The purpose of this analysis is to better understand laws and practices guiding prevention activities in childhood lead poisoning prevention programs funded by the Centers for Disease Control and Prevention (CDC).
In 2022, CDC surveyed 62 funded programs using the Awardee Lead Profile Assessment. Information was collected about childhood lead poisoning-related laws and guidance, surveillance and prevention strategies, and program services including at what blood lead levels (BLLs) various activities are performed. Separately, CDC reviewed state health department websites to obtain information on which states implemented CDC’s updated blood lead reference value.
Awardee Lead Profile Assessment results are only reported for 47 states, the District of Columbia, and Puerto Rico. Almost all programs (96%) have laws requiring reporting of BLLs, and 51% require BLLs be reported electronically to jurisdictional health departments. Most programs (80%) prioritize areas and populations that are high risk for lead poisoning prevention activities. Approximately half of the programs (51%) have a lead elimination plan or goal. Thirty-nine percent of the programs have already implemented policies, laws, or regulations to achieve lead elimination, and 74% are in the Northeast and Midwest regions of the country. As of March 2023, 71% of the programs have implemented CDC’s updated blood lead reference value, and most (65%) did so via guidance for health care providers and laboratories for what BLL should initiate case management and other services for lead-exposed children.
Almost all programs have mandatory BLL reporting laws, and about two-thirds of the programs updated their BLLs that trigger public health action.
In May 2021, the Centers for Disease Control and Prevention’s (CDC’s) Lead Exposure and Prevention Advisory Committee voted unanimously in favor of updating the blood lead reference value (BLRV) to 3.5 μg/dL on the basis of data derived from the 2015–2018 National Health and Nutrition Examination Survey cycles. CDC updated the BLRV to 3.5 μg/dL in October 2021.1 Updating the BLRV allows CDC, federal partners, and health departments to prioritize children with higher levels of lead in their blood compared with most children. The Centers for Medicare and Medicaid Services requires universal testing of children enrolled in Medicaid at ages 12 and 24 months or between 24 and 72 months if there is no record of a previous test.2
CDC's Childhood Lead Poisoning Prevention Program (CLPPP) is dedicated to reducing childhood lead poisoning as a public health problem. Currently, CDC funds 62 health departments through cooperative agreements to support childhood lead poisoning prevention through strengthened blood lead testing, reporting, and surveillance; linkages of children to recommended services; and targeted population-based interventions. Public health practitioners rely on information from surveillance systems to support decision-making for improved population health.3 The purpose of this analysis is to better understand the laws and practices that guide childhood lead poisoning prevention activities in CDC-funded state and local CLPPPs by examining self-reported data from recipients and reviewing publicly available information on implementation of the updated BLRV.
Methods
Data and information on policies and practices that guide state and local health departments in preventing childhood lead poisoning were obtained from a CDC-developed survey called the Awardee Lead Profile Assessment (ALPA) and a review of state Web sites pertaining to lead poisoning prevention. More details about each of these efforts are provided below.
Laws and Practices That Guide Lead Poisoning Prevention Activities
CDC developed the ALPA to collect information about childhood lead poisoning-related laws and guidance, surveillance and prevention strategies, and program services including at what blood lead levels (BLLs) various case management activities are performed. ALPA is administered annually. The survey included 34 questions and was estimated to take about 47 minutes to complete. ALPA asked about testing and reporting policies, abatement and remediation, lead elimination plans, action levels for performing various case management activities, and Medicaid reimbursement.
A link to complete the ALPA as an Epi Info Web-based survey was e-mailed to CLPPP program managers funded by CDC’s cooperative agreement in June 2022. In 2022, CDC funded 62 state and local programs via cooperative agreements entitled “Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children” (Fig 1). Arkansas, Maryland, and North Dakota were not surveyed because they were not funded under this cooperative agreement. However, Maryland chose to voluntarily respond to the ALPA survey, which they received from a CDC-funded local health department in their state. Programs were given 3 weeks to respond, and e-mail reminders were sent to encourage participation. CLPPPs were instructed to interpret “screening and/or testing” as testing of a capillary or venous blood sample for lead. Data were analyzed descriptively, and frequencies were produced.
