Objective. Beginning in 1995, Illinois law permitted targeted—as opposed to universal—blood lead screening in low-risk areas, which were defined by ZIP code characteristics. State guidelines recommended specific lead risk assessment questions to use when targeting screening. This study was designed to evaluate the sensitivity and specificity of Illinois lead risk assessment questions.
Design. Parents bringing their 9- or 10- or 12-month and 24-month-old children for health supervision visits at 13 pediatric practices and parents of children (aged 6 through 25 months and who needed a blood lead test) receiving care at 5 local health departments completed a lead risk assessment questionnaire concerning their child. Children had venous or capillary blood lead testing. Venous confirmation results of children with a capillary level ≥10 μg/dL were used in analyses.
Children. There were 460 children with both blood and questionnaire data recruited at the pediatric practices (58% of eligible) and 285 children (51% of eligible) recruited at local health departments. Of the 745 children studied, 738 provided a ZIP code that allowed their residence to be categorized as in a low-risk (n = 456) or high-risk (n = 282) area.
Results. Sixteen children (3.5%) living in low-risk areas versus 34 children (12.1%) living in high-risk areas had a venous blood lead level (BLL) ≥10 μg/dL; 1.8% and 5.3%, respectively, had a venous BLL ≥15 μg/dL. For children living in low-risk areas, Illinois mandated risk assessment questions (concerning ever resided in home built before 1960, exposure to renovation, and exposure to adult with a job or hobby involving lead) had a combined sensitivity of .75 for levels ≥10 μg/dL and .88 for levels ≥15 μg/dL; specificity was .39 and .39, respectively. The sensitivity of these questions was similar among children from high-risk areas; specificity decreased to .27 and .28, for BLLs ≥10 μg/dL and ≥15 μg/dL, respectively. The combination of items requiring respondents to list house age (built before 1950 considered high risk) and indicate exposure to renovation had a sensitivity among children from low-risk areas of .62 for BLLs ≥10 μg/dL with specificity of .57; sensitivity and specificity among high-risk area children were .82 and .36, respectively. For this strategy, similar sensitivities and specificities for low and high-risk areas were found for BLLs ≥15 μg/dL.
Conclusions. The Illinois lead risk assessment questions identified most children with an elevated BLL. Using these questions, the majority of Illinois children in low-risk areas will continue to need a blood lead test. This first example of a statewide screening strategy using ZIP code risk designation and risk assessment questions will need further refinement to limit numbers of children tested. In the interim, this strategy is a logical next step after universal screening.
- IDPH =
- Illinois Department of Public Health •
- CDC =
- Centers for Disease Control and Prevention •
- LHD =
- local health departments •
- IDPHL =
- Illinois Department of Public Health Laboratory •
- BLL =
- blood lead level •
- WIC =
- the Special Supplemental Food Program for Women, Infants, and Children •
- CI =
- 95% confidence interval •
- RR =
- relative risk
Between 1993 and 1995, Illinois law required universal blood lead screening before entry into a state-licensed day care, preschool, or kindergarten.1 In 1995, Illinois law was amended to allow for targeted blood lead screening. The law required identification of high- and low-risk areas and development of statewide guidelines for determining which children residing in low-risk areas should have a blood lead test.
The first step, the determination of high- and low-risk areas in the state, was completed by the Illinois Department of Public Health (IDPH).2 Using 1990 census data, ZIP code areas were ranked based on 3 equally weighted criteria: 1) the percentage of residential buildings built before 1950, 2) the percentage of residential buildings built 1950 to 1959, and 3) the percentage of residents at or below 200% of the federal poverty level. A medical advisory panel recommendation to consider ZIP code areas ranking in the highest two quintiles or in the city of Chicago as high risk was adopted. In high-risk areas, continued universal blood lead screening for children was recommended.
