Table 1.1. Quantity and percentage of U.S. housing built before 1950, by state 15 Table 2.1. Assessing children’s exposure to lead 22 Table 2.2. Childhood lead poisoning prevention activities and 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 with DLLs >10 by year house built, and geometric mean BLL, by year house built, U.S., 1991-1994 39 Table 3.2. Percentage of children with BLLs >10 by race/ethnicity and income, U.S., 1991- 1994 41 Table 3.3. Percentage of children ages 1-11 years with 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 with an elevated BLL on a screening test 92 ii Screening Young Children for Lead Poisoning Table 4.2. Clinical evaluation 98 Table 4.3 Comprehensive follow-up services, according to diagnostic BIX 106 Figure 1.1. Geometric mean blood lead levels of children ages 1-5 years in the U.S.: NHANESII and III 17 Figure 3.1. Housing built before 1950 in South Carolina: geographic analysis at three different levels-county, zip code, and census tract 59 Screening Young Children for Lead Poisoning Hi iv Screening Young Children for Lead Poisoning Foreword We find ourselves at a crossroads. On the one hand, blood lead levels in the U.S. population continue to decline, offering the hope that lead poisoning can be eliminated in the not too distant future. On the other hand, children, who are most vulnerable to the harmful effects of lead, continue to be exposed to this toxicant at an unacceptable rate. Some 890,000 U.S. children have lead levels high enough to cause adverse effects on their ability to leam, mainly because of exposure to deteriorating lead-based paint in their homes. To better protect our children, we must step up our efforts to identify those with elevated blood lead levels so that they can receive the care they need. At present, too many children with elevated lead levels are not being identified. More effective screen- ing is necessary and must be focused where children are most likely to benefit. The policy outlined in this document has two main purposes: to increase screening and follow-up care of 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 of risk for lead exposure may not justify the screening of all children. In many other places, more screening than is cur- rently being done will be necessary. The process described in the pages that follow will succeed or fail to the extent that it is embraced by state and local health departments, Medicaid agencies, health-care providers, Screening Young Children for Lead Poisoning V and other community members. Chapter 3 contains our recommendations for developing screening that is responsive to community situations and needs. We believe that the community should be involved in planning and carrying out screening, and we have tried to outline a process that is easy to follow, even though it involves complex decisions. The Centers for Disease Control and Prevention (CDC) will continue to support state and local public health agencies as they lead the development of statewide screening plans, and our agency stands ready to guide and encourage communities in all facets of lead poisoning prevention. In its effort to combat lead poisoning among children, CDC works with other Federal agencies, especially the Department of Housing and Urban Development (HUD) and the Environmental Protection 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 time and talents to this guidance. I believe that the approach described in these pages will move the nation closer to its goal of eliminating childhood lead poisoning. Certainly, the children of this nation deserve no less. RichardJ. Jackson, M.D., M.P.H. Director National Center for Environmental Health vi Screening Young Children for Lead Poisoning J| reface This guidance on childhood lead screening was devel- oped by CDC in consultation with the members and consultants of the Advisory Committee on Childhood Lead Poisoning Prevention. The committee comprises non- Federal experts drawn from health departments, pediatric practices, managed-care organizations, academia, and non-governmental agencies working on affordable hous- ing and public lead poisoning prevention education. The guidance was also reviewed by childhood lead poisoning prevention program managers and was available during a 6-week period for public comment. The final document is from CDC and does not necessarily reflect the views of all members of the advisory committee. In 1991, the U.S. Public Health Service (PHS) called for a society-wide effort to eliminate childhood lead poisoning in 20 years (CDC, 1991), and in 1997, PHS remains com- mitted to this goal. Childhood lead screening should be part of a comprehensive program to reach this goal. Chapter 3 of this document discusses the development of statewide plans for childhood blood lead screening. The purpose of these plans is to increase the screening and follow-up care of children who most need these services and to ensure that screening is appropriate for local conditions. The main intended audience for this guidance is state and local health officials; however, it may also be used by Screening Young Children for Lead Poisoning 1 child health-care providers, managed-care organizations, and others. Several topics are not covered or are considered only briefly in this document. Some of these topics have been 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 of Housing and Urban Development, 1995). • National policy for controlling lead hazards in housing (Lead-Based Paint Hazard Reduction and Financing Task Force, 1995). The continued expansion of knowledge about childhood lead poisoning prevention will be reflected in future changes in CDC guidance. References American Academy of Pediatrics Committee on Drugs. Treatment guidelines for lead exposure in children. Pediatrics 1995;96:155-60. 2 Screening Young Children for Lead Poisoning Centers for Disease Control. Strategic plan for the elimination of childhood lead poisoning. Atlanta: Department of Health and Human Services, 1991- Lead-Based Paint Hazard Reduction and Financing Task Force. Putting the pieces together: controlling lead hazards in the nation’s housing. Washington, D.C.: U.S. Department of Housing and Urban Development, 1995. National Research Council. Measuring lead exposure in infants, 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 of lead-based paint hazards in housing. Washington, D.C.: HUD, 1995. Screening Young Children for Lead Poisoning 3 Advisory Committee on Childhood Lead Poisoning Prevention Chairperson J. Routt Reigart, II, MD Professor of Pediatrics Medical University of South Carolina 171 Ashley Avenue Charleston, SC 29425 Executive Secretary Henry Falk, MD Director, Division of Environmental Hazards and Health Effects National Center for Environmental Health Centers for Disease Control and Prevention Atlanta, GA 30341-3724 Members Isabella J. Clemente, CPNP Associate Director, Division of Environmental Sciences Pediatric Clinics Montefiore Medical Center Moses 401 111 East 210th Street Bronx, NY 10467 Cushing N. Dolbeare Consultant on Housing and Public Policy 215 Eighth Street, NE Washington, DC 20002-6105 Alvaro Garza, MD, MPH Health Officer, Stanislaus County 820 Scenic Drive Modesto, CA 95350 4 Screening Young Children for Lead Poisoning Rita Marie Gergely Director, Lead Poisoning Prevention Programs Iowa Department of Public Health Lucas State Office Building Des Moines, IA 50319-0075 Andrew K. Goodman, MD Assistant Commissioner, Division of Community and Occupational Health New York City Department of Health 125 Worth Street New York, NY 10013 Birt Harvey, MD Pediatrician 101 Alma Street, #1201 Palo Alto, CA 94301-1011 Sanders Francis Hawkins, PhD Director, Laboratory Services Connecticut Department of Public Health 10 Clinton Street Hartford, CT 06106 Patricia L. McLaine, BSN, MPH Assistant Director for Program Management National Center for Lead-Safe Housing 10227 Wincopin Circle Columbia, MD 21044 Janet A. Phoenix, MD, MPH Manager, Public Health Programs National Safety Council National Lead Information Center 1019 19th Street, NW Washington, DC 20036-5105 Screening Young Children for Lead Poisoning 5 Joel D. Schwartz, PhD Associate Professor, Environmental Epidemiology Harvard School of Public Health 665 Huntington Avenue Boston, MA 02115 Roger F. Suchyta, MD Associate Executive Director American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL 60009-0927 Consultants J. Julian Chisolm, Jr., MD Director, Lead Poisoning Prevention Program Kennedy Kreiger Institute 707 North Broadway Baltimore, MD 21205 Charles G. Copley Director, Department of Community Health and the Environment St. Charles County Department of Community Health 305 N. Kings Highway St. Charles, MO 63301 Andrew M. Davis, MD, MPH Associate Medical Director, Rush Prudential Health Plans 233 Wacker Drive Suite 3900 Chicago, IL 60606 Dwala S. Griffin Administrator, Division of Health Services Louisville-Jefferson County Health Department 400 East Gray Street ■ Louisville, KY 40202 Screening Young Children for Lead Poisoning 6 Philip J. Landrigan, MD Chairman, Department of Community Medicine Director, Division of Environment and Occupational Medicine Mount Sinai Medical Center New York, NY 10029 Herbert L. Needleman, MD Professor of Psychiatry and Pediatrics Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine 3600 Forbes Avenue Pittsburgh, PA 15213-2593 Patrick Jeremy Parsons, PhD Director, Lead Poisoning Laboratory Wadsworth Center for Laboratories and Research New York State Department of Health Albany, NY 12201-0509 Sergio Piomelli, MD Director, Division of Pediatric Hematology and Oncology Columbia University Babies Hospital 3959 Broadway New York, NY 10032 Stephanie L. Pollack, JD Conservation Law Foundation of New England 62 Summer Street Boston, MA 02110-1008 Lewis Bradford Prenney Director, Childhood Lead Poisoning Prevention Program Massachusetts Department of Public Health 470 Atlantic Avenue Boston, MA 02110 Screening Young Children for Lead Poisoning 7 Thomas L. Schlenker, MD Executive Director Salt Lake City-County Health Department 2001 South State Street, S-2500 Salt Lake City, UT 84190-2130 Peter Simon, MD, MPH Assistant Medical Director Division of Family Health Rhode Island Department of Health 3 Capitol Hill, Room 302 Providence, RI 02908 Screening Young Children for Lead Poisoning 8 Summary Childhood lead poisoning is a major, preventable environ- mental health problem. Blood lead levels (BLLs) as low as 10 are associated with harmful effects on children’s learning and behavior. Very high BLLs (>70 pig/dL) cause devastating health consequences, including seizures, coma, and death. It is currently estimated that some 890,000 U.S. children have BLLs >10 (CDC, 1997). Since the virtual elimination of lead from gasoline, lead- based paint hazards in homes are the most important remaining source of lead exposure in U.S. children. In 1991, the U.S. Department of Health and Human Services called for elimination of childhood lead poisoning and in 1997 retains its commitment to see this effort through. Blood lead screening is an important element of a comprehensive program to eliminate childhood lead poisoning. The goal of such screening is to identify children who need individual interventions to reduce their BLLs. The 1991 edition of Preventing Lead Poisoning in Young Children called for virtually universal screening of children 12-72 months of age. Nonetheless, a 1994 national survey showed that only about one-fourth of young children had been screened and only about one-third of poor children, who are at higher risk of lead exposure than other children, had been screened. Some populations of children are heavily exposed to lead while others are not. A recent national estimate Screening Young Children for Lead Poisoning 9 (CDC, 1997) showed that 21.9% of black children living in housing built before 1946 had elevated BLLs (>10 pg/dL). Studies of other groups of children have shown quite low prevalence of elevated BLLs. For example, a 1994 survey of 967 poor children in Alaska found that none had a BLL above 11 pg/dL (Robin et al., 1997). Many children, especially those living in older housing or who are poor, need screening and, if necessary, appropriate interventions to lower their BLLs. At the same time, children living where risk for lead exposure has been demonstrated to be extremely low do not all need to be screened. The task for public health agen- cies, parents, and health-care providers is to identify those children who will benefit from screening and to ensure that they receive the services they need. CDC Recommendations - Statewide Plan State health officials should develop a statewide plan for childhood lead screening and convene an inclusive planning committee composed of child health-care providers as well as representatives from local health departments, 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. 