Fiscal year 2022 CDC-funded programs under notice of funding opportunity entitled Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children.
Fiscal year 2022 CDC-funded programs under notice of funding opportunity entitled Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children.
State Health Department Progress in Implementing CDC’s Updated BLRV
Additionally, CDC reviewed state health department Web sites to obtain information on which states implemented CDC’s updated BLRV between October 28, 2021, and March 31, 2023. Web sites for all 50 states, the District of Columbia (DC), and Puerto Rico (PR) were reviewed. Web site reviews were divided among 2 staff members, and quality assurance and quality control were done by having each staff member review the other’s assessment. Any discrepancies were adjudicated by the project manager. A program’s implementation status was categorized as
implemented if Web sites indicated that the program updated their BLRV to align with CDC;
“no change” if Web sites acknowledged CDC’s updated BLRV, but the program decided not to change their laws or guidance at this time; or
“unknown” if Web sites did not indicate any change to current action levels.
For programs with a status of implemented, date and method of implementation were also collected. Method of implementation was categorized as either (1) automatic on the basis of CDC updating its BLRV, (2) passage of a law, or (3) via guidance distributed to health care providers, laboratories, and others.
Data obtained from the Web site review were analyzed by sociodemographic variables to evaluate if programs with higher percentages of potential lead exposure risk factors identified in the literature were more likely to update their BLL action levels for triggering public health actions. American Community Survey 1-year estimates for 2021 on the following variables (percentages) were obtained for each program analyzed: housing built before 1980, Black race alone or in combination with other races, foreign-born, persons ages 25 years and older with less than a high school diploma, and population <6 years of age with Medicaid coverage.4–6 For each implementation category, the median of each risk factor for states in that category was calculated; differences of distributions or their medians were evaluated using the Kruskal–Wallis χ2 test. This nonparametric test was used to assess differences in the distribution of these potential risk factors across the 3 implementation categories (implemented, no change, and unknown).
Results
1. ALPA Survey
Analysis of ALPA data included only responses from 46 funded states, DC, and PR. One funded state did not respond. Additionally, 1 unfunded state voluntarily provided responses. Responses from the 12 CDC-funded localities are not included because they did not differ from their respective states, except for New York City. New York City has a local reporting law for BLLs that covers children up to age 18 years and included only BLLs ≥5.0 µg/dL.
1.1. Testing and Reporting Policies
Childhood blood lead testing policies for the programs are shown in Table 1. Almost half of the states (45%) have legislation requiring blood lead testing for children not enrolled in Medicaid. Universal testing is the predominant testing strategy used, and most testing legislation focuses on children up to 6 years of age. Four states (8%) have legislation mandating blood lead testing for pregnant women.
Program Policies Related to Childhood Blood Lead Testing, CDC Awardee Lead Profile Assessment (ALPA), 2022
Policy . | Number (%) . |
---|---|
Legislation mandating the existence or operation of a childhood lead poisoning prevention program | 27 (55%) |
Children not enrolled in Medicaid | |
Legislation mandating blood lead testing for children not enrolled in Medicaid | 22 (45%) |
Testing strategya | |
Universal testing | 13 (59%) |
Targeted testing | 7 (32%) |
Universal and targeted testing | 1 (5%) |
Ages covered by mandated testing legislationb | |
Up to age 2 y | 3 (15%) |
Up to age 3 y | 1 (5%) |
Up to age 5 y | 1 (5%) |
Up to age 6 y | 14 (70%) |
Up to age 20 y | 1 (5%) |
Policy . | Number (%) . |
---|---|
Legislation mandating the existence or operation of a childhood lead poisoning prevention program | 27 (55%) |
Children not enrolled in Medicaid | |
Legislation mandating blood lead testing for children not enrolled in Medicaid | 22 (45%) |
Testing strategya | |
Universal testing | 13 (59%) |
Targeted testing | 7 (32%) |
Universal and targeted testing | 1 (5%) |
Ages covered by mandated testing legislationb | |
Up to age 2 y | 3 (15%) |
Up to age 3 y | 1 (5%) |
Up to age 5 y | 1 (5%) |
Up to age 6 y | 14 (70%) |
Up to age 20 y | 1 (5%) |
a Testing strategy for children not enrolled in Medicaid missing for 1 program.