Risk assessment questions to be used to target blood lead screening in low-risk areas were chosen by IDPH based on recommendations by a medical advisory panel and local health department representatives.2 Three key questions (related to exposure to a house built before 1960, exposure to renovation, and job or hobby exposure) to determine which children living in low-risk ZIP code areas should have blood lead screening were identified. Four additional questions, to be used at the discretion of the provider, were also included in state lead guidelines.
In November 1997, after this study was conducted, the Centers for Disease Control and Prevention (CDC) released revised lead risk assessment recommendations.3 Included in that document were guidelines for state and local health departments to use to develop local screening strategies and 3 questions to consider when developing a personal-risk questionnaire: 1) Does your child live in or regularly visit a house that was built before 1950? 2) 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)? and 3) Does your child have a sibling or playmate who has or did have lead poisoning? Related Illinois risk questions (see “Methods”) differ regarding the years of concern and the duration of exposures. Illinois risk questions do not include question 3, above. The performance of the CDC personal-risk questions has not been determined.
When a strategy is adopted to target blood lead screening, two central themes of evaluation emerge: 1) Does the methodology used to identify areas of high- and low-risk effectively designate areas in which children are at highest risk for exposure? and 2) Are the risk assessment questions used to evaluate the need for a blood lead test sensitive and specific? This study was designed to answer the second of these questions. Because we included a request to list year or decade respondents home was built, we were also able to examine the data to provide a first look at the performance of questions similar to those proposed by the CDC in the 1997 recommendations.3
The survey requested parents to provide demographic information about their child and family. Eight risk questions, each with three response choices (no, yes, don't know) were listed on the parent-completed questionnaire.
Has your child ever lived in or regularly visited a house, building, day care center, preschool, or home of a relative built before 1960?
Does your child live in or regularly visit a house or building built before 1960 with recent renovation or remodeling?
Does your child live with an adult whose job or hobby involves exposure to lead?
Did you or any other person ever give your child home remedies like greta, azarcon, pay-loo-Ah or Hai ge fen?
Do you fix meals, keep food, or eat from ceramic dishes or pottery not made in the US?
Has your child ever been in Mexico, Central America, or South America?
Do you live near an active lead smelter, battery recycling plant, or other industry likely to release lead?
Does your child live in or regularly visit a house or building built before 1960 with peeling or chipping paint?
Illinois guidelines mandate the use of questions 1 through 3; questions 4 through 7 are optional.2 The eighth question evaluated was taken from the 1991 CDC recommendations4 and included to determine if its addition would improve sensitivity or specificity of the risk assessment instrument. Additional items requesting parents to list the year or decade their home was built and whether they owned or rented their home were included for the same reason and to determine internal agreement between question responses. For children enrolled at local health departments, staff provided information about each child's reason for the visit and previous lead testing.
Blood Lead Measurement
Blood lead testing at no cost was offered to all participating children. Pediatric practices and local health departments (LHDs), described below, obtained an initial capillary or venous test that was processed by atomic absorption spectrophotometry at the IDPH Laboratory (IDPHL) in Springfield, IL. Children with initial capillary blood lead levels (BLLs) ≥10 μg/dL were requested to return for confirmation venous sampling. Only venous blood lead samples processed at the IDPHL were considered to be confirmatory.
Physicians at 38 practices around the state, excluding Chicago, were invited to participate. Each of these practices served children living in low-risk areas or a mix of high- and low-risk areas. (Practices in the city of Chicago were not invited to participate because the entire city is designated high risk. Consequently, sites in Chicago were not considered appropriate to evaluate a screening strategy designed for use among children living in low-risk areas.) Thirteen practices completed the study and 25 declined participation. The two most common reasons for refusal to participate were difficulty with the in-office blood sampling process (n = 10) and staffing shortages/too busy (n = 7). Other reasons included: unwillingness of physicians to conform to a uniform screening age; lack of reimbursement for sample handling; children at the practice had already been tested; and the practice routinely tested children at a different age. Six participating practices were located in the suburban Chicago area and the 7 others were scattered throughout the state (4 in northern, 2 in central, and 1 in southern Illinois).
