VII. Conclusion and Recommendations
It’s tragic that children are still exposed to lead in 2016, despite all that we know about its dangers. Since there is no safe level of lead in a child’s blood, and symptoms from low levels of exposure are not immediately obvious, testing is a key part of a strategy to address lead exposures and prevent further injury. Most states agree that lead poisoning and EBLLs should be taken seriously. But some have made a greater commitment to tackling these issues. Table 3, below, summarizes the types of state lead testing policies.
Table 3 – Summary of Lead Testing and Reporting Policies
|Require universal testing||10 + District of Columbia|
|Require targeted testing (apart from Medicaid policies)||8|
|Recommend targeted testing (apart from Medicaid policies)||27|
|Have no requirements or recommendations on website (apart from Medicaid policies)||5|
|Clearly follow the federal Medicaid lead-testing requirement||45 + District of Columbia|
|Require BLL test results to be reported by all laboratories and at least all providers using point-of-care analyzers||40 + District of Columbia|
No state reports testing 100% of the children they want to have tested for lead, where the testing policy requires testing of all children at the critical ages of 1 and 2. But, some are closer. One state recently took strong action to test more at-risk children and overhauled their program by adopting universal testing, recognizing that it could result in significant cost savings and improvements in health and wellbeing.
We analyzed the best practices employed by these states and used them as the foundation for our recommendations below.
Recommendations for Successful State Testing Programs
- Adopt universal screening to discover the full extent of elevated blood lead levels in childrenStates should determine whether to move to universal screening to better protect the children in their state, based on the data that is available and accounting for gaps in the data. As Maryland discovered, the new reference level of 5 µg/dL and the inherent limitations of targeted screening methods mean these methods may overlook significant numbers of at-risk children. Maryland found that reducing all BLLs of 5 µg/dL or higher in those aged one and two, identified through testing, would lead to cost savings of between $143 and $556 million. This translates into a return of $24-142 for each dollar invested, and is in addition to significant societal benefits both for children’s health and wellbeing, and for society as a whole.
- Implement strategic education campaigns for health care providers and parentsSimply adopting universal testing isn’t enough to make the program successful. Lead program staff should be invested in its implementation. It’s important to have regular contact with providers to remind them of their obligation to test, as Massachusetts does through phone calls, letters, and in-person visits. Another form of education is showing individual providers the names of children in their practice who need to be tested. The discussion in Best Practices above showed a close correlation between these “provider report cards” and higher testing rates. Providers have a lot to look for and document at a well-child exam, and these report cards can be effective reminders.Parents may not bring their child to the doctor at the recommended intervals. Some parents also refuse blood draws. To overcome these obstacles, states should focus on community outreach and educating parents on the importance of having their children tested, especially at ages 1 and 2, and on the significant costs of not addressing lead poisoning.To help disseminate the information, states can partner with non-profit organizations (or businesses) to expand the lead program’s reach, similar to New Jersey’s program.
- Make the testing more accessible and affordableWhen providers have to refer children to an outside laboratory for a blood lead test, follow-up may become difficult. In-office testing saves patients the trouble of going somewhere else, and enables them to see the results immediately and receive necessary follow-up services much more quickly.It’s important for doctors to have the ability to test using point-of-care devices. While these can be expensive, the Vermont Department of Health works with the state chapter of the American Academy of Pediatrics to provide LeadCare II analyzers free of charge to selected practices. Idaho provides them free to doctors testing patients enrolled in Medicaid.Parents are more likely to get their child tested for lead if they know that the test is free or available at a low cost.
- Require universal reporting of test resultsStates can’t accurately assess their lead program if they do not receive all blood lead test results. It should be mandatory to report all BLL test results – including those from point-of-care devices – to the state’s lead program.
- Publish data on tests done at both 12 and 24 monthsThere is a gap in knowledge about the level of screening at the critically important ages of 1 and 2. All states should publish data on the rate of children who have been tested at both of these ages. This data was only available from four universal testing states. Many states provide data on the number of 1- and 2-year-olds in their state that are tested once in a given year, and CDC’s Environmental Public Health Tracking Program provides data for most states on the percentages of children under three years old who were tested at least once for lead. However, to be most effective in identifying children with elevated levels, since children’s BLLs are rising by age 1 and peaking around age 2, the tests should happen at both of these ages. Once this data is collected and reported, it will help states and stakeholders determine whether the children with the greatest need are actually being tested.
The author thanks Andy Igrejas and Liz Hitchcock at Safer Chemicals, Healthy Families and Juliana Bilowich at Maryland PIRG for their review of the drafts, and for providing suggestions and insights. She is also grateful to colleagues Beth Kemler for formatting the print version of the draft and Amanda Frayer for creating the cover and formatting the HTML version of the draft.
Special thanks to the multitude of state and federal personnel who patiently provided comprehensive answers to our many questions, and to the National Committee for Quality Assurance for providing us with useful data on the lead screening measure in the Healthcare Effectiveness Data and Information Set. Additional thanks to Joshua Schneyer of Reuters who provided helpful insight on certain data sources and was willing to exchange information about this issue.
Safer Chemicals, Healthy Families bears responsibility for any factual errors. The views expressed in this report are those of Safer Chemicals, Healthy Families and do not necessarily reflect the views of our funders.
Safer Chemicals, Healthy Families (https://saferchemicals.org/) is a project of Kitchen Table Campaigns, a 501(c)(3) nonprofit organization. Safer Chemicals, Healthy Families is staffed by a seasoned group of organizers that is part of the Kitchen Table Campaigns team. We emphasize public education and strategies that blend traditional grassroots organizing with online communications, rapid response articles to new science and policy updates, and building coalitions that merge diverse organizations and businesses.