In 2010, Puerto Rico experienced a cluster of childhood lead poisoning cases stemming from parental occupational exposure to lead. Following the immediate response to this crisis, a dedicated coalition of pediatricians and public health practitioners sustained a collaborative effort to advance pediatric environmental health initiatives across Puerto Rico. Their commitment laid the groundwork for the establishment and evolution of Puerto Rico's comprehensive Childhood Lead Poisoning Prevention and Blood Lead Level Surveillance Program. This compelling case study showcases the potential for concerted, multidisciplinary action to leverage an acute event to influence public policy and clinical practice to promote children's health. By drawing on the lessons learned and strategies used in Puerto Rico, other jurisdictions can overcome challenges in pursuit of enhanced secondary lead poisoning prevention measures, with the goal of achieving primary prevention in the near future.
Exposure to lead remains a major environmental risk for children worldwide.1,2 Even at the lowest measurable blood lead levels, early childhood lead poisoning can result in neurocognitive delays, behavioral and developmental problems, and learning disabilities among other lifelong problems.3,4
States and territories establish their own guidelines regarding blood lead testing and reporting. In Puerto Rico (PR), blood lead testing was recommended at 1 and 2 years of age, but, in practice, was mostly complied with as a requisite for Head Start Program enrollment. In 2010, the Centers for Disease Control and Prevention (CDC) conducted a population-based prevalence study on blood lead levels (BLLs) among children younger than 6 years of age living in PR.5 The goals of the study were, among others, to understand child lead poisoning and healthy housing issues in PR; evaluate the progress toward eliminating childhood lead poisoning in PR; increase activities in lead poisoning prevention, healthy housing, or blood lead surveillance; and evaluate the need to change from universal screening to targeted screening based on the study results. The study, published in 2016, found comparable prevalence of high BLLs between children living in PR and the US national estimate. The investigators suggested shifting guidance to targeted screening and BLL testing of specific higher risk groups of children younger than 6 years old. The events and collaborative work described later illustrate how such screening requires collective buy-in, sufficient public and health care provider perception of risk, and a lead toxicity prevention infrastructure to take hold and be sustained and how this reality is coming to be possible in PR.
In 2010, concurrently, but separately from the CDC study, reached out to a pediatric consultant at the Puerto Rico Department of Health (PRDOH), with the rare report of 2 children with BLLs surpassing the CDC’s the “level of concern” for lead toxicity of ≥10 mcg/dL. Drawing on her clinical expertise and public health experience, this pediatrician promptly initiated an investigation that led to the identification of 50 children with confirmed lead toxicity of ≥5 mcg/dL linked to parental occupational exposure at a battery recycling plant.6
The short- and medium-term response to this outbreak required a multisectoral collaboration of federal (CDC, US Department of Housing and Urban Development, the Environmental Protection Agency [EPA], Head Start/Early Head Start, the Special Supplemental Nutrition Program for Women, Infants, and Children) and local government agency counterparts, academic and nongovernmental organizations, Region 2 Pediatric Environmental Health Specialty Unit (R2 PEHSU), the Puerto Rico Chapter of the American Academy of Pediatrics (PRAAP), and community leaders. These collaborations of stakeholders in lead poisoning prevention were essential in addressing the outbreak comprehensively.
The outbreak was a watershed moment for lead prevention and early detection, spurring energized advocacy, reinvigorated education, revised guidelines, and, ultimately, developing a surveillance system. These changes were possible through the leadership of another pediatrician consultant at the PRDOH who had a long track record of championing pediatric health, a pediatric consultant supporting CDC in PR, and the PR state epidemiologist. In 2013, the PRDOH implemented a lead exposure risk questionnaire, which was integrated into its Preventive Pediatric Care Periodicity Schedule, starting at the 6-month well-child care visit. In 2016, PRDOH Administrative Order 358 added lead poisoning to the list of notifiable conditions.
The 2010 lead toxicity outbreak prompted a reevaluation of the threat of lead poisoning among children within PR's public health system. Yet, it underscored the glaring challenge posed by the lack of data and surveillance tools to tackle the issue effectively. Our goal for this case study is to offer an example of how federal, state/territory, and local government organizations can partner with their local AAP Chapter and other key stakeholders to optimize pediatric lead prevention and management and overcome health inequities. It underscores the importance of the integration of primary care and public health to address lead toxicity among children at the individual and population levels.