In keeping with routine care, children were enrolled at pediatric practices at two selected health supervision visits; a 9-, 10-, or 12- month health supervision visit (one specific visit was selected by each practice) and the 24-month health supervision visit. All children enrolled were within ±2 months of the target age for the visit. Practices participated for 8 consecutive weeks between May and December 1996. Daily appointment schedules or sign-in logs indicating patient age and reason for visit were reviewed retrospectively for all practices except one, where this was impossible. For the 12 practices where schedules or sign-in logs were available, the number of children eligible who were not surveyed was determined.
Eleven LHDs were invited to participate. Six LHDs declined for reasons that included low frequency of blood lead screening, staffing considerations, previous unfavorable experience with lead questionnaires, and no interest. No participating LHDs were located in the suburban Chicago area; 2 were in central and 3 in southern Illinois.
Children present for LHD services sporadically. Therefore, age eligibility at LHDs was expanded, as compared with the practice sites, to more closely mimic the way risk assessment would be used to determine the need for lead screening in that setting. Staff at LHDs enrolled children who were due for blood lead testing and were presenting to the LHD between the ages of 7 through 25 months of age (1 LHD) or 6 through 25 months (4 LHDs). Children presenting for either health supervision care, visits associated with the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC), or lead testing only were included. Each LHD maintained a log of eligible children who were missed or refused to participate. Three LHDs surveyed all appropriately-aged children regardless of the need for a blood lead test. At the LHDs that surveyed all children, those considered eligible for the study (for calculation of response rates) were children 12 months of age or older who had not had a previous blood lead test. Four LHDs participated during 8 consecutive weeks between May and December 1996. One LHD participated for 5 weeks because of a commitment to other activities.
Treatment and follow-up of children with elevated BLLs were determined by the participating sites. This study was approved by Institutional Review Boards at Children's Memorial Hospital and at the University of Chicago.
Data were maintained and analyzed in SPSS for Macintosh, version 6.1.1 (SPSS, Inc; Chicago, IL, 1995). Significance level was P < .05. χ2 tests were used to test differences between respondents from high- and low-risk areas on individual questions. In analyses of screening strategies, a “yes” or “don't know” or missing response to any one question included in a strategy was considered sufficient to trigger the need for a blood lead determination. For the screening strategies, the positive predictive value (the probability of an elevated BLL among children targeted for screening), the negative predictive value (the probability of children not targeted for screening having an elevated BLL), the sensitivity (the probability that children with an elevated BLL will be targeted for screening), and the specificity (the probability that children without an elevated BLL will not be targeted for screening) for cutoff levels of 10 μg/dL and 15 μg/dL were determined.
During the study months, 1354 eligible Illinois children were seen at participating sites. Table 1 lists the extent of participation at pediatric practices and LHDs. Seventy-one percent (414/580) of parents whose children did not have an analyzable BLL completed a survey.
Practice and LHD Participation
Of the 460 children enrolled through the practices with both completed questionnaire and analyzable blood lead results, 281 (62%) and 178 (38%) were being seen for a 9- to 12-month or a 24-month health supervision visit, respectively. Parent survey completion by practice ranged from 22% to 100%. Children attending a 9- to 12-month visit were more likely to have both survey and blood lead completed than children attending a 24-month visit (60% vs 39%, respectively,P < .001).
Questionnaires and analyzable blood lead results were obtained on 285 children from the LHDs. Ability of the LHDs to obtain blood samples on eligible children varied from 6% to 94% of eligible children. However, survey forms were obtained on 97% of eligible children (range by LHD, 94%–99%). Of children enrolled through the LHDs with both questionnaire and analyzable blood lead results, 146 (51%), 78 (27%), and 61 (21%) were 6 through 13 months, 14 through 21 months, and 22 through 25 months of age, respectively. Seventy-five percent of the children were being seen for a WIC visit, 17% for health supervision, and 8% for a lead test only. Eligible children from the LHDs without questionnaire and analyzable blood lead results did not significantly differ in age from those who completed both.