10 Screening Young Children for Lead Poisoning A Basic Targeted-Screening Recommendation State health officials should use this basic recommenda- tion only as an interim measure. A recommendation that is based on assessment of local data and an inclusive planning process is preferred. Within the state or locale for which this recommendation is made, child health-care providers should use a blood lead test to screen children at ages 1 and 2, and children 36-72 months of age who have not previously been screened, if they meet one of the following criteria: • Child resides in one of these zip codes: [place here a list of all zip codes in the state or jurisdiction that have >27% of housing built before 1950. This information is available from the U.S. Census Bureau.] • Child receives services from public assistance programs for the poor, such as Medicaid or the Supplemental Food Program 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 questionnaire consisting of these three questions: -Doesyour child live in or regularly visit a house that was built before 1950? This question could apply to a facility such as a home day-care center or the home of a babysitter or relative. -Doesyour child live in or regularly visit a house built before 1978 with recent or ongoing renovations or re- modeling (within the last 6 months)? -Does your child have a sibling or playmate who has or did have lead poisoning? Screening Young Children for Lead Poisoning 11 In the absence of a statewide plan or other formal guidance from health officials, universal screening for virtually all young children, as called for in the 1991 edition of Preventing Lead Poisoning in Young Children (CDC, 1991), should be carried out. CDC provides funding and technical advice to assist states and locales in all activities that are called for in this guidance document. In this document, CDC also provides general guidelines about the roles and responsibilities of child health-care providers in preventing childhood lead poisoning, including anticipatory guidance, 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: blood lead 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, Seller M, Middaugh JP. Statewide assessment of lead poisoning and exposure risk among children receiving Medicaid services in Alaska. Pediatrics 1997;99:E91-E96. 12 Screening Young Children for Lead Poisoning 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 environmental health problem in the United States. Blood lead levels (BLLs) as low as 10 are associated with harmful effects on children’s ability to learn. Very high BLLs (>70 jig/dV) can cause devastating health consequences, including seizures, coma, and death. It is currently estimated that some 890,000 U.S. children have BLLs >10 pig/dl (CDC, 1997). Lead exposure. Children can be exposed to lead in many ways. Sources of exposure include lead-based paint and industrial 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 all contribute to childhood lead exposure. Lead-contaminated house dust, ingested in the course of normal hand-to-mouth activity, is of major significance. House dust is most often contaminated by lead-based paint in the home, when such paint is peeling, deteriorating, or scattered about during home renovation or preparation of painted surfaces for repainting. Housing with lead-based paint. Lead-based paint in homes is the most important remaining source of lead expo- sure for U.S. children. Substantial progress has been made in reducing other environmental sources of lead exposure, especially from gasoline and food. But 83% of all homes built in the United States before 1978 still contain some lead- Screening Young Children for Lead Poisoning 13 Chapter 1: Childhood Lead Poisoning based paint at a concentration of at least one mg/cm2 (U.S. Environmental Protection Agency, 1995). The older the house, the more likely it is to contain lead-based paint and to have a higher concentration of lead in the paint. Housing built before 1950 poses the greatest risk of exposure to children. Such housing is present in every state. (Table 1.1.) Even states with low overall rates of older housing have areas that contain predominately older housing. Temporal trend of elevated BLLs in children. Average DLLs for the population as a whole have declined dramati- cally since the 1970s. As shown in Figure 1.1., the geometric mean BLLs for children ages 1-5 years declined from 15.0 jig/dL during 1976-1980 (Mahaffey et al., 1982) to 2.7 Vg/dL during 1991-1994 (CDC, 1997). 14 Screening Young Children for Lead Poisoning Chapter 1: Childhood Lead Poisoning Table 1.1. Quantity and percentage of U.S. housing built before 1950, by state State Total Housing Units Housing Units Built Before 1950 Built Before 1950 (%) 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 1 Idaho 413,327 100,738 24.4 1 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 j 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 i Minnesota 1,848,445 585.539 31.7 Mississippi 1,010,423 167,685 16.6 Missouri I 2,199,129 629,868 28.6 Screening Young Children for Lead Poisoning 15 Chapter 1: Childhood Lead Poisoning Table 1.1. (Continued) State Total Housing Units Housing Units Built Before 1950 Built Before 1950 (%) 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 United States 102,263,678 27,508,653 26.9 Source: 1990 U.S. census 16 Screening Young Children for Lead Poisoning Chapter 1: Childhood Lead Poisoning Figure 1.1. Geometric mean blood lead levels of children ages 1-5 years in the United States: NHANESII and III Screening Young Children for Lead Poisoning 17 Chapter 1: Childhood Lead Poisoning Distribution of elevated BLLs among children. Some populations of children are heavily exposed to lead while others are not. For example, a recent national estimate (CDC, 1997) showed that 21.9% of black children living in housing built before 1946 had elevated BLLs Studies of other groups of children have shown quite low prevalence of elevated BLLs. For example, a 1994 survey of 967 poor children in Alaska found that none had a BLL above 11 (Robin et al., 1997). Blood-lead screening of children. If we are to elimi- nate childhood lead poisoning, a comprehensive approach is necessary. (See Chapter 2.) Blood lead screening is an important element of such an approach. The goal of screen- ing is to identify children who need individual interventions to reduce their BLLs. The 1991 edition of Preventing Lead Poisoning in Young Children called for virtually universal screen- ing of children 12-72 months of age. Nonetheless, a 1994 national survey showed that many children who are at risk for lead exposure are not being screened (Binder et al., 1996). According to the survey, only about 24% of young children had been screened; fewer than one-third of those at increased risk for lead exposure because of poverty or residence in older housing had been screened. Current situation. Many children, especially those living in older housing or who are poor, are still being harmed by the effects of lead exposure. These children need screening and, if necessary, appropriate interventions to lower their BLLs. At the same time, children in places with populations that are known to be at extremely low risk for lead exposure do not all need to be screened. The task for public health agencies, parents, and health-care providers is to identify 18 Screening Young Children for Lead Poisoning Chapter 1: Childhood Lead Poisoning those children who will benefit from screening and to ensure that they receive the services they need. References Binder S, Matte TD, Kresnow M, Houston B, Sacks JJ. Lead testing of children and homes: results of a national telephone survey. Public Health Rep 1996;111:342-6. Centers for Disease Control. Preventing lead poisoning in young children: a statement by the Centers for Disease Control, October 1991. Atlanta: Department of Health and Human Services, 1991. Centers for Disease Control and Prevention. Update: blood lead 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 Mahaffey KR, Annest JL, Roberts J, Murphy RS. National estimates of blood lead levels: United States, 1976-1980. N EnglJ Med 1982;307:573-9. Robin LF, Beller M, Middaugh JP. Statewide assessment of lead poisoning and exposure risk among children receiving Medicaid services in Alaska. Pediatrics 1997;99:E91-E96. Office of Pollution Prevention and Toxics (OPPT). Report on the National Survey of Lead-Based Paint in Housing: base report. Washington, DC: US Environmental Protection Agency, OPPT; 1995. Report No.: EPA/747-R95-003. Screening Young Children for Lead Poisoning 19 Chapter 1: Childhood Lead Poisoning 20 Screening Young Children for Lead Poisoning Chapter 2: A Comprehensive Approach 2 A Comprehensive Approach to Childhood Lead Poisoning Prevention Although lead poisoning among children is a bigger problem in some places than in others, there is potential for lead exposure in nearly all jurisdictions. Public health agencies should develop a comprehensive approach to preventing childhood lead poisoning that is based on the three functions defined in The Future of Public Health: assessment, policy development, and assurance (National Academy of Sciences, 1988). 1. Assessing Children’s Exposure to Lead Sources of data for assessment of children’s exposure to lead are summarized in Table 2.1. Sources include childhood blood lead surveillance systems (complete data are currently unavailable in most places, but many such systems are being developed); the U.S. Census (widely available data on older housing and young children living in poverty); the Toxic Release Inventory (TRI) from the ERA (widely available data on local industrial sources of lead exposure); and local surveys. Local surveys may be conducted to gather data on industrial sources not included in the TRI; on drinking water that might be contaminated by lead; and on households where lead may be present in traditional remedies, ceramicware, cosmetics, or materials used in hobbies. Screening Young Children for Lead Poisoning 21 Chapter 2: A Comprehensive Approach Table 2.1. Assessing children’s exposure to lead Exposure Source or Risk Factor Examples of Sources of Data for Assessment Pre-1950 housing Census data, tax-assessor data Demographic factors (e.g., poverty) Census data, blood lead surveillance data Industrial sources, parental occupation (take-home exposure) Toxic Release Inventory, local surveys, blood lead surveillance data Drinking water Local surveys, EPA, local utility companies Hobbies, traditional remedies, ceramic ware, cosmetics Local surveys, blood lead surveillance data 22 Screening Young Children for Lead Poisoning Chapter 2: A Comprehensive Approach 2. Developing Policies for Childhood Lead Poisoning 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. Primaryprevention activitiespvovent children from being ex- posed to lead. Especially significant are actions to reduce residential lead hazards before children are bom, are suffi- ciently mobile to be at increased risk for exposure to house- hold lead, or before children move into a home with lead hazards. (Alliance to End Childhood Lead Poisoning, 1994.) Secondary prevention activities reduce the harmful effects of elevated BLLs after elevations have occurred. Activities include BLL screening and follow-up care. “Universal” screening is the BLL screening of all children in an area; “targeted” screening is the BLL screening of children who are selected on the basis of; 1) environmental assess- ment to determine where children are being exposed to lead hazards, or 2) individual risk assessment to identify children who meet certain criteria, which may include place of resi- dence, membership in a high-risk group, or “yes” answers to a personal-risk questionnaire. (See Chapter 3 for more detail on secondary prevention activities.) Monitoring (surveillance) activities provide information that forms the basis for planning, evaluation, and public support of policies and programs. Activities include development of systems to monitor children’s BLLs, sources of exposure, Screening Young Children for Lead Poisoning 23 Chapter 2: A Comprehensive Approach reduction of lead hazards, and availability of lead-safe housing. Of particular importance are childhood blood lead surveil- lance systems containing information on elevated and non- elevated BLL results, demographics, results of environmental investigations, probable sources of exposure, and prescribed medical treatments. 