Blood Lead Levels
William O. Robertson, MDWashington Poison Center
Seattle, WA 98125-8012
To the Editor.—
With reference to the commentary by Binns et al,1 the message regarding immigrant populations is a critical one. (We here in the Pacific Northwest include migrants from Boston and Baltimore among our population!) However they really present a mixed message regarding universal versus targeted screening. The rules of the Health Care Financing Administration (now known as the Centers for Medicare and Medicaid Services [CMS]) are quite explicit; universal screening is mandated for all Medicaid recipients with the threat of nonreimbursement for failure to comply. The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on the matter encouraged HCFA’s action several years ago and despite our requests to CDC to publically modify its position more than a year ago, no action whatsoever has taken place. CDC’s Advisory Committee apparently has the matter under study.
We here in Washington have a monitoring program that finds our rate of elevated blood lead levels among a random population of children to be <1%. Alaska has monitored the blood lead levels of some 967 childhood Medicaid recipients only to find a single elevation—all the way up to 11 µg/dL!
With health care costs continuing to inflate, in appears fiscally irresponsible not to make it clear that targeted testing—not universal testing!—is the way of the future—and today. We plan to continue to "universally test" all immigrants from Central America—as well as Boston and Baltimore—but not immigrants from downtown Norway or the Yukon Territory.
REFERENCE
- Binns HJ, Kim D, Campbell C. Targeted screening for elevated blood lead levels: populations at high risk.
Pediatrics.2001; 108
:1364
–1366
[Free Full Text]
Dennis Kim, MD, MPH
Helen J. Binns, MD, MPH
Carla Campbell, MD, MS
Atlanta, GA
Chicago, IL
Philadelphia, PA
In Reply.—
We thank Dr Robertson for his thoughtful comments and wish to further discuss universal and targeted screening. In 1991, the CDC lowered the blood lead level of concern to 10 µg/dL and adopted a policy of universal blood lead screening, ie, every child should receive a blood lead test.1 After a series of studies that defined low-risk groups of children and a drop in the prevalence of elevated blood lead levels (EBLLs), criteria were identified to promote targeted screening efforts.2 Localities were encouraged to determine high- and low-risk children by examining their surveillance data. Lower-risk children could be given a lead risk assessment to determine if they needed selective blood lead testing. Criteria to consider in a targeted screening strategy included: residence in a particular geographic area (using risks defined by local data, when possible), membership in a high-risk group, and response to a personal-risk questionnaire.
Children living in poverty were identified as being at particularly high risk for elevated blood lead levels. A 1998 report by the US General Accounting Office (GAO) reviewed national data from NHANES III, Phase 2 (1991–1994) and found that children receiving Medicaid were more than 3 times as likely to have an EBLL as those not on Medicaid, and 81% of children receiving Medicaid had never been tested for lead poisoning.3 Given these appalling national statistics, the Centers for Medicare and Medicaid Services (CMS) required that this high-risk group, children on Medicaid, be tested for lead. The Omnibus Budget Reconciliation Act of 1989 requires states to report compliance rates for this directive. State statistics are available at the web site http://www.hcfa.gov/medicaid/epsdthm.htm. According to an audit by the US General Accounting Office 24 of 51 state Medicaid program policies did not meet the CMS requirements.4 Some states are hampered in their reporting efforts because of their inability to track blood lead results. Given their potentially high risk, one has to wonder how many children living in poverty have unidentified EBLLs.
In some areas of the United States, poverty is not a risk factor for lead poisoning, as was shown in a study of Alaskan children by Robin et al.5 We encourage states to examine the risk of lead poisoning among their Medicaid recipients and to further study methods to target higher-risk children among that group of children. You are correct that the CDC Advisory Committee has this matter under consideration, and we welcome comments and findings of studies which further define risk of EBLLs among Medicaid children, particularly in areas of the country where prevalence of EBLLs is low.
On another note, we acknowledge Dr Robertson’s recognition of the importance of our call for blood lead screening of children who have entered the United States from other countries through immigration or adoption. It is important to consider that even if such children have not had lead exposure before arrival, upon entering the United States, they may move into older houses with deteriorated paint, placing them at risk for EBLLs. In 1999, a child who had recently immigrated into the United States died from lead poisoning attributable to lead paint exposure in the first month of residence.6 Careful consideration of the lead poisoning risks faced by these children is needed.
REFERENCES
- Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1991
- Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1997
- US General Accounting Office. Medicaid: Elevated Blood Lead Levels in Children. Washington, DC: US General Accounting Office; 1998. GAO Publ. No. GAO/HEHS-98-78
- US General Accounting Office. Lead Poisoning: Federal Health Programs Are Not Effectively Reaching At-Risk Children. Washington, DC: US General Accounting Office; 1999. GAO Publ. No. GAO/HEHS-99-18
- Robin LF, Beller M, Middaugh JP. Statewide assessment of lead poisoning and exposure risk among children receiving Medicaid services in Alaska. Pediatrics.1997; 99(4) . Available at: http://www.pediatrics.org/cgi/content/full/99/4/eq
- Centers for Disease Control and Prevention. Fatal pediatric lead poisoning—New Hampshire, 2000. MMWR Morb Mortal Wkly Rep.2001; 50 :457 –459[Medline]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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