Capillary Blood Lead Elevation
Five hundred fifty-three children had an analyzable capillary BLL. Of these, only 58 (8.3%) had a capillary BLL ≥10 μg/dL. Thirty-eight children with a capillary BLL ≥10 μg/dL returned for a confirmatory venous sample a median of 20 days after the capillary screen. Among those who returned, venous levels ranged from 3 to 21 μg/dL (mean difference between venous confirmation level and capillary level was −5.7 μg/dL, SD 5.4 μg/dL, range −22 to +5 μg/dL); 18 (47%) had a confirmed elevated BLL. Based on this ratio, we estimate 9 additional children (95% confidence interval [CI], 5.9–12.1) would have had a confirmed elevated venous level, if all children with capillary BLL ≥10 μg/dL had returned for a retest. Nine of 20 children without a confirmatory venous sample lived in a high-risk area, 10 lived in a low-risk area, and 1 was not classified because a survey was not completed. Venous samples on 6 children with capillary blood lead elevation were not considered confirmatory because they were analyzed at laboratories other than the IDPHL (venous BLL results from the other laboratories were all <10 μg/dL). If we had included them as confirmed low BLLs in the analyses, results would not be appreciably different.
Prevalence of Elevated Blood Lead Levels
Fifty-two of 767 children tested had a venous BLL ≥10 μg/dL (7%; 95% CI, 5.2%–8.8%); 34 with a high level were detected via initial venous screening and 18 via venous confirmation after capillary screening. ZIP code data sufficient to classify children into residence in high- or low-risk areas was available for 738 (96%) of the 767 children tested, including 50 of the children with a high level and 688 with a low level.
The prevalence of elevated BLLs was 12.1% (34/282) among children living in a high-risk area and 3.5% (16/456) among children living in a low-risk area (P < .001). Among the children from high- and low-risk areas, there were 9 and 6 children, respectively, with a level 15 to 19 μg/dL and 6 and 3 children with a level ≥20 μg/dL.
Demographic information by ZIP code area for children with both questionnaire and analyzable blood lead results is presented in Table 2. Responses to risk questions by ZIP code area for these same children are presented in Table 3.
Overall, only 1 of the 8 risk questions significantly, individually predicted children with elevated blood lead. This was the question concerning exposure to peeling or chipping paint (relative risk [RR], 2.3; 95% CI, 1.2–4.1). Two additional survey items also individually predicted children with elevated blood lead: the year the home was built, and home rental. Risk was increased for children living in older homes (if the parent listed a year before 1950, RR, 4.1; 95% CI, 2.2–7.6; or if the parent listed a year before 1960, RR, 3.2; 95% CI, 1.5–7.0) and for those who rented their home (RR, 3.1; 95% CI, 1.7–5.7).
To assess bias we compared information obtained on eligible children with both blood results and surveys with eligible children with only partial information. Risk responses differed for only for one item. Those having both survey and blood lead results were more likely to report using or being unsure of the use of imported pottery (16% vs 9%, P < .01). Of those surveyed, children living in low-risk areas were more likely than those living in high-risk areas to have a BLL (low-risk areas 69%, high-risk areas 58%, P < .001); however, percentage of children with a BLL did not differ by housing age.
Agreement Between Related Risk Questions
Our initial assumption was that the single question “Has your child ever lived in or regularly visited a house, building, day care center, preschool, or home of a relative built before 1960?” would also identify children exposed to buildings of this age with peeling or chipping paint or with recent renovation or remodeling. However, among all survey respondents, only 83% (127 of 153) of those who responded “yes” to the chipping/peeling paint question also responded “yes” to exposure to a home built before 1960. Of those who responded “yes” to exposure to recent renovation or remodeling, only 82% (221 of 268) answered “yes” to exposure to a home built before 1960. We had also assumed that those who listed a year before 1960 as when their house was built would answer “yes” to the more general question about child exposure to a house of this age. However, only 83% (255 of 308) parents who listed a year before 1960 as when their home was built responded “yes” to child exposure to a home built before 1960.