24 Screening Young Children for Lead Poisoning Chapter 2: A Comprehensive Approach Table 2.2. Childhood lead poisoning prevention activities and associated policies Activity Examples of Associated Policies Primary Prevention Evaluation and control of residential lead-based paint hazards Protective housing codes or statutes Public lead education State- or area-wide plan calling for community-wide lead education 1 Professional lead education and training State certification for lead- abatement workers Anticipatory guidance by child health-care providers State Medicaid policies requiring anticipatory guidance Identification and control of sources of lead exposure other than lead-based paint State- or area-wide plan to reduce exposures from industry and drinking water Secondary Prevention Childhood blood lead screening State- or area-wide screening plan; state Medicaid policies and contracts calling for screening; protocols and policies for providers and managed-care organizations Follow-up care for children with elevated BLLs Local policies to establish a follow- up care team; protocols for care coordination, and for medical and environmental management; Medicaid policies and contracts calling for follow-up care Monitoring (Surveillance) Monitoring of children’s BLLs State policy requiring laboratories to report all BLL test results of resident children Monitoring of targeted (older, deteriorating) housing stock, hazard-reduction activities, and lead-sate housing State certification and licensing procedures for monitoring safety of lead-hazard reduction activities and occurrence of such activities in areas with targeted housing; procedures for tracking lead-safe housing Screening Young Children for Lead Poisoning 25 Chapter 2: A Comprehensive Approach 3. Assuring the Performance of Activities to Prevent Childhood Lead Poisoning Health departments should, at a minimum, support, oversee, and monitor the activities necessary to prevent childhood lead poisoning. In a comprehensive approach, there are roles for many different collaborators in both the public and the private sector. (See, for example, Alliance to End Childhood Lead Poisoning, 1996; and Lead-Based Paint Hazard Reduction and Financing Task Force, 1995.) Examples of activities, collabo- rating groups, and health department roles are shown in Table 2.3. 26 Screening Young Children for Lead Poisoning Chapter 2: A. Comprehensive Approach Table 2.3. Examples of childhood lead poisoning prevention activities and collaboration Activity Collaborators Roles of public health de partments Primary prevention Anticipatory guidance Health-care providers, medical groups, managed-care organizations Provide educatbnal materials; publicize, disseminate, and market preventbn information Public education Health-care providers, medical groups, managed-care organizations, community-based organizations, realtors, contractors, home remodelers, home inspectors, the press Assess community needs; provide educatbnal materials; convene planning groups; oversee, carry out, or evaluate campaigns; respond to consumer inquiries Maintenance or improvement of older housing Property owners, realtors, bankers, community-based organizations, remodelers, housing maintenance staff Convene policy- devebpment groups; maintain system for monitoring targeted (older, deterbrating) housing; provide training for maintenance staff'and remodelers; provide contractor training and certificatbn Lead hazard evaluation and control Lead inspectors, risk assessors, lead abatement contractors, trainers, community- based organizations, and licensing agencies Accredit training providers, certify lead protessbnals, provide advice and referrals to property owners Screening Young Children for Lead Poisoning 27 Chapter 2: A Comprehensive Approach Table 2.3. Examples of childhood lead poisoning prevention activities and collaboration (continued) Activity Collaborators Roles of public health departments Secondary prevention Screening Health-care providers, medical groups, managed-care organizations Provide patient-education materials and screening protocols; conduct screening Follow-up care: medical management Health-care providers, medical groups, managed-care organizations Provide referrals, protocols, and care coordination; provide medical management. Follow-up care: environmental investigation Public and private- sector environmental health specialists Provide referrals; investigation services; training, licensing, and certification of investigators; laboratory quality controls Follow-up care; family lead education, home visiting Visiting nurse associations, community-based organizations Provide referrals, training, and home-visiting services Follow-up care; lead-hazard control Property-owners, bankers, realtors, policy makers, enforcement agencies Convene policy-making groups; provide referrals, training, licensing, and certification; provide hazard-reduction services 28 Screening Young Children for Lead Poisoning Chapter 2: A Comprehensive Approach Table 2.3. Examples of childhood lead poisoning prevention activities and collaboration (continued) Activity Collaborators Roles of public health departments Monitoring (surveillance) Using BLL information for program development Health-care providers, medical groups, managed-care organizations, clinical laboratories Conduct outreach and policy development to encourage BLL reporting; provide systems to collect, manage, analyze, and disseminate results Using information on lead- hazard control activities to monitor safety of these activities and lead-safe housing Environmental sanitarians, lead hazard-reduction contractors Encourage reporting as part of training, licensing, and certification programs; provide systems to collect, manage, analyze, and disseminate results Screening Young Children for Lead Poisoning 29 Chapter 2: A Comprehensive Approach References Alliance to End Childhood Lead Poisoning (AECLP). Child- hood lead poisoning: developing prevention programs and mobilizing 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 Task Force. Putting the pieces together: controlling lead hazards in the nation’s housing. Washington, D.C.: U.S. Department of Housing and Urban Development, 1995. National Academy of Sciences Committee for the Study of the Future of Public Health. The future of public health. Washington, D.C.: National Academy Press, 1988. 30 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan 3 The Statewide Plan for Childhood Blood Lead Screening State public health officials should develop a statewide plan for 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 as an example.) • Dissemination of screening recommendations for each area. • Evaluation. Screening policy should be based on data that is representa- tive of the entire population. Children should be screened according to state policy. In the absence of a statewide plan or other formal guidance from health officials, universal screening for virtually all young children, as called for in the 1991 edition of Preventing Lead Poisoning in Young Children (CDC, 1991), should be carried out. Screening Young Children for Lead Poisoning 31 Chapter 3: The Statewide Plan 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 data and an inclusive planning process is preferred. Within the state or locale for which this recommendation is made, child health-care providers should use a blood lead test to screen children at ages 1 and 2, and children 36-72 months of age who have not previously been screened, if they meet one of the following criteria: • Child resides in one of these zip codes: [place here a list of all zip codes in the state or jurisdiction that have >27% of housing built before 1950. This infor- mation is available from the U.S. Census Bureau.] • Child receives services from public assistance programs for the poor, such as Medicaid or the Supplemental Food Program 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 questionnaire consisting of these three questions: -Doesyour child live in or regularly visit a house that was built before 1950? This question could apply to a facility such as a home day-care center or the home of a babysitter or relative. -Does your child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within the last 6 months)? -Does your child have a sibling or playmate who has or did have lead poisoning? 32 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan There are six steps to developing and imple- menting the statewide screening plan. 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 universal screening and for those with targeted screening. 6. Implement the statewide plan. Editor’s Note: In the rest of this chapter, we outline (on the left hand pages) the step-by-step process for developing and implementing a statewide screening plan and provide a discussion of those steps on the facing right hand pages. Screening Young Children for Lead Poisoning 33 Chapter 3: The Statewide Plan The Advisory Committee 1. Form an advisory committee. State health officials should form an advisory committee to develop the statewide plan. The committee should include child health-care providers as well as representa- tives from local health departments, managed-care organizations, Medicaid, private insurance organizations, and the community. 34 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan The Advisory Committee The advisory committee The statewide plan for childhood blood lead screening developed by the health department should, at a minimum, have the input of child health-care providers, insurers, and parents. Involvement of health-care providers, their organizations, and managed-care organizations throughout the process will improve acceptance of screening recommendations. The importance of community collaboration in public health decision-making is underscored by community health re- search (e.g., Green and Kreuter, 1991). Studies (e.g., Greco and Eisenberg, 1993) also indicate that health-care providers respond well to information and recommendations that come from peers and from their organizations. Working with insurers, especially the state Medicaid agency, will help ensure that screening is included, as appropriate, in contracts and policies. Screening Young Children for Lead Poisoning 35 Chapter 3: The Statewide Plan Assessment 2. Assess lead exposure and screening capacity. 2.1. Examine information on children’s risk for lead exposure. 2.1.1. Examine BLL data. Exercise caution in using BLL data to assess risk for lead exposure, because these data may not reflect the risk of the entire population. If BLL data are not thought to be reliable, other data should be used (see following sections) until improved BLL data are available. Use the following criteria to evaluate BLL data. Data should meet all of these criteria. If they do not, they are probably not an adequate basis for screening decisions. Criteria for evaluating BLL data 1. 