Inclusion is a Key to Health Equity in Lead Toxicity Prevention and Management
Children in PR are impacted by several social and environmental drivers of health that put them at an increased risk for lead exposure. The high prevalence of childhood poverty and food insecurity, PR’s high density of Superfund sites, particular climate vulnerabilities, and a deteriorating infrastructure are some examples.7–10
In February 2021, the CDC announced a grant opportunity for Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children (CDC-RFA-EH21-2102). This funding presented an opportunity to establish the necessary infrastructure for blood lead poisoning prevention in PR. Recognizing the need to include pediatric expertise, PRDOH officials sought to engage PRAAP leaders who had persevered in urging for lead prevention measures. PRDOH, with the collaboration of PRAAP, applied for the funding, only to discover later that, according to 42 U.S.C. Section 247b(k)(2), US territories were ineligible to apply. This situation revealed a glaring health inequity, ironically placed within an otherwise promising public health initiative. This challenge presented an opportunity for PRAAP to argue for (1) the inclusion of US territories in this and future federally funded lead prevention initiatives, (2) establishing a lead poisoning prevention system in PR that meaningfully incorporates and supports pediatricians and, and (3) improved integration between pediatric primary care and public health.
The Beginning of a New Era in the Prevention of Lead Poisoning in PR
Pediatricians play a vital role in the secondary prevention of lead poisoning by screening for risk factors, conducting timely blood lead testing, and referring children and families to appropriate services.1 However, beyond assuring that children are tested, pediatricians are called by the AAP to work with federal, state, and local governments to ensure appropriate case management and environmental investigation.1
The linkages born out from the lead poisoning outbreak grew stronger in its aftermath. In 2014, the EPA partnered with R2 PEHSU, Icahn School of Medicine at Mount Sinai, and the graduate PR School of Public Health to train 5 fellows on pediatric environmental medicine. The AAP supported leadership development of the 2 pediatricians who championed lead prevention public policy in 2015 and supported the role of an early childhood champion in conducting lead prevention educational activities for Head Start personnel. The Caribbean Division of the EPA supported a public health trainee predoctoral trainee (who eventually became the leader applying for CDC-RFA-EH21-2102) and engaged the PEHSU in advocacy efforts to develop other pediatric environmental health projects, including integrated pest management in schools and a soilSHOP event (testing for lead in soil) in an underserved area. In 2017, with the advocacy work of the 2 pediatricians involved in the 2010 childhood lead poisoning outbreak response and in compliance with Medicaid Early Periodic Screening, Diagnosis, and Treatment, PRDOH reaffirmed universal blood lead testing at 12 and 24 months of age.
These activities (Table 1) were instrumental in preparing PRAAP leadership to advocate effectively for the inclusion of US territories in the Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children funding announcement. This advocacy work involved:
persuasive communication with the leadership of the CDC Lead Poisoning Prevention and Environmental Health Tracking Branch through phone call meetings and e-mail correspondence; and
summoning other stakeholders to promote awareness of and buy-in, including Region 2 offices of the EPA and US Department of Housing and Urban Development, to address this inequity in access to funding consideration.
Advocacy Actions by Pediatricians to Shape the Path to a Lead Prevention Infrastructure
Year . | Advocacy Action . | Outcome . |
---|---|---|
2010 | Pediatrician initiated an investigation at PRDOH to evaluate the rare reporting of children with lead poisoning (blood lead reference value was 10 mcg/dL). | PRDOH conducted a voluntary blood lead screening that identified 68 children with lead in blood (confirmed 50) linked to parental occupational exposure at a battery recycling plant. This led the intervention of stakeholders and the eventual closure of the facility. |
2012 | After noticing that the blood lead level reports did not reflect the updated CDC reference level of 5 mcg/dL, a pediatrician outreached the president of the CMTPR requesting that the BLRV in the reports be updated accordingly. | The CMTPR informed all clinical laboratories in PR about the updated reference level for lead in blood in children and asked for an update in the laboratory reports. |
2013 | Pediatricians reviewed the NYC lead risk assessment questionnaire, adapting it culturally and linguistically for PR. They also met with the PRDOH Secretary to advocate for adopting this questionnaire as the lead screening tool for clinicians evaluating children. | PRDOH Secretary sent a letter to all physicians in PR recommending using this risk assessment questionnaire and being mindful of occupations associated with lead exposure. |