Evaluation of Screening Strategies
Screening strategies were evaluated separately for high- and low-risk ZIP code areas and for identification of BLLs ≥10 μg/dL or ≥15 μg/dL. Table 4 presents the positive predictive value, the negative predictive value, the sensitivity, and the specificity for each strategy. For these evaluations, we considered any “yes,” “don't know,” or missing response as indicative of the need for a blood lead test. Sensitivity of the questions was lower when considering “yes” answers only as indicative the need for a blood lead test (data not presented).
The three primary Illinois questions (ever lived in house built before 1960, renovation, job/hobby) had a high sensitivity for children living in low-risk ZIP code areas; 75% of children with a BLL ≥10 μg/dL and 88% of children with a BLL ≥15 μg/dL would have been identified. Sensitivity of the questions in high-risk ZIP codes was quite similar. However, specificity was low; most Illinois children would have needed a blood lead test. Sixty-two percent of children living in a low-risk ZIP code and 73% of children living in a high-risk ZIP code had at least one “yes,” “don't know,” or missing response to a primary Illinois question. A strategy including all 7 Illinois questions increased the percentage of low-risk ZIP code children having at least one “yes,” “don't know,” or missing response to 69%, and did not improve the sensitivity.
A strategy including the two response items most similar to the 1997 CDC personal-risk questions2 was evaluated. For a strategy requiring the parent to list home age (before 1950 considered high risk) and respond to the question about exposure to renovation, 43% of children from low-risk ZIP code areas and 67% of children from a high-risk ZIP code would have been identified as needing a blood lead test (ie, had 1 or more “yes,” “don't know,” or missing responses). As shown in Table 4, sensitivity for this 2-criteria strategy in low-risk ZIP code areas was lower than the Illinois strategy.
The addition of questions concerning job/hobby exposure and exposure to peeling/chipping paint in a house built before 1960 to the 2-criteria strategy improved the sensitivity (see Table 4) and would have required screening more children; 54% of children from low-risk ZIP code areas and 76% of children from high-risk ZIP code areas had 1 or more “yes,” “don't know,” or missing responses.
A strategy including 5 criteria (list year house built as before 1950, renovation of house built before 1960, job/hobby exposure, peeling/chipping paint in house built before 1960, home rental) would have identified all children with a BLL ≥15 μg/dL and required a blood lead test on 65% of children living in low-risk ZIP codes and 87% of children living in high-risk ZIP codes.
Among those surveyed, bias attributable to not obtaining BLLs on all children was assessed for each of the three strategies presented above. For each strategy, no significant difference was found (ie, children classified as high risk—and therefore in need of a blood lead test—were not more likely to have a BLL than those classified as low-risk).
The prevalence of elevated BLLs differed between high- and low-risk ZIP code areas in this sample. For children living in high-risk ZIP code areas, the prevalence (12.1%) was approximately 3 times higher than the prevalence found among children living in low-risk ZIP code areas (3.5%).
Each screening strategy evaluated had a low specificity. Based on study responses, the majority of children living in Illinois low-risk ZIP code areas—where targeted blood lead screening is allowed—will continue to need a blood lead test if physicians use Illinois risk assessment questions as recommended by Illinois guidelines. Physicians will need to evaluate whether such a reduction in screening at their practice is worth the effort it takes to apply the risk assessment. This will be highly dependent on the age of housing among their patients.
Although the risk assessment strategies are designed for use among low-risk children, those tested also had a high sensitivity for children living in high-risk ZIP code areas where universal screening is required. This is probably because most children in high-risk areas would have been considered “at-risk” according to their responses and therefore tested. In practice settings that include children from both high- and low-risk ZIP code areas, a uniform system—targeted screening based on response to risk assessment questions—may work for all children.
Multiple questions with a similar focus were evaluated. Parents did not always respond as expected. The need to limit the number of questions asked must be balanced with the variety of ways in which parents choose to interpret them.
