III. State Lead Screening Policies and Reporting Requirements
The stronger a state’s policy on testing and reporting, the more likely it is to have a higher number of children tested in a given year, and to find more children with EBLLs. Tables 1.A – 1.D, using the most recent available data, estimate states’ screening rates and match them with lead testing policies to provide context. Tables 1.A and 1.B show which states require proof that a child had received a lead test when enrolling in childcare, preschool, kindergarten, or as late as first grade. Additionally, these tables note whether a state has a law or regulation requiring insurance companies to cover lead tests. Other best practices are discussed below in Section V.
Reporting requirements are also provided because this may explain some lower testing rates. When laboratories or providers’ offices are not required to report the results of all lead tests, the screening rate may be artificially lowered.
The percentages shown in Tables 1.A – 1.D in the column entitled “% of kids < 36 mo. tested” reflect the number of children under 36 months old (3 years) who were reported as tested in a recent year out of the total population of children under 36 months. Children are much more likely to be tested – and should be tested – around ages 1 and 2, so this data from the CDC’s Environmental Public Health Tracking Program (Tracking Program) gives a better idea of how states are doing on testing children closer to these critical ages. We also provide data in the age grouping of “under 72 months” because CDC has historically recommended a test up to 72 months if the child wasn’t tested earlier. It captures more of the tests that are completed. The National Surveillance Data on CDC’s lead page reflects this grouping, as do data from most states.
Most universal testing states also provided the screening rate of at least one age group of the population they required to be screened. Those percentages are in Table 1.A., in column G labeled “% of kids tested in target age range” and are explained in the footnotes below the table.
- Table 1.A –States With Universal Childhood Lead Testing Policies
- Table 1.B –States Requiring Targeted Childhood Lead Testing
- Table 1.C –States with Formal (Written) Childhood Lead Testing Recommendations
- Table 1.D –States With No Formal Childhood Lead Testing Policy
As stated in the Methodology section above, “All” in the columns showing the reporting requirements in Tables 1.A – 1.D (column D of Tables 1.A and 1.B and column B of Tables 1.C and 1.D) means that states require all laboratories and at least all health care providers using point-of-care analyzers to report results of tests for children under age 6 to the state health department. Most states (40 + D.C.) do this. One state, Pennsylvania, requires all results to be reported by traditional laboratories, but doctors using point-of-care machines only have to report results over a certain threshold. Others require reporting of results only at or above 5 µg/dL or 10 µg/dL (and in one case, at or above 2.3 µg/dL). One state – Nevada – did not have a clear statewide reporting requirement, although “exposures and elevated levels” are reportable in Clark County.
States with Universal Testing Requirements
Table 1.A shows that universal screening is required in 10 states and the District of Columbia: Connecticut, Delaware, Iowa, Louisiana, Maryland (for at least three years beginning in 2016, for children born on or after January 1, 2015), Massachusetts, New Jersey, New York, Rhode Island and Vermont. All of the states listed above except Delaware and Iowa require all children in their state to be tested for BLLs at or close to ages 1 and 2. Several of these have additional testing requirements. For example, Massachusetts mandates universal testing at age 3, testing for children living in high-risk areas at age 4, and additional testing when warranted by specific risk factors.
Delaware requires universal testing only at or around 12 months, and children between 22 and 26 months old are tested based on positive answers to a risk questionnaire. Iowa mandates blood lead testing for all children entering kindergarten, before age 6 or as soon as possible after and strongly encourages that children be tested by age 2.
For children born before 2015, Maryland requires testing at 24 months of age if they have lived in an “at-risk” area as designated in 2004; if they have never lived in one of these at-risk areas, they must still be tested if indicated by the required risk questionnaire or if a parent requests it (or if the child is enrolled in Maryland’s Medicaid program).
Some of these states reported on the percentage of children who were tested in specific age groups at least once, ranging from 68% to over 100%. For example, Iowa reported testing 100.5% of their children born in 2009 by the time they were 6 years old, and it’s likely that most of this testing happened by age 3. Connecticut tested 97% of children born in 2011 at least once before age 3; New Jersey reported that 75% of children who turned three during the period July 2013 to June 2014 had at least one lead test. DC reported testing 91% of children two years old by July 1, 2015. Rhode Island reported that 78% of children who turned 36 months in 2015 received at least one test by 18 months of age. Vermont stated that 80% of children aged 1 and 68% of children aged 2 were tested for lead in 2015 (although they noted these may include more than one test per child for the reporting year). In Massachusetts, 76% of children 9 – 47 months of age were reported as tested in 2015.