2015 | Pediatrician assisted R2 EPA in planning a soilSHOP activity in Caño Martín Peña, San Juan, PR, by meeting and working with several stakeholders. | The soilSHOP took place in collaboration with R2 PEHSU, R2EPA, PRDOH, UPR, and CMTPR. Activities included: generic soil screening for lead (XRF), capillary blood lead testing, gardening workshop, and lead prevention education by health educators. |
2016 | Pediatricians advocate for universal blood lead testing at 12 and 24 mo of age. | The 2017 PRDOH Pediatric Preventive Services Periodicity Schedule included universal blood lead testing at the 12- and 24-mo well-child care visits. |
2019 | PRAAP applied for funding to conduct a Lead Testing ECHO (Extension for Community Healthcare Outcomes) series. | The PRAAP Lead Testing ECHO series launched, supported by the Cooperative Agreement NU38OT000282, funded by the CDC with a quality improvement component. |
2021 | PRDOH consulted PRAAP for assistance with the application for the Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children (CDC-RFA-EH21-2102). | PR and other territories were not eligible to apply. |
2022 | A pediatrician writes to CDC leadership to advocate for including PR and other territories in the list of eligible organizations for CDC-RFA-EH21-2102. | PR becomes eligible to apply for CDC-RFA-EH21-2102. PRDOH applies and is awarded funding to establish the PR-CLPPP Program. |
Year . | Advocacy Action . | Outcome . |
---|---|---|
2010 | Pediatrician initiated an investigation at PRDOH to evaluate the rare reporting of children with lead poisoning (blood lead reference value was 10 mcg/dL). | PRDOH conducted a voluntary blood lead screening that identified 68 children with lead in blood (confirmed 50) linked to parental occupational exposure at a battery recycling plant. This led the intervention of stakeholders and the eventual closure of the facility. |
2012 | After noticing that the blood lead level reports did not reflect the updated CDC reference level of 5 mcg/dL, a pediatrician outreached the president of the CMTPR requesting that the BLRV in the reports be updated accordingly. | The CMTPR informed all clinical laboratories in PR about the updated reference level for lead in blood in children and asked for an update in the laboratory reports. |
2013 | Pediatricians reviewed the NYC lead risk assessment questionnaire, adapting it culturally and linguistically for PR. They also met with the PRDOH Secretary to advocate for adopting this questionnaire as the lead screening tool for clinicians evaluating children. | PRDOH Secretary sent a letter to all physicians in PR recommending using this risk assessment questionnaire and being mindful of occupations associated with lead exposure. |
2015 | Pediatrician assisted R2 EPA in planning a soilSHOP activity in Caño Martín Peña, San Juan, PR, by meeting and working with several stakeholders. | The soilSHOP took place in collaboration with R2 PEHSU, R2EPA, PRDOH, UPR, and CMTPR. Activities included: generic soil screening for lead (XRF), capillary blood lead testing, gardening workshop, and lead prevention education by health educators. |
2016 | Pediatricians advocate for universal blood lead testing at 12 and 24 mo of age. | The 2017 PRDOH Pediatric Preventive Services Periodicity Schedule included universal blood lead testing at the 12- and 24-mo well-child care visits. |
2019 | PRAAP applied for funding to conduct a Lead Testing ECHO (Extension for Community Healthcare Outcomes) series. | The PRAAP Lead Testing ECHO series launched, supported by the Cooperative Agreement NU38OT000282, funded by the CDC with a quality improvement component. |
2021 | PRDOH consulted PRAAP for assistance with the application for the Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children (CDC-RFA-EH21-2102). | PR and other territories were not eligible to apply. |
2022 | A pediatrician writes to CDC leadership to advocate for including PR and other territories in the list of eligible organizations for CDC-RFA-EH21-2102. | PR becomes eligible to apply for CDC-RFA-EH21-2102. PRDOH applies and is awarded funding to establish the PR-CLPPP Program. |
BLRV, blood lead reference value; CDC, Centers for Disease Control and Prevention; CDC-RFA-EH21-2102, CDC-Request for Application-Environmental Health21-2102; CMTPR, College of Medical Technologists of Puerto Rico; NYC, New York City; PR, Puerto Rico; PRAAP, Puerto Rico Chapter, American Academy of Pediatrics; PR-CLPPP, Puerto Rico Childhood Lead Poisoning Prevention Program; PRDOH, Puerto Rico Department of Health; R2EPA, Region 2 Environmental Protection Agency; R2PESHSU, Region 2 Pediatric Environmental Health Specialty Unit; UPR, University of Puerto Rico; XRF, x-ray fluorescence spectrometry.
Ultimately, US territories were included in the list of eligible organizations for this grant opportunity. PRDOH successfully applied, and the cooperative agreement EH21-2102 is now in its third funding year.