Our low venous confirmation rate for elevated capillary samples (47%) was not unexpected. Other studies in low-risk practice settings had confirmation rates of 32%5 and 30%.6Our low confirmation rate reflects fluctuations that occur with blood lead levels over time, regression to the mean,7 random analytic error that occurs in the analysis of blood lead samples,8 and a positive bias for capillary samples.9 We have no reason to believe sampling or analytic techniques were faulty, although we did not systematically examine these.
Comparison With Other Studies
Other studies (Table 5),5 10–15 among samples of children with low prevalence of elevated venous BLLs (<12%), have evaluated the lead risk questions suggested by the CDC in 1991.4 The risk questions recommended in 1991 included1: exposure to pre-1960 housing with peeling or chipping paint,2 exposure to renovation,3friend or sibling with blood lead elevation,4 job/hobby exposure, and5 home near lead industry. At the expense of specificity, the sensitivities of strategies examined in the current study were generally higher than the sensitivity of the CDC 5-question strategy evaluated in other studies. The value of individual CDC questions appears to depend on the population being assessed. Some studies have improved the sensitivity of risk questions by adding or substituting questions relevant to local conditions.5 ,12 ,14 16–20
The additional strategies we evaluated were both included on the key questions about house age and exposure to renovation. Using data from our 1992 study, which included questionnaire and blood lead information on 1393 children attending 12- or 24-month well-child visits at suburban Chicago pediatric practices,5 we evaluated 2 of the alternative strategies examined in the current study. (We did not ask about rental status in the 1992 study; therefore, we could not evaluate the strategy that included that item.) In the 1992 study, the 2-question strategy (listing house as built before 1950; renovation to house built before 1960) had a sensitivity of 77% for BLLs ≥10 μg/dL and 82% for BLLs ≥15 μg/dL and specificity of 67% and 67%, respectively. The 4-question strategy (listing house built before 1950; renovation to house built before 1960; job/hobby involving lead; exposure to peeling/chipping paint) improved sensitivity to 83% for BLLs ≥10 μg/dL and 91% for BLLs ≥15 μg/dL with specificity of 50% and 50%, respectively. Thus, alternative strategies worked similarly for both past and recent Illinois samples.
The practices and LHDs that participated in this study can not be presumed to be representative of Illinois children. Many practices declined participation, most commonly because of difficulty with blood drawing. Many perceived prevalence of an elevated BLL among the children they see to be extremely low, making study participation less attractive. Without further study we can not determine how children in other areas of Illinois would respond. However, the similarity in results between the suburban Chicago study5and this one is reassuring.
Parents in this study were less willing to have their child's blood lead tested than parents in our 1992 suburban Chicago study.5 Possibly, with the change in the Illinois law, parents were not as willing to subject children to what they considered to be an unnecessary test or parents declined testing of children with a previously known low BLL. Some sites were much more successful in obtaining blood lead tests on eligible children than others. This likely reflects the attitude of the office staff toward lead testing (whether a lead test was perceived as a necessity) and the ability of the staff to obtain an adequate sample on a young child.
Because the questions were designed for use among children living in low-risk ZIP codes, the most appropriate evaluation of these questions is among children in those areas. Most children enrolled at practices lived in a low-risk ZIP code area. Children enrolling at local health departments were generally presenting for WIC services and therefore live in low-income households, a characteristic associated with a higher prevalence of blood lead elevation.21
Large sample sizes are required to determine the most effective risk assessment questions in areas with a low prevalence of elevated BLLs. The cooperation of physicians and parents is an important component of evaluation and may be difficult to establish in areas of low risk.
Most children residing in Illinois low-risk ZIP code areas will continue to need a blood lead test if questions from current Illinois guidelines are applied as recommended. However, based on this study, few children with an elevated BLL will be missed. This first example of a statewide screening strategy using ZIP code risk designation and risk assessment questions will need further refinement to limit numbers of children targeted for a blood lead test. In the interim, this strategy is a logical next step after universal screening.
The study was funded by Contract No. 63000094 from the Illinois Department of Public Health.