Four states also reported on whether children received two tests. In DC, by July 1, 2015, 31% of children 24 to 35 months old were reported to have received lead tests in both of the statutorily required age ranges. In Connecticut, 53% of children born in 2011 were tested around age 1 and 2. Rhode Island reported that 55% of children who turned 36 months in 2015 had received two tests at least 1 year apart. New York indicated 56% of children born in 2011 were tested at least twice by 36 months.
Health care providers are largely responsible for making sure children are tested for lead or for administering the test themselves. In some cases, health care facilities are also given this task. However, Iowa’s Administrative Code makes it the responsibility of the students entering kindergarten (and, by extension, their parent or guardian), and of school authorities.
States with Requirements to Test Less Than Universally but Beyond the Medicaid Population
Eight states have targeted testing requirements for children, beyond Medicaid policies: California, Illinois, Maine, Michigan, Missouri, Ohio, Virginia, and West Virginia. These states require blood lead testing for children with a risk factor for lead exposure, including such factors as living in housing built before 1950, living near a lead smelter, or receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). (See the Appendix for a sample risk assessment.) Some of these states have also designated specific high-risk zip codes for testing based on calculations of where children are most likely to be exposed to lead – e.g., where there is a high percentage of old housing and poverty.
West Virginia’s testing rate for children under 72 months is notably low compared with the other states that have testing requirements. This may be because West Virginia staff did not consistently refer to the screening policy as a requirement and mentioned only encouraging testing by sending letters to providers reminding them to screen.
Many states also used inconsistent terminology that would make it difficult for a parent or potentially even a doctor to know when testing is or isn’t required. A few states have issued risk assessments or screening guidelines stating or implying that children should be tested after an affirmative answer to one of the questions, while the laws required this testing through the use of shall.
States that Have Public Policies for Recommended Testing Only (aside from Medicaid screening requirements)
Many states (27) only recommend blood lead testing for specific groups of children, outside the Medicaid population. These suggestions mostly follow the same pattern as in states with targeted screening requirements.
Some of these recommendations were hard to find or unclear. For example, Pennsylvania had only limited recommendations on their website, mainly in a “Frequently Asked Questions: Lead Poisoning” document whose link was off to the side of the main page. Alaska’s testing recommendations were not immediately apparent from a search of their website. The current and official recommendations were confirmed to be at the end of a 2014 bulletin entitled: “Blood Lead Surveillance in Children Aged < 18 Years – Alaska, 1995-2012.” A few states, such as Georgia and Indiana, stated in screening plans that a test was “necessary” for children at risk without legal requirements for the testing.
Staff in Hawaii and Kansas mentioned their lead programs lost CDC funding but recommendations can still be found on their websites. Despite its law encouraging providers to test, Nevada no longer has an active state lead poisoning prevention program. One county in that state has its own reporting requirement for blood lead tests and its own procedures for case management.
A 2015 New Hampshire law requires that state’s health department to issue regulations for doctors to ensure testing of 1- and 2-year-olds living in high risk communities and those enrolled in Medicaid, WIC, or Head Start, if screening percentages in those populations aren’t at 85% by 2017. In Pennsylvania, the governor and health department staff support a universal testing mandate, and legislation has been introduced to require this.
States Without Official Screening Recommendations (apart from Medicaid)
Five states – Arkansas, Montana, North Dakota, South Dakota, and Wyoming – provided no recommendations on the Internet regarding which population of children to screen, outside the Medicaid population. A few of these states had no state-maintained childhood lead poisoning prevention website. Interviewed by phone, health department staff from two states said they recommended that all children be tested, although it’s unclear how widely or strongly these recommendations are communicated to doctors or parents. Staff from North Dakota recommends doctors use the state Medicaid questionnaire to screen children whether or not they are enrolled in Medicaid to determine whether they should be tested.
With no official recommendations on the state websites, parents may not have access to definitive state-specific guidance on when they should have their child tested for lead poisoning, or on lead poisoning prevention. Many of the other states’ websites provided a variety of helpful tips, like sources of lead that are especially relevant to residents, in addition to proper house cleaning techniques and nutrition to minimize the chance of lead poisoning.