Advocating for a Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children Program That Augments the Role of the Pediatrician
Pediatricians in PR encounter numerous obstacles when delivering comprehensive primary care services, including lead prevention. Some of those challenges include inequitable access to a medical home amid the growing shortage of pediatric workforce, limited time for well-child visits, and poor reimbursement for preventive services.11,12 These barriers undermine compliance with local lead toxicity secondary prevention recommendations. For example, a recent analysis of the blood lead tests reported to the PRDOH (unpublished) showed that in 2022, only 20% of 1-year-old children and 17% of 2-year-old children had at least 1 blood lead test done in the past.
From its inception, PRAAP has forged a collaborative partnership with the Puerto Rico Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children Program (PR-CLPPP) based at the PRDOH, leveraging pediatric expertise in the development and execution of programmatic endeavors. The PR-CLPPP was launched during the COVID-19 pandemic. Being mindful of the increase in pediatricians’ workload and physician burnout,13 PRAAP increased awareness of the need to ensure that the incipient surveillance system did not result in excess work or additional stress related to administrative hurdles to assist patients with lead toxicity. One of the most crucial initiatives undertaken by the PR-CLPPP is the establishment of an efficient infrastructure for promptly notifying the PRDOH of blood lead testing results in children. This infrastructure plays a pivotal role in supporting clinicians and ensuring that affected children are connected to the necessary resources for intervention and support.
Drawing on the AAP policy statement on lead toxicity and prevention, PRAAP has established a robust foundation for its joint initiatives with PR-CLPPP, aimed at fostering sustainable activities that reinforce the role of pediatricians in lead prevention. After all, there is no identification of lead in blood if the pediatricians do not order the test. This objective has been accomplished through 3 primary avenues: (1) optimizing lead test result notification and management of lead toxicity to reduce the time and administrative burden during clinical visits; (2) enhancing educational opportunities on the topic of lead screening and toxicity management for pediatricians and other health care providers, thereby bolstering their capacity to adhere to blood lead testing recommendation; and (3) redistributing time-consuming tasks that are essential to the optimal lead case management, including (1) education and orientation of families about the basics of lead in blood, how to prevent further exposure and absorption, and the importance of optimizing diet and nutrition; and (2) creating a method to send a written report that includes a summary of the possible source(s) of exposure, the date for the follow-up level (or a confirmatory level when testing is from a capillary sample), and the referrals made for lead management and prevention services.
To aid the PR-CLPPP team in comprehending the attitudes, practices, and knowledge of the health care providers regarding the secondary prevention and management of lead toxicity, the PRAAP collaborated with the Medical College of Toxicologists and R2 PEHSU to conduct a survey targeting pediatricians. Although the survey yielded a low response rate, the results offer valuable insights that merit further investigation. These findings have been instrumental in shaping educational initiatives tailored for pediatricians and other health care professionals. The survey highlighted systemic obstacles, notably the limited time allocated for well-child visits and inadequate insurance reimbursement for lead-related services. Furthermore, respondents expressed a low level of confidence and proficiency in the clinical management of lead poisoning. Based on this data, a 2-hour webinar was developed and attended by 159 providers, offering free continuing medical education credits. The webinar focused on the prevention and management of lead poisoning in PR and the supportive services provided by PR-CLPPP. In a postwebinar evaluation survey, 85% of attendees indicated their intention to modify their practices based on the insights gained during the session. PRAAP has continued messaging pediatricians through social media platforms about the importance of blood lead testing for children and has been acquainting them about the comprehensive services of PR-CLPPP.
PRAAP is actively advocating for resources to support those families with children with lead poisoning who have no health insurance or whose private insurance does not cover nutrition, developmental, or other lead poisoning–related services.
Facing the Future With Hope: Lessons Learned and Conclusions
Public health surveillance systems play a pivotal role in comprehending the extent and characteristics of lead exposure and toxicity at the local level. Secondary prevention and management of lead poisoning begin with pediatricians adhering to recommended blood lead testing protocols and following the updated reference value, which continues to decrease because of ongoing public policy efforts. Addressing health inequities in access to lead prevention resources has been partially achieved through the advocacy and perseverance of fellow pediatricians from the PRAAP. This advocacy resulted in PR's inclusion as an eligible applicant for the CDC-RFA-EH21-2102. The PR experience can help inform national conversations on health equity. This collaborative agreement with the CDC has empowered the PRDOH to enhance the longstanding efforts of dedicated public health and primary care practitioners. Despite resource constraints, these professionals have persisted in advancing public health policies pertaining to lead prevention and management. Consequently, a robust Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children program has emerged, prioritizing vital surveillance activities related to lead in children and providing support to pediatricians and families, through strong collaborations (Table 2). Additionally, the program has strengthened coalitions of stakeholders (Fig 1), such as R2 PEHSU, to further the eradication of childhood lead poisoning in PR, and has established an open communication system between clinical and public health practitioners.