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 be made. 36 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Evaluating BLL data, additional consider- ations • Labs reporting data should be successful participants in an approved proficiency-testing program. • BLL test results should be maintained in a way that allows identification of duplicate and sequential tests on a single child. It must be possible to distinguish between number of children tested and number of tests performed. • The results of all tests, regardless of BLL, should be available, so that calculation of rates of elevated BLLs among screened children can take place. • The data should be representative, i.e., the demographic, socioeconomic, and geographic distribution of children screened should be similar to that of all children in the jurisdiction. • Screening data that are not representative of the entire population, although not ideal, may be useful. For ex- ample, data showing low prevalence among those at highest risk would tend to support a targeted-screening recommendation; data showing high prevalence among those at lowest risk would tend to support a universal- screening recommendation (see Step 5). Screening Young Children for Lead Poisoning 37 Chapter 3: The Statewide Plan Assessment 2.1.2. Examine data on housing. These data are widely available from the U.S. census and can be used to estimate potential lead-exposure risk in an area. If adequate BLL data are unavailable, housing data can be used alone. Data are available for states, counties, zip codes, census tracts, and census block groups. The focus should be on housing built before 1950 because it poses the greatest risk for lead exposure. 38 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Age of housing Housing built before 1950 poses the greatest risk for lead exposure because it is much more likely to contain lead-based paint than is newer housing. • Paint manufactured before 1950 has more lead than paint manufactured after that year (Lead-Based Paint Hazard Reduction and Financing Task Force, 1995). • 27% of U.S. housing was built before 1950. Percentages of pre-1950 housing vary widely among states and coun- ties. • Data from the most recent National Health and Nutrition Examination Survey (NHANES III, Phase 2) confirm the relationship between housing age and BLLs (CDC, 1997). Table 3.1. Percentage of children ages 1-5 years with BLLs >10 pg/dL, by year house built, and geometric mean BLL, by year house built, U.S., 1991-1994 Year house built % with BLLs >10 Geometric mean BLL (fig/dL) Before 1946 8.6 3.8 1946-1973 4.6 2.8 1973 onward 1.6 2.0 Screening Young Children for Lead Poisoning 39 Chapter 3: The Statewide Plan Assessment 2.1.3. Examine data on demographic character- istics of children. The focus should be on poor children and children of racial/ ethnic minority groups because generally they are at higher risk than other children. Demographic data on children are widely available from the U.S. census and can be used to identify places with high proportions of children who may be at higher than average risk for lead exposure. 40 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Data on demographic characteristics of chil- dren: race/ethnicity and income Data from NHANES III, Phase 2, show strong relationships between BLL and race/ethnicity and between BLL and income. Table 3.2. Percentage of children with BLLs >10 by race/ethnicity and income, U.S., 1991-1994 Characteristic % children, ages 1-5 with BLLs >10 //g/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% Screening Young Children for Lead Poisoning 41 Chapter 3: The Statewide Plan Assessment 2.1.3. Examine data on demographic character- istics of children (continued). The focus should be on children between the ages of 12 and 36 months (1- and 2-year-old children) because BLLs tend to be highest in this age group, and more children in this age group have BLLs >10^g/dL. Examine census and local information to determine whether there are places with high percentages of young children. Estimates generated since the last U.S. census (conducted in 1990) are available to help identify these areas. 42 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Data on demographic characteristics of children: age Focus on children at ages 1 and 2. One- and 2-year-old children are at greatest risk for elevated BLLs 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 association between children’s age and their risk for elevated BLLs. Table 3.3. Percentage of children ages 1-11 years with BLLs >10 by age group, U.S., 1991-1994 Age group (years) % with BLLs >10 fig)dL 1-2 5.9% 3-5 3.5% 6-11 2.0% Screening Young Children for Lead Poisoning 43 Chapter 3: The Statewide Plan Assessment 2.1.4. Examine data on the presence of other sources of lead. Examine data from within the state on other sources of lead exposure, such as pottery, traditional remedies and cosmetics, operating or abandoned industrial sources, waste-disposal sites, occupational and take-home exposure, and drinking water. (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 information about local sources of lead exposure. BLL surveillance data may also reveal the presence of unusual sources. 44 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Other sources and pathways of lead exposure Industries, work sites, occupations, and associated materials Secondary smelting and refining of nonferrous metals Brass/copper foundries Firing ranges Automotive repair shops Bridge, tunnel, and elevated highway construction Motor vehicle parts and accessories Storage batteries (lead batteries) Valve and pipe fittings Plumbing fixture fittings and trim Pottery Chemical and chemical preparations Industrial machinery and equipment Inorganic pigments Primary batteries, dry and wet Hobbies and home activities Recreational use of firing ranges Home repairs, repainting, or remodeling Furniture refinishing Stained glass making Casting ammunition Making fishing weights or sinkers, or toy soldiers Using lead solder (e.g., for electronics) Using lead-containing artists’ paints or ceramic glazes Burning lead-painted wood Car or boat repair Screening Young Children for Lead Poisoning 45 Chapter 3: The Statewide Plan Assessment 2.2. Assess the capacity of local public health systems within the state to oversee and provide lead screening. This assessment will be one basis for deciding whether to divide the state into areas with different recommended screening. 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. 46 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Assessment Information on local health systems Some locales have long-standing, comprehensive childhood lead poisoning prevention programs with ties to managed- care organizations and support from providers. Other places have less experience, fewer allocated resources, and less provider involvement. Information about local activities should be used to develop a plan that is responsive to local needs and respectful of local capacities. Screening Young Children for Lead Poisoning 47 Chapter 3: The Statewide Plan Recommendation Areas 3. Determine the boundaries of recommendation areas. If necessary, subdivide the state into recommendation areas. A recommendation area is a geographic area for which a screening recommendation can be reasonably made. Efforts should be made to draw boundaries so that recommendation areas are reasonably homogeneous both in magnitude of risk and in health-system capacity to provide screening. 48 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Recommendation Areas Boundaries of recommendation areas Some states have relatively widespread and homogeneous risk, while others have less risk or scattered pockets of risk. States also differ with regard to the capacity of local health systems to oversee and provide screening. Universal screening is appropriate in areas with widespread risk. A state with widespread risk may comprise a single recommendation area with universal screening. Other states with less risk or scattered pockets of risk may be divided into different areas, some with universal screening and others with taigeted screening. Example: A state is divided into two recommendation areas: 1) a large city, designated as a universal-screening area because of its high percentage of older housing, and 2) the rest of the state, throughout which older housing is scattered, which is designated as a targeted- screening area. The large city’s health department, with its experienced lead program, will oversee screening in the city; the state health department will oversee screening in the rest of the state. Screen ing You ng Ch ildren for Lead Poison ing 49 Chapter 3: The Statewide Plan Appropriate Screening 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 screening recommendation % children, ages 12-36 months, with DLLs >10 fig/dL % housing built before 1950 Recommended screening >12% — universal <12% >27% universal (or targeted--see discussion) 3-12% <27% targeted <3% <27% see discussion unknown >27% universal unknown <27% targeted 50 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Appropriate Screening Cut-off points These should be used as guides to decision making and should not inhibit, for example, universal screening at prevalences of elevated BLLs or older housing that are slightly lower. 12% prevalence: The vast majority of children in recom- mendation areas where less than 12% of children have BLLs >10 will have BLLs below 20 the level requir- ing medical and environmental intervention. The members of CDC’s advisory committee reached substantial, although not unanimous, agreement on the 12% cut-off, which is also supported by a cost-benefit analysis. 27% pre-1950 housing: Housing data can be used as a proxy for BLL data; 27% of U.S. housing was built before 1950. (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 in housing conditions should trigger universal screening. <3% prevalence: Where reliable BLL prevalence estimates are extremely low and exposure sources are demonstrably lacking, methods other than routine screening should be used. Examples of alternatives are periodic focused surveys, routine review of BLL lab data, and public health alerts about newly identified sources of lead exposure. Note: Whenever a parent or a health-care provider suspects that a child is at risk for lead exposure, a BLL test should be performed regardless of health-department recommenda- tion. Screening Young Children for Lead Poisoning 51 Chapter 3: The Statewide Plan Writing Recommendations 5. Write screening recommendations for areas with universal screening, and for those with targeted screen- ing. 5.1. Write a universal-screening recom- mendation. A sample Using a blood lead test, screen all children at ages 1 and 2, and screen all children from 36-72 months of age who have not been screened previously. Implementation of universal screening is discussed in Step 6. 52 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations The universal-screening recommendation In many places, universal screening will be the policy of choice. In practice, universal screening has often been difficult to achieve. Barriers to screening and how to overcome them are discussed in Step 6. Screening Young Children for Lead Poisoning 53 Chapter 3: The Statewide Plan Writing Recommendations 5.2. Write a targeted-screening recommen dation. A sample: Using a blood lead test, screen children at ages 1 and 2, and screen children from 36-72 months of age who have not been screened previously if they meet 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 risk for lead exposure. (See 5.2.2.) • Parent/guardian answers “yes” or “don’t know” to any question in a personal-risk questionnaire. (See 5.2.3.) 54 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations The importance of targeted-screening criteria The criteria established by the health department and its advisors will make it possible for child health-care providers and parents to identify children who need screening. These criteria must be crafted to enable identification of as many at-risk children as possible. The criteria must be tailored to local conditions and easy to use. Development of these criteria is discussed in detail on the following pages. Screening Young Children for Lead Poisoning 55 Chapter 3: The Statewide Plan Writing Recommendations 5.2.1. Criterion: residence in a geographic area. This criterion makes it possible to identify children within a recommendation area who live in places where likelihood of lead exposure is increased (e.g., places with older housing). 