We wish to thank practices and health departments who assisted with this study and especially those listed who guided participation in their offices: Carle Clinic, Mattoon, IL–D. Stoltz, MD, C. Hopkins, RN, B. Hall, RN; Child Life Center, Homewood, IL–J. Schreier, MD, K. Saak, RN; Dixon Clinic, Dixon, IL–E. Gale, MD, M. Downey, RN, C. Baker; Freeport Clinic, Freeport, IL–P. Parek, MD, A. Barbon, MD, S. Sproule, LPN;Glenbrook Pediatrics, Glenbrook, IL–L. Walsh, MD, L. Walsh;North Arlington Pediatrics, Arlington Heights, IL–D. Dobkin, MD, M. Mayer, RN; Pediatric Center, Ottawa, IL–A. Davé, MD, S. Moals; Pediatric Partners, Highland Park, IL–S. Sirota, MD, J. Lieb, RN, J. Berg, RN, C. Randall, RN;Pediatric Specialists, Crystal Lake, IL–B. Altshuler, MD, S. Lenz, RN; Quincy Medical Group, Quincy, IL–D. Go, MD; S. Feller, RN; Rural Health, Inc, Anna, IL–K. Swafford, MD, B. Frank, RN, J. Hayes, D. Hogg, RN; University Child Health, Rockford, IL–M. Potts, MD; Wheaton Pediatrics, Wheaton, IL–P. Liber, MD, L. Rozema, RN; Jackson County Health Department, Murphysboro, IL–C. Griffin, RN, T. Brewer, RN;Jefferson County Health Department, Mt. Vernon, IL–T. Darden, RN; Kankakee County Health Department, Bourbonnais, IL–J. Marshall, RN, L. Coffie; Rock Island County Health Department, Rock Island, IL–C. Bileddo, RN; and Wayne County Health Department, Fairfield, IL–S. Vaughn, RN.
Valuable assistance was provided by the Illinois Department of Public Health staff (R. Zimmerman, D. Lee, C. Carver, RN, J. Fornoff, PhD) and the Children's Memorial Medical Center staff (J. Gagliardi, B. Uniejewski, R. Sandoval).
- Received March 3, 1998.
- Accepted July 22, 1998.
Reprint requests to (H.J.B.) Children's Memorial Medical Center, 2300 Children's Plaza, #208, Chicago, IL 60614.
Contents are solely the responsibility of the authors and do not necessarily represent the official views of the Illinois Department of Public Health.
- ↵Lead Poisoning Prevention Act (410 ILCS 45/1 et seq)
- ↵Illinois Department of Public Health. Guidelines for the Detection and Management of Lead Poisoning for Physicians and Health Care Providers. Springfield, IL: Illinois Department of Public Health; 1996
- ↵Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning. Guidance for State and Local Public Health Officials. Atlanta, GA: Centers for Disease Control and Prevention; 1997
- ↵Centers for Disease Control. Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta, GA: Centers for Disease Control; 1991
- Binns HJ,
- LeBailly SA,
- Poncher J,
- Kinsella TR,
- Saunders SE,
- and the Pediatric Practice Research Group
- Markowitz MD,
- Bijur PE,
- Ruff H,
- Rosen JF
- Parsons PJ,
- Reilly AA,
- Esernio-Jenssen D
- Paulozzi LJ,
- Shapp J,
- Drawbaugh RE,
- Carney JK
- Schaffer SJ,
- Kincaid MS,
- Endres J,
- Weitzman M
- Snyder DC,
- Mohle-Boetani JC,
- Palla B,
- Fenstersheib M
- Tejeda DM,
- Wyatt DD,
- Rostek BR,
- Solomon WB
- Rooney BL,
- Hayes EB,
- Allen BK,
- Strutt PJ
- Schaffer SJ,
- Szilagyi PG,
- Weitzman M
- Haan MN,
- Gerson M,
- Ziskla BA
- Nordin J,
- Rolonick S,
- Ehlinger E,
- et al.
- Copyright © 1999 American Academy of Pediatrics