Puerto Rico Childhood Lead Poisoning Prevention Program Agreements With Stakeholders to Optimize Case Management of Lead Toxicity in Children
Puerto Rico Child Lead Poisoning Prevention Program Core Collaborations and Agreements . | |
---|---|
Stakeholder . | Agreements/Contributions . |
Early Intervention Program | Referrals for developmental evaluation and follow-up |
Puerto Rico Health Insurance Administration and Medicaid Program | Provides data related to blood lead testing of children in Puerto Rico |
Special Supplemental Nutrition Program for Women, Infants, and Children Program | Referrals for nutritional services of children with lead poisoning |
Head Start and Early Head Start Programs | Require blood lead test as part of the enrollment process |
Puerto Rico Department of Housing | Referrals for environmental risk assessment for children with lead poisoning living in public housing |
Puerto Rico Child Lead Poisoning Prevention Program Core Collaborations and Agreements . | |
---|---|
Stakeholder . | Agreements/Contributions . |
Early Intervention Program | Referrals for developmental evaluation and follow-up |
Puerto Rico Health Insurance Administration and Medicaid Program | Provides data related to blood lead testing of children in Puerto Rico |
Special Supplemental Nutrition Program for Women, Infants, and Children Program | Referrals for nutritional services of children with lead poisoning |
Head Start and Early Head Start Programs | Require blood lead test as part of the enrollment process |
Puerto Rico Department of Housing | Referrals for environmental risk assessment for children with lead poisoning living in public housing |
The Puerto Rico Childhood Lead Poisoning Prevention Program (PR-CLPPP) has engaged stakeholders to enhance the early identification, management, and referral services for children with lead poisoning. These stakeholders are part of the PR-CLPPP advisory committee, which meets quarterly to share updates on their efforts to promote lead poisoning prevention in Puerto Rico and collaboratively address barriers related to prevention, remediation, testing, reporting, and access to health care.
The Puerto Rico Childhood Lead Poisoning Prevention Program (PR-CLPPP) has engaged stakeholders to enhance the early identification, management, and referral services for children with lead poisoning. These stakeholders are part of the PR-CLPPP advisory committee, which meets quarterly to share updates on their efforts to promote lead poisoning prevention in Puerto Rico and collaboratively address barriers related to prevention, remediation, testing, reporting, and access to health care.
PRAAP has played a critical role in designing creative strategies and standardized lead case management procedures, which have significantly reduced the time and workload burden on pediatricians. This collaborative approach, leveraging the strengths of pediatricians, the local AAP chapter, and the regional PEHSU, can serve as a model for advancing the effectiveness and sustainability of lead poisoning prevention efforts through the local Childhood Lead Poisoning Prevention and Blood Lead Level Surveillance programs. By leveraging their knowledge and influence, pediatricians can contribute significantly to enhancing secondary prevention measures for lead poisoning. Moreover, through proactive advocacy initiatives, pediatricians can strive to overcome systemic barriers and pave the way for achieving primary prevention goals.
Acknowledgments
The authors thank the Puerto Rico Department of Health for their support. The data and assistance offered were extremely helpful in completing this manuscript. The authors also are grateful for the invaluable support provided by the Region 2 Pediatric Environmental Health Specialty Unit, Francisco Alvarado-Ramy, MD, and Brenda Rivera, DVM. The authors’ sincere gratitude to the editorial team, whose careful editing significantly improved the clarity of the study.
Dr Huerta-Montañez drafted the initial manuscript; Dr Muñiz-Forestier critically reviewed and revised the manuscript for intellectual content; Drs Calderón and Sheffield contributed data and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
- AAP
American Academy of Pediatrics
- BLL
blood lead level
- CDC
Centers for Disease Control and Prevention
- EPA
Environmental Protection Agency
- PR
Puerto Rico
- PRAAP
Puerto Rico Chapter, American Academy of Pediatrics
- PR-CLPPP
Puerto Rico Childhood Lead Poisoning Prevention Program
- PRDOH
Puerto Rico Department of Health
- R2 PESHSU
Region 2 Pediatric Environmental Health Specialty Unit
References
Competing Interests
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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