56 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations Effectiveness of screening on the basis of place of residence An analysis was performed on a state’s BLL surveillance data in order to test the effectiveness of screening that is based on residence 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 and has 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 to comprise 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 children with BLLs >10 pig/dL. • Using the criterion “screen all in census tracts with >27% pre-1950 housing” would result in identifying 93% of children with BLLs >10 Screen ing You ng Ch ildren for Lead Poison ing 57 Chapter 3: The Statewide Plan Writing Recommendations 5.2.1. Criterion: residence in a geographic area (continued). Within a larger recommendation area, smaller places where lead exposure is likely should be pinpointed. Residence in such a place constitutes a screening criterion. The use of relatively small units of analysis (e.g., census tract, census block group) may reveal “pockets of risk” that would be invisible within a larger unit (e.g., county, zip code). However, small analytic units whose boundaries are not widely recognized will not be useful as screening criteria in a clinical setting, where providers and parents must be easily able to identify children for screening. For example, most people cannot readily identify the census tract in which they live. Another possible criterion might be residence in a widely recognized neighborhood whose boundaries approximate those of a relatively small analytic unit, such as a census tract, in which increased risk is identified. 58 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations Geographic analysis Computerized mapping software and U.S. census data files make it easy to search recommendation areas for smaller areas with older housing or with high-risk groups. For ex- ample, the maps of South Carolina (Map 1), and of Greenville County, S.C. (Maps 2 and 3), below show areas of older housing (shaded areas) for counties (Map 1), zip codes (Map 2), and census tracts (Map 3). The use of smaller units of analysis (zip code or census tract) reveals areas of older housing that are obscured when the larger unit (county) is used. (Note that zip code boundaries do not necessarily 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 built before 1950.) Map 1: Counties in S.C. with > 27% of housing built before 1950 Map 3: Census tracts in Greenville County, S.C. with >27% of housing built before 1950 Map 2: Zip codes in Greenville County, S.C. with >27% of housing built before 1950 Screening Young Children for Lead Poisoning 59 Chapter 3: The Statewide Plan Writing Recommendations 5.2.2. Criterion: membership in a high-risk group. This criterion should make it possible to identify children who may be at risk for reasons other than place of residence. The focus should be on children who 1) are poor; 2) are members of racial/ethnic minority groups, including black children and some groups of Hispanic and Asian-American children; 3) have occupationally exposed parents; or 4) have some other significant group characteristic that puts them at high risk. Current (1997) Medicaid policy reflects the assumption that all child beneficiaries are at risk for lead poisoning and requires lead screening for all children who receive Medicaid benefits. Anticipated changes in this policy may give states the responsibility of deciding whether all Medicaid-recipient children should be screened. In general, children who receive Medicaid benefits should be screened unless there are reliable, representative BLL data that demon- strate the absence of lead exposure in this population. 60 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations Screening among children in a high-risk group Ways to increase screening of poor children: • Screen all children who receive Medicaid benefits or vouchers from the Supplemental Food Program for Women, Infants, and Children (WIC). • Add questions to the personal-risk questionnaire that elicit the 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: Data from NHANES (CDC, 1997) and other studies (e.g., Rothenberg et al., 1996) demonstrate that children who are poor, are members of racial-ethnic minority groups, or who have occupationally exposed parents are at higher risk of lead exposure than are other children. Membership in a minority group does not predict risk in every community, and children in minority groups who are not exposed to lead do not have elevated BLLs. Traditional remedies and lead-glazed cooking pots and ceramicware used by some Mexican-American and other (e.g., Southeast Asian) families may cause BLL eleva- tions. Children may also be exposed to lead brought home on clothes 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 repair of older housing, construction and demolition, pottery work, stained-glass making, radiator repair, electronic components manufacturing, work in gold-assay labs, and gold and silver recovery. Screening Young Children for Lead Poisoning 61 Chapter 3: The Statewide Plan Writing Recommendations 5.2.3. Criterion: response to a personal-risk questionnaire. This criterion makes it possible to identify children who may be at risk but who do not meet other criteria. CDC recom- mends a basic three-question questionnaire as a starting point. A basic personal-risk questionnaire: 1. Does your child live in or regularly visit a house that was built before 1930? This question could apply to a facility such as a home day-care center or the home of a babysitter or relative. 2. Does your child live in or regularly visit a house built before 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 did have lead poisoning? Screen all children whose parent/guardian responds “yes” or “don’t know” to any question. 62 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations The personal-risk questionnaire Educational value of questionnaires. A personal-risk questionnaire stimulates dialogue between the health-care provider and parent about whether or not an individual child should be screened and gives health-care providers the opportunity to educate families about lead hazards. Predictive value of recommended questions. Many, but not all, studies* have associated increased risk for elevated BLLs with positive answers to the first two questions. The third question is unlikely to cause a large amount of unnecessary screening, and it may be important in individual situations. Sensitivity in predicting markedly elevated BLLs. Results of some studies have suggested that the ques- tionnaire is more sensitive for identifying children with more severe BLL elevations, e.g., >15 or >20 pig/ dL, than for identifying children with BLLs in the range of 10-14 pig/dL. Cut-off date, 1978. The cut-off date, 1978, is recommended in question 2 because there was some lead in residential paint until this time. Renovations have been shown in many studies to be associated with children’s increased risk for elevated BLLs. Lead hazards from unsafe renovations could occur in housing before 1978. * For a list of studies of personal-risk questionnaires, see Chapter 5, List of Additional Information Available from CDC. Screening Young Children for Lead Poisoning 63 Chapter 3: The Statewide Plan Writing Recommendations 5.2.3. Criterion: response to a personal-risk questionnaire (continued). Other questions. State health officials and their advisors should tailor the questionnaire to include questions about local sources of exposure in addition to housing, which is covered by the recommended basic three-question question- naire. In recommendation areas where exposure to lead from older housing is unlikely, the personal-risk questionnaire could contain questions about other risk factors such as parental occupation or the use of lead-containing ceramicware or traditional remedies. 64 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Writing Recommendations 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 into the 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 (eg 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? Screening Young Children for Lead Poisoning 65 Implementation 6. Implement the statewide plan. It is up to state health officials and their advisors to ensure that: 1) Staff members of state and local public health agencies understand their roles as established by the statewide plan. 2) Health-care providers, medical groups, managed-care organizations, and parents know what type of screening is recommended for their communities. 3) Other parties affected by the plan, including the state Medicaid agency, private insurers, and policy makers, are involved in the implementation process. 4) The plan is monitored, evaluated, and revised as appropri- ate. 66 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Implementation Implementation Health-care provider groups and parent groups should edu- cate their members about recommended screening through their newsletters and meetings. Maps of areas of likely exposure are helpful in showing areas of risk. Health-care provider groups should be made aware of how screening will be monitored and of the importance of their participation in evaluating recommendations. Providers should receive supportive materials. (For a prototypic provider handbook, see list of additional resources available from CDC in Chapter 5.) These materials include information 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 about screening of Medicaid enrollees, as recommended. Contracts between the state Medicaid agency and managed-care organi- zations should include screening, follow-up, and reporting requirements. (For samples of contract language, see list of additional resources available from CDC in Chapter 5.) Screening Young Children for Lead Poisoning 67 Chapter 3: The Statewide Plan 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 has often been inadequate. Health officials should not assume that making and commu- nicating a universal-screening recommendation are sufficient to bring about such screening. It is critical to involve health- care providers, medical groups, managed-care organizations, Medicaid agencies, and community members in the decision to recommend universal screening and to use the decision- making process to educate these groups about preventing lead poisoning. In areas where universal screening is recommended, health departments should monitor the effectiveness of the recom- mendation to ensure that screening rates are high. 68 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Implementation Universal screening Since 1991, when CDC recommended virtually universal screening of U.S. children, barriers to such screening have been identified. The two most important are: • Many providers and parents do not believe that lead exposure is a problem in their community. • Some children who are at high risk for lead exposure because of poverty and residence in deteriorating housing do not receive routine well-child care and thus are not screened for lead. To address these barriers, health departments have stepped up outreach and lead education for parents and providers and have worked with other agencies and communities to in- crease rates of well-child care. Monitoring of screening activity is necessary so that efforts to improve screening rates can be directed to areas where screening is inadequate. See discussion in 6.2. Screening Young Children for Lead Poisoning 69 Chapter 3: The Statewide Plan Implementation 6.2. Steps to take in implementing recom- mendations. Screening recommendations should be based on data. Of particular interest are BLL data. These data should be used to explain and support the recommendations to those who must cany them out, especially child health-care providers, medical groups, managed-care organizations, insurers, and parents. Ongoing collection and dissemination of data are necessary. Public health officials should: • Collect BLL information. • Determine the number and location of children with elevated BLLs. • Determine where screening is taking place and where it is not. • Compare information about screening activity and BLLs. (Graphics that display both screening and case information are helpful in this comparison.) • Target education and outreach to areas where more screen- ing is indicated. 