PEDIATRICS Vol. 108 No. 6 December 2001, pp. 1364-1366
COMMENTARY |
Targeted Screening for Elevated Blood Lead Levels: Populations at High Risk
Abbreviations: NHANES, National Health and Nutrition Examination Survey
Lead poisoning is a preventable environmental disease without borders, affecting children worldwide. Currently, the Centers for Disease Control and Prevention defines an elevated blood level to be 10 µg/dL or greater.1 The most recent National Health and Nutrition Examination Survey (NHANES) 1999 data demonstrated that the geometric mean blood lead level in the United States has decreased to 2 µg/dL.2 That report did not present prevalence data because of small numbers. Despite the lowering of blood lead levels nationally, complacency about lead poisoning is not indicated. An analysis of childhood blood lead data collected by state surveillance programs found that prevalence of elevated blood lead levels varied from state to state and county to county, indicating that lead poisoning is still a problem at the local level.2
Additionally, data suggests that there may be effects of lead on cognitive ability at levels lower than previously reported.3 Other data suggests that standard application of chelation therapy did not improve neuropsychological function in lead-poisoned children.4 These data point out the need for improved prevention efforts, specifically, a shift to primary prevention through improved housing paired with continued, vigilant blood lead screening among populations at risk.
In areas where universal blood lead screening is not indicated,5 identifying populations at high risk for lead poisoning permits effective use of targeted screening for elevated blood lead levels. Additionally, identification of risk permits communities to focus education and preventive efforts, such as housing remediation. Recent reports highlight the risks of children in low-income families and children who have immigrated to the United States.
An important risk factor for lead poisoning is low socioeconomic status, a criterion for Medicaid eligibility. Based on data from NHANES III, Phase 2 (1991–1994), among an estimated 890 000 children with elevated blood lead levels, 535 000 (60%) were on Medicaid.6 Furthermore, Medicaid children accounted for 83% of children ages 1 to 5 with blood lead levels 
20 µg/dL. Although the Centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) mandates that children enrolled in Medicaid receive blood lead screening, an estimated 81% of Medicaid children had not been screened for lead poisoning.6
In the July 2001 issue of Pediatrics, Geltman et al demonstrated that refugee children entering the United States from abroad constitute an additional population at risk for lead poisoning. Geltman et al reported elevated blood lead levels in 693 refugee children who resettled in Massachusetts from 1995 to 1999 from multiple countries.7 Most striking was that 37% of children from Asia and 40% from Central America and the Caribbean had blood levels 10 µg/dL. Among children without elevated levels when they were resettled in the United States, 6% had elevated levels when tested 6 months or more later. The authors also cite several other reports of lead poisoning in refugee populations that have resettled in the United States.
In part, elevated blood lead levels in these children may be attributed to low socioeconomic status: refugee children in the United States are often among the most financially disadvantaged, and therefore may be more likely to live in older, substandard housing that may contain deteriorated, lead-based paint. Also, other nations may have less stringent regulation of environmental lead sources (eg, gasoline, paint); children may enter the United States with blood lead levels already elevated as a result of environmental exposures in their countries of origin. Similarly, environmental and occupational lead exposure of the parents may result in exposure to children, through take-home or intrauterine exposure routes. Use of lead-glazed cooking vessels or folk remedies and herbal and mineral preparations, which have been documented as a source of lead exposure, may be continued in immigrant communities within the United States. Lastly, immigrant children may receive continuing lead exposure during visits back to their native countries.
Like refugees, children adopted from abroad may be at particular risk for lead poisoning. Chinese and Russian children adopted by US citizens have been reported to have elevated blood lead levels.8,9 The American Academy of Pediatrics recommends that children who have been adopted or emigrated from countries where lead poisoning is prevalent should receive blood lead tests.10 When indicated, testing should be performed as a component of medical screening of refugees, which is mandated by federal regulation to occur within 90 days of arrival into the United States.11 As nearly all refugee children have Medicaid coverage for a minimum of 8 months after arrival in the United States, such screening meets Medicaid Early and Periodic Screening, Diagnosis, and Treatment program testing requirements, which should be applied regardless of local risk once in the United States.12 Content of refugee health screening varies between states; therefore, clinicians evaluating newly arrived refugees and immigrants in localities with low environmental lead exposure risk must be both cognizant of the elevated prevalence of lead poisoning among refugees and immigrants and mindful of Medicaid screening requirements.
The article by Geltman et al suggests the need for heightened concern and additional study about the risk for elevated lead levels in immigrant and refugee populations. To eliminate childhood lead poisoning, health programs and providers should be particularly vigilant about lead screening in high-risk groups. There are >6 000 000 Medicaid enrollees between ages 1 and 6 who are 3 times more likely than non-Medicaid children to have elevated blood lead levels; better enforcement of existing screening guidelines for these children is of paramount importance.12 Similarly, immigrant and refugee children deserve close attention. We would agree with the Academy recommendation for lead screening of children who have emigrated (or been adopted) from countries where lead poisoning is prevalent. Whether the data will support screening of all adopted or emigrated children or only targeted children from specific regions remains to be determined. At this time it would be prudent to consider lead screening of these children.
Chicago, IL
Atlanta, GA
for the Advisory Committee on Childhood Lead Poisoning Prevention
Department of Health and Human Services
Philadelphia, PA
FOOTNOTES
Received for publication Jun 8, 2001; Accepted Aug 14, 2001.
Address correspondence to Helen J. Binns, MD, MPH, Children’s Memorial Hospital, 2300 Children’s Plaza, #208, Chicago, IL 60614
PEDIATRICS (ISSN 1098-4275). ©2001 by the American Academy of Pediatrics
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