b Ages covered by mandated testing legislation were missing for 2 programs for children not enrolled in Medicaid.
Forty-seven programs (96%) have a reporting law for BLLs. Of these, 66% require reporting of BLLs for all ages. Forty-one programs (87%) require that all BLLs be reported, whereas 4 states (9%) require that only BLLs ≥5 µ g/dL be reported (2 programs did not specify what BLLs are required to be reported). Twenty-five programs (51%) require electronic reporting of BLLs (Fig 2).
Presence of electronic reporting laws for blood lead test results, by program, 2022.
Presence of electronic reporting laws for blood lead test results, by program, 2022.
1.2. Abatement and Remediation
Thirty programs (61%) have lead paint abatement or remediation legislation. Twenty-seven (90%) of these require that contractors or workers perform abatement. In 21 states (70%), only certain types of buildings are required to be remediated (eg, child care centers, Section 8 housing, rental properties). In 16 states (53%), the condition of the building (eg, pre-1978, ≥2 square feet of deteriorating paint) determines whether remediation is required. Nineteen states (63%) have legislation that triggers lead paint abatement and/or remediation on the basis of BLLs. BLLs ≥5 µg/dL are the most common trigger (47%). Sixteen programs (53%) have legislation that triggers lead paint abatement or remediation legislation on the basis of the presence of children;16 years of age is the most common trigger (63%).
1.3 High-Risk Areas and Populations
Programs were asked if their CLPPP focuses interventions on areas or populations that are high risk. Thirty-nine programs (80%) focus on both areas and populations that are high risk, 6 states (15%) focus on areas that are high risk, 4 states (8%) do not focus on either. Of the 32 programs that publish geographic information systems maps, 18 (56%) publish maps of both areas and populations that are high risk, 13 (41%) publish maps of areas that are high risk, and 1 state (3%) publishes maps of populations that are high risk.
1.4 Lead Elimination
Twenty-five programs (51%) have a formal jurisdictional lead elimination plan or goal. Of these 25 programs, 19 (76%) have a timeline set for their plan or goal, and 18 (72%) have a quantifiable standard set for their plan or goal. Nineteen programs have implemented policies, laws, or regulations for lead elimination (Fig 3).
Presence of lead elimination policies, laws, and regulations, by program, 2022.
1.5 Action Levels
Programs were asked at what confirmed BLL various types of activities are initiated either by mandate or practice. Confirmed BLL refers to 1 venous or 2 capillary tests drawn at least 12 weeks apart with results that are above the state action level. At least 1 type of case management service (phone calls, mailing letters or brochures, referrals, or coordination of services) is initiated at confirmed BLLs of ≥5 µg/dL by mandate in 45% of the states and by practice in 55% of the states.
Assessment and remediation of residential lead exposure included inspection of the child’s home and other sites, obtaining exposure history, measuring environmental lead levels, educational interventions to reduce ongoing exposure, and abatement interventions to reduce ongoing exposure. At least 1 type of assessment or remediation activity is initiated with a confirmed BLL of ≥5 µg/dL by mandate in 38% of the states and by practice in 65% of the states.
Medical assessments and interventions included caregiver lead education (nutritional and environmental), follow-up blood lead monitoring and testing, taking a complete history and conducting a physical exam, performing physical and neurologic exams, additional laboratory tests, temporary or permanent measures for hazard reduction, and neurodevelopmental monitoring. At least 