70 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan Implementation Importance of feedback Research, as well as common sense, suggests that health-care providers are more compliant with clinical practice guidelines when 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 supply providers with screening data showing BLLs among children in the areas where they practice. Sources of BLL information Childhood blood lead surveillance systems that collect results of all BLL tests from all laboratories that serve residents of the area are preferred. Such systems make possible the analysis of screening and case data so that rates of elevated BLLs among screened children can be calculated, trends in BLLs and in service delivery can be detected, and appropri- ate improvements made. Alternatively, other monitoring methods can be used, such as serial BLL surveys; surveys of knowledge, attitudes, and behaviors of health-care providers and parents in targeted communities; and studies performed by providers and pro- vider groups using chart-review or other methods to ascertain screening practices. Public health agencies, Medicaid agencies, and managed-care organizations have a mutual interest in monitoring screening delivered under Medicaid and can share data to achieve this goal. Screening Young Children for Lead Poisoning 71 Chapter 3: The Statewide Plan Implementation 6.3. Revise screening recommendations as better data become available. As time passes, screening recommendations may become obsolete. Health officials should periodically evaluate the recommendations 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 recommendations that have been made. Health officials should develop a review process to explore background and supporting evi- dence, and to consider the reasons both for retaining and for changing current recommendations. 72 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan 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 a change 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 prevalence and to use these estimates to refine recommendations, including the recommended personal-risk questionnaire. Better tools for analyzing and presenting data will also be developed, allowing better prediction of risks for lead expo- sure. Local input. Local medical groups and managed-care organizations may perform blood lead surveys of their patient populations. Data from such surveys should be carefully evaluated, since these data can enhance the local decision-making process. Screening Young Children for Lead Poisoning 73 Chapter 3: The Statewide Plan References References Centers for Disease Control. Preventing lead poisoning in young children: a statement by the Centers for Disease Control. Atlanta: Department of Health and Human Ser- vices, 1991- Centers for Disease Control and Prevention. Update; blood lead 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 Bureau of the Census. 1990 Census of population and housing. Washington, D.C.: U.S. Department of Commerce, 1992. Elrodt AG, Conner L, Riedinger M, Weingarten S. Measuring and improving physician compliance with clinical practice guidelines; a controlled interventional trial. Ann Intern Med 1995;122:277-82. Greco PJ, Eisenberg JM. Changing physicians’ practices. Pediatrics 1993;329:1271-4. Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. 2nd ed. Toronto: Mayfield Publishing Company, 1991. 74 Screening Young Children for Lead Poisoning Chapter 3: The Statewide Plan References Lead-Based Paint Hazard Reduction and Financing Task Force. Putting the pieces together: controlling lead hazards in the nation’s housing. Washington, D.C.: U.S. Department of Housing and Urban Development, 1995. National Research Council. Measuring lead exposure in infants, children, and other sensitive populations. Washing- ton, D.C.: National Academy Press, 1993. Rothenberg SJ, Williams FA Jr, Delrahim S, et al. Blood lead levels in children in South Central Los Angeles. Arch Environ Health 1996:51:383-8. Screening Young Children for Lead Poisoning 75 Chapter 3: The Statewide Plan 76 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers 4 Roles of Child Health-Care Providers in Childhood Lead Poisoning Prevention Roles of Child Health-Care Providers 1. Use and disseminate information from state and local public 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 with elevated DLLs. 6. Provide clinical management for children when appro- priate. 7. Participate in a follow-up team. 8. Collaborate with public health agencies. Screening Young Children for Lead Poisoning 77 Chapter 4: Roles of Child Health-Care Providers In addition to routine screening and follow-up care, child health-care providers should per- form blood lead testing when children have unexplained symptoms or signs that are con- sistent with lead poisoning. Children with lead poisoning can present with seizures, other neurological symptoms, abdomi- nal pain, developmental delay, attention deficit, hyperactivity, other behavior disorders, school problems, hearing loss, or anemia. 78 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Editor’s Note: In the following discussion of the roles of the child health-care provider, we provide the roles on left hand pages, and discussion on the facing right hand pages. Screening Young Children for Lead Poisoning 79 Chapter 4: Roles of Child Health-Care Providers 1. Use and disseminate informa- tion from state and local public health agencies. Utilize information supplied by public health agen- cies on: • Recommended screening. • Educating families about lead. • Follow-up care. • Referral sources. 80 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Information from public health agencies Public health agencies will make recommendations about screening. These recommendations will be based on local risk for exposure to lead. Screening policy should be based on data that are representa- tive of the entire population, and not limited to a provider practice. Children should be screened according to state and local policy. In the absence of a statewide plan or other formal guidance from health officials, universal screening for virtually all young children, as called for in the 1991 edition of Preventing Lead Poisoning in Young Children (CDC, 1991), should be carried out. Public health agencies will supply: • Lead-education materials that reflect local policies and exposure sources. • Protocols for follow-up care for children with elevated BLLs. Comprehensive follow-up includes in-home assess- ment, education, environmental investigation, and reduc- tion of lead exposure; supports clinical management; and is 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. Screening Young Children for Lead Poisoning 81 Chapter 4: Roles of Child Health-Care Providers 2. Give anticipatory guidance. During prenatal care and during preventive care at 3-6 months and again at 12 months, provide infor- mation about: • Hazards of deteriorating lead-based paint in older housing. • Methods of controlling lead hazards safely. • Hazards associated with repainting and renova- tion of homes built prior to 1978. • Other exposure sources, such as traditional remedies. 82 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Anticipatory guidance Anticipatory guidance should be provided prenatally, when children are 3-6 months of age, and again when they are 12 months of age, because parental guidance at these times might prevent some lead exposure and the resulting increase in DLLs that often occurs during a child’s second year of life. When children are 1-2 years of age, parental guidance should be provided at well-child visits and when the personal-risk questionnaire is administered. (See Section 3.3 below.) Screening Young Children for Lead Poisoning 83 Chapter 4: Roles of Child Health-Care Providers 3. Perform routine blood lead screen- ing as recommended. 3.1. Sampling method. Screening should be done by a blood lead measurement of either a venous or capillary (fmgerstick) blood specimen. 3.2 Recommended screening. Follow health-department recommendations on screening. In the absence of recommendations from the health depart- ment, screen all children at ages 1 and 2 and children 36-72 months of age who have not been previously screened. 84 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Choice of sample collection method The choice of a sample-collection method (venipuncture or fingerstick) should be determined by the accuracy of test results, the availability of trained personnel, conve- nience, and cost. If children’s fingers are cleaned care- fully, capillary (fingerstick) sampling can perform well as a screening tool. Screening recommendations Universal screening will be recommended where the risk for lead exposure is widespread. A sample universal screening recommendation: Using a blood lead test, screen all children at ages 1 and 2 and all children 36-72 months of age who have not been previously screened. Targeted screening will be recommended where risk is less or is confined to specific geographic areas or to certain subpopulations. A sample targeted-screening recommendation: Using a blood lead test, screen children at ages 1 and 2, and children 36-72 months of age who have not previ- ously been screened, if they meet one of the following health-department criteria: • Residence in a geographic area (eg., a specified zip code). • Membership in a high-risk group (eg., Medicaid recipients). • Answers to a personal-risk questionnaire indicating risk. Screening Young Children for Lead Poisoning 85 Chapter 4: Roles of Child Health-Care Providers 3.3. The personal-risk questionnaire. In places with targeted screening, the health department may recommend routine use of a questionnaire to help identify children who should receive BLL screening. Such a questionnaire should also be used at times other than the routine screening schedule if it is suspected that a child faces increased risk for lead exposure (e.g., because the family has moved to an older house). 86 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers The personal-risk questionnaire A basic personal-risk questionnaire: 1. Does your child live in or regularly visit a house that was built before 1950? This question could apply to a facility such as a home day-care center or the home of a babysitter or relative. 2. Does your child live in or regularly visit a house built before 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 did have lead poisoning? The health department may recommend additional or different questions for soliciting information about local sources of exposure. Screening Young Children for Lead Poisoning 87 Chapter 4: Roles of Child Health-Care Providers 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 an exposure to lead. • Parents have knowledge of a child’s lead exposure and request screening. 88 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Indications for additional screening Increased likelihood of exposure. Children’s risk for lead exposure may increase, for example, because the family has moved to older housing or to a geographic area with a higher prevalence of older housing, or because the child lives in an older home that has recently been repaired or reno- vated. Parental request. Parents may express concern about their children’s potential lead exposure because of residence in older housing, nearby construction or renovation, an elevated BLL 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 is reason to suspect that lead exposure has occurred. Screening Young Children for Lead Poisoning 89 Chapter 4: Roles of Child Health-Care Providers 4. Provide family lead education. Provide families of children with capillary or venous BLLs >10 /ig/dL with prompt and individualized education about the 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 to reduce exposure. • Importance of wet cleaning to remove lead dust on floors, window sills, and other surfaces; the ineffectiveness of dry methods of cleaning, such as sweeping. • Importance of good nut ition in reducing the absorption and effects of lead. If there are poor nutritional patterns, discuss adequate intake of calcium and iron and encourage regular meals. • Need for follow-up BLL testing to monitor the child’s BLL, 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 dry sanding and scraping. 90 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Family lead education Education should be reinforced during follow-up visits, as needed. Health departments can often furnish educational mate- rials to the health-care provider, including print materials in various languages. Screening Young Children for Lead Poisoning 91 Chapter 4: Roles of Child Health-Care Providers 5. Provide diagnostic and follow-up testing for children with elevated BLLs. 5.1 Diagnostic testing. The following schedule is recommended. Table 4.1. Schedule for diagnostic testing of a child with an elevated BLL on a screening test If result of screening test (/ig/dL) is: Perform diagnostic test on venous blood within: 10-19 3 months 20-44 1 month-1 week* 45-59 48 hours 60-69 24 hours >70 Immediately as an emergency lab test * The higher the screening BLL, the more urgent the need for a diagnos- tic test. 92 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Diagnostic testing A diagnostic test is the first venous BLL test performed within 6 months on a child with a previously elevated BLL on a screening test. If the diagnostic test is not performed within 6 months, the next test is considered a new screening test, and decisions about follow-up testing should be made on the basis of the new test, and not on the basis of the original screening test. It is relatively common for children to have slightly elevated screening test results that do not persist on additional testing. For this reason, it is preferable to base interventions on the results of diagnostic testing. Exception to the recommended schedule If a child with an elevated screening test result is less than 12 months old, or if there is reason to believe that a child’s BLL may be increasing rapidly, consider perform- ing the diagnostic test sooner than indicated in the accompanying schedule. Screening Young Chilciren for Lead Poison ing 93 Chapter 4: Roles of Child Health-Care Providers 5.2. Follow-up testing for children with elevated diagnostic BLLs. • Children with diagnostic BLLs of 10-14 should have at least one follow-up test within 3 months. • Children with diagnostic BLL tests of 15-19 //g/dL should have a follow-up test within 2 months. • If the result of follow-up testing is >20 jag/dL, or if the child has had two or more venous BLLs of 15-19 at least 3 months apart, the child should receive clinical management (see next section). • Children with diagnostic BLLs >20 should receive clinical management, which includes additional follow-up testing (see next section). 94 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Follow-up testing A follow-up test is a venous BLL test used to monitor the status of a child with an elevated diagnostic BLL test. Regular measurement of the BLL of a child with an elevated diagnostic test result is important because the BLL may continue to rise. Rising BLLs are especially likely in children 6 months to 2 years of age because this is the age group in which mouthing behavior is most frequent. Screening Young Children for Lead Poisoning 95 Chapter 4: Roles of Child Health-Care Providers 6. Provide clinical management for children when appropriate. Clinical management includes: 6.1. Clinical evaluation for complications of lead poisoning. 6.2. Family lead education and referrals. 6.3. Chelation therapy, if appropriate. 6.4. Follow-up testing at appropriate intervals. 96 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Clinical management Clinical management is part of comprehensive follow-up care and 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, such as home visits by a nurse, social worker, or community health worker; environmental investigation; and control of lead hazards identified in the child’s environment. See Table 4.3. for a summary of comprehensive follow-up care. Note: The accompanying recommendations about clinical management are based on the experience of clinicians who have treated lead-poisoned children. They should not be seen as rigid rules and should be used to guide clinical decisions. Screening Young Children for Lead Poisoning 97 Chapter 4: Roles of Child Health-Care Providers 6.1 Perform a clinical evaluation. Table 4.2. Clinical evaluation Medical history. Ask about: • Symptoms. • Developmental history. • Mouthing activities. • Pica. • Previous BLL measurements. • Family history of lead poisoninj Environmental history. Ask about: • Age, condition, and ongoing remodeling or repainting of primary residence and other places that the child spends time (including secondary homes and day-care centers). Determine whether the child may be exposed to lead-based paint hazards at any or all of these places. • Occupational and hobby histories of adults with whom the child spends time. Determine whether the child is being exposed 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 and to the child’s psychosocial and language development. 98 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Clinical evaluation Medical history. Developmental progress should be monitored carefully. If there are delays or lags, the child should be referred to an early intervention program for further assessment. Environmental history. State and local health depart- ments may provide additional questions about local exposure sources. Nutritional status. Identified nutritional problems should be 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 when the stomach is empty, the scheduling of smaller and more frequent meals may be helpful. Physical examination. Findings of language delay or other neurobehavioral or cognitive problems should prompt referral to appropriate programs. Children may need early intervention programs and further examina- tions during the early school years to facilitate entry into an appropriate educational program. Screening Young Children for Lead Poisoning 99 Chapter 4: Roles of Child Health-Care Providers 6.2. Provide family lead education and referrals. See Section 4 for topics that should be covered as part of family lead education. Refer children for appropriate social services if problems such as inadequate housing, lack of routine health care, or need for early intervention educational services are discov- ered. 100 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Family lead education and referrals The first opportunity to educate families about the causes and consequences of a child’s elevated BIX usually occurs in the health-care provider’s office. Health-care providers should discuss both short-term repercussions of elevated BLLs (e.g., the need for follow-up testing and treatment, the need to control lead hazards in the child’s environment) and long-term repercussions (e.g., the potential for future learning problems, 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, and housing services. Screening Young Children for Lead Poisoning 101 Chapter 4: Roles of Child Health-Care Providers 6.3. Provide appropriate chelation therapy. A child with a BLL>45 pig/dL should be treated promptly with appropriate chelating agents and be removed from sources of lead exposure. BLL testing for children undergoing chelation. Before chelation therapy is initiated, a child with a BLL <70 pig/dL should have a second BLL test, performed on a venous specimen, to ensure that therapy is based on the most recent and reliable information possible. Children with screening BLLs of 60-69 pig/dL should have a venous BLL test within 24 hours. Children with BLLs >70 pig/dL should have an urgent repeat BLL 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 at least once a month. When chelation is terminated, BLLs should be monitored frequently until sources of lead expo- sure have been identified and addressed. 102 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Chelation therapy Chelation therapy should be initiated immediately for all children with an initial screening-test result that is >70 If such an elevated BLL is obtained on a fingerstick sample, the health-care provider should order an immediate diagnostic test and consider initiating chelation while that test is being performed, if there is reason to believe that the results of the screening test are accurate (eg., if it was obtained by a skilledphlebotomist under controlled conditions). Screening Young Children for Lead Poisoning 103 Chapter 4: Roles of Child Health-Care Providers 6.4. Provide follow-up BLL testing at appropriate intervals. Children who are receiving clinical management should be tested at 1- to 2-month intervals until these three conditions are met: 1) The BLL has remained <15 //g/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 tested approximately every 3 months. Children for whom these three conditions are met and who have reached 36 months of age no longer need to receive follow-up testing. 104 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Follow-up testing A follow-up test is a venous BLL test used to monitor the status of a child with an elevated BLL on a diagnostic test. Children who are receiving clinical management should receive follow-up testing to monitor the effectiveness of services they receive (e.g., lead education, home visitation and environmental investigation, lead-hazard control, chela- tion therapy). Screening Young Children for Lead Poisoning 105 Chapter 4: Roles of Child Health-Care Provider* 7. Participate in a follow-up team. Table 4.3. Comprehensive follow-up services, according to diagnostic* BLL BLL O/g/dL) Action <10 Reassess or rescreen in 1 year. No additional action necessary unless exposure sources change. 10-14 Provide family lead education. Provide follow-up testing. Refer for social services, if necessary. 15-19 Provide family lead education. Provide follow-up testing. Refer for social services, if necessary. If BLLs persist (i.e., 2 venous BLLs in this range at least 3 months apart) or worsen, proceed according to actions for BLLs 20-44. 20-44 Provide coordination of care (case management). Provide clinical management (described in text). Provide environmental investigation. Provide lead-hazard control. 45-69 Within 48 hours, begin coordination of care (case management), clinical management (described in text), environmental investigation, and lead hazard control >70 Hospitalize child and begin medical treatment immediately. Begin coordination of care (case management), clinical management (described in text), environmental investigation, and lead-hazard control immediately. * A diagnostic BLL is the first venous BLL obtained within 6 months 1 of an elevated screening BLL. 106 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers The follow-up team and comprehensive follow- up services Comprehensive services are best provided by a team that includes the health-care provider, care coordinator, com- munity-health nurse or health advisor, environmental specialist, 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 coordinated by the health department. Because childhood lead exposure is likely to be associated with poor and deteriorating communities, children with elevated BLLs may also have problems such as inadequate housing, lack of routine medical care, and poor nutrition. Children may also need educational services, and the team may be instrumen- tal in ensuring that children with a history of elevated BLLs receives early intervention or special education services for which they are eligible. Screening Young Children for Lead Poisoning 107 Chapter 4: Roles of Child Health-Care Providers 8. Collaborate with public health agencies. Health departments and child health-care providers should interact in a number of ways: • They should exchange information on local exposures to lead. • Providers should put complete information on laboratory BLL test-requisition slips and should report children with elevated BLLs to the health department, as re- quired. • Health departments should collect lab data, analyze it, and prepare reports for providers and the public. • Providers should encourage health departments to review data and to adjust screening recommendations as neces- sary. 108 Screening Young Children for Lead Poisoning Chapter 4: Roles of Child Health-Care Providers Working with the health department Some states require that laboratories report the results of all children’s BIX tests, along with demographic and address information. These reports are the foundation of BLL surveillance systems and depend on complete and accurate information 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. Screening Young Children for Lead Poisoning 109 Chapter 4: Roles of Child Health-Care Providers 110 Screening Young Children for Lead Poisoning Chapter 5: Resources 5 CDC Resources and Information for Implemen- tation of Guidance The guidance in this document calls upon state and local health departments to use data and an inclusive process to develop screening recommendations. Some health depart- ments are already carrying out this process. Others will need support for additional efforts. CDC provides resources and support to health departments to ensure that this guidance is implemented in an effective and timely way. Statewide plan. CDC gives technical assistance to health departments in the statewide planning process and in the dissemination of screening recommendations. Census data. U.S. census data are available from many sources. CDC offers assistance in analyzing and displaying these data, and, with other Federal agencies, has future plans to make appropriate parts of the census data files available on the Internet to support lead poisoning prevention activities. Grant program. CDC provides funding to states and localities through the State and Community-Based Childhood Lead Poisoning Prevention Program grants for screening, for ensuring 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 disseminating screening recommendations. Screening Young Children for Lead Poisoning 111 Chapter 5: Resources Blood lead surveillance data. CDC assists state and local lead programs in collecting, managing, analyzing, and disseminating 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 aid them in communications with other agencies, child health- care providers, managed-care organizations, and the public. For example, CDC provides a prototype for a handbook for health-care providers. (See Section A) List of additional information available from CDC. A. Support for child health-care providers: a prototypic handbook for providers. For use by health departments in preparing materials for health-care providers, this template includes background information and space for additional state and local materials such as state policies, screening recommendations, patient- education brochures, and local referral sources. B. Developing a statewide plan: materials for examining and analyzing data and making screening recommendations. For use by state and local health officials and epidemiologists, and their advi- sors in decision making, these materials provide important background B.l Update: Blood Lead Levels-United States, 1991- 1994. Morbidity and Mortality Weekly Report, February 21, 1997. MMWR article containing data from Phase 2 of the Third National Health and 112 Screening Young Children for Lead Poisoning Chapter 5: Resources Nutrition Examination Survey (NHANES III), from 1991 to 1994. B.2 Brody DJ, Pirkle JL, Kramer RA, et al. Blood lead levels in the U.S. population: phase 1 of the Third National Health and Nutrition Examination Survey (NHANESIII, 1988 to 1991). JAMA 1994;272:277- 83. B.3 Pirkle JL, Brody DJ, Gunter EW, et al. The decline in blood lead levels in the United States: the National Health and Nutrition Examination Surveys (NHANES). JAMA 1994;272:284-91. B.4 Costs and benefits of a universal screening program for elevated blood lead levels in 1-year-old children. Cost-benefit analysis performed by scientists within and outside CDC. B.5 Relationship between prevalence of BLLs > 10 pig/dL and prevalences above other cut-off levels. Table of expected proportions of children with BLLs higher than selected thresholds, given different prevalences of elevated BLLs. B.6 Exact confidence intervals for some hypothetical estimates of prevalence of BLLs >10 pig/dL, by num- ber of children screened. B.7 Conditions required for a source of lead to be a lead hazard. Screening Young Children for Lead Poisoning 113 Chapter 5: Resources B.8 Samples of Medicaid contract language on child- hood blood lead screening. B.9 List of studies of effectiveness ofpersonal-risk ques- tionnaires for selecting children for blood lead screening. C. Materials for Laboratorians C.l The lead laboratory. A summary of laboratory issues, including quality assurance and accredita- tion. C.2 Capillary blood sampling protocol. C.3 Proficiency testing and quality control. Table A: Proficiency Testing Programs for Lead Laboratories Table B: Quality Control Materials for Use in Blood Lead Testing Table C: Quality Control Materials for Use in Urine Lead Testing Table D: Quality Control Materials for Erythrocyte Protoporphyrin Tests 114 Screening Young Children for Lead Poisoning Chapter 6: Research Priorities 6 Childhood Lead Poisoning Prevention Research Priorities If we are to improve lead poisoning prevention strategies, we need additional research in the following areas: 1) Effectiveness of interventions aimed at preventing or reducing elevated BLLs and their adverse health effects among children, including studies of: • The effectiveness and cost effectiveness of interven- tions to control lead hazards in housing. • The effectiveness of family education about lead poisoning prevention in preventing BLL elevations or in reducing already elevated BLLs. • The effectiveness of chelation therapy in preventing or reducing neurobehavioral effects of elevated DLLs, especially among children with modestly elevated BLLs. 2) Barriers to screening and other lead poisoning prevention activities, especially in places with high prevalences of elevated BLLs. Screening Young Children for Lead Poisoning 115 Chapter 6: Research Priorities 3) Prediction of places with high and low prevalences of elevated BLLs. Such information could be used to allocate resources and target efforts. 4) Methods of identifying individual children with BLLs >20^g/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 prevention programs and BLL monitoring. 6) The contribution to elevated DLLs in children of nonpaint sources of lead exposure, including studies of exposure to lead taken home from workplaces of adults. 116 Screening Young Children for Lead Poisoning Glossary Glossary Included below are two sets of definitions. One set is generally used in public health, child health care, and preventive medi- cine. The second set is specific to this document. General Specific to this document Anticipatory guidance is the education provided to parents or caretakers during a routine prenatal or pediatric visit to prevent or reduce the risk that their fetuses or children will develop a particular health problem. Anticipatory guidance is the education provided to parents or caretakers during a routine prenatal or pediatric visit to prevent or reduce the risk that their fetuses or children will develop lead poisoning. In general, anticipatory guidance for lead should include informa- tion about the dangers of deteriorating lead-based paint in homes and of improper renova- tion or remodeling that disturbs lead-based paint. Assessment is the process, usually carried out or coordinated by a public health agency, of determining the nature and extent of hazards and health problems within a jurisdiction. A blood lead level (BLL) is the concentration of lead in a sample of blood. This concentration is usually expressed in micrograms per deciliter or micro moles per liter One is equal to 0.048 Screening Young Children for Lead Poisoning 117 Glossary General Specific to this document Care coordination is the formal coordination of the care of a child with a BLL that exceeds a specific value—as determined by local or state officials—and the assurance that services needed by that child are provided. Clinical management is the care of a child with an elevated BLL that is usually performed by a child health-care provider. It includes 1) clinical evaluation for complications of lead poisoning; 2) family lead education and referrals; 3) chelation therapy, if appropriate; 4) follow-up testing at appropriate intervals. A diagnostic test is a laboratory test used to determine whether a person has a particular health problem. A diagnostic test is the first venous blood lead test performed within 6 months on a child who has previously had an elevated BLL on a screening test. A follow-up test is a laboratory test for the purpose of monitoring the care of a person with a particular health problem. A follow-up test refers to a blood lead test used to monitor the status of a child with a previously elevated diagnostic test for lead. 118 Screening Young Children for Lead Poisoning Glossary General Specific to this document A jurisdiction is the geographic area over which a state or local government has political author- ity. Counties and incorporated places, such as cities, boroughs, towns, and villages, are examples of jurisdictions. One jurisdiction may lie partially or totally within another, such as a county within a state. A lead poisoning prevention program is an organized set of activities, including primary and secondary prevention activities, to prevent childhood lead poisoning. A personal-risk questionnaire is administered by a child health- care provider to the parents or guardians of a young child to help determine whether that child is at increased risk of having an elevated BLL. The personal-risk questionnaire is one component of an individual risk evaluation. A place is any geographic area. Prevalence is the percentage of a population with a particular characteristic. Prevalence is the percentage of a population with an elevated BLL. rimary prevention is the prevention of an adverse health effect in an individual or population. One method of accomplishing this is reducing or eliminating a hazard in the environment to which an individual or population is exposed. Screening Young Children for Lead Poisoning 119 Glossary General Specific to this document A recommendation area is a place for which a public health agency makes a recommendation on how to screen resident children for lead poisoning. A recommendation area can be a country, state, county, city, or other place. Screening is a method, usually involving a physical examination or a laboratory test, to identify asymptomatic individuals as likely, or unlikely, to have a particular health problem. BLL screening for lead poisoning is the routine measurement of BLLs in asymptomatic children. A screening program consists of screening for a health problem, a diagnostic evaluation for those with positive screening- test results, and treatment for those in whom the health problem is diagnosed. A screening program for lead poisoning is BLL screening, the diagnostic evaluation of children with elevated BLLs, and the provision of educational, environmental, medical, and other services to children found to have elevated BLLs. A screening program is one component of a childhood lead poisoning prevention program. 120 Screening Young Children for Lead Poisoning Glossary General Specific to this document A screening test is a laboratory test to identify asymptomatic individuals as likely or unlikely to have a particular health problem. A screening test for lead poisoning is a laboratory test for lead that is performed on the blood of an asymptomatic child to determine whether the child has an elevated BLL. Secondary prevention is the prevention or slowing of the progression of a health problem in affected individuals. Secondary prevention is the identification of children with elevated BLLs and the prevention or reduction of further exposure of those children to lead. Targeted screening is the BLL screening of some, but not all, children in a recommendation area. The selection of children to be screened is based on the presence of a factor that places these children at increased risk for lead exposure. Universal screening is the BLL screening of all children at ages 1 and 2 in a recommendation area. Screening Young Children for Lead Poisoning 121 Glossary Notes 122 Screening Young Children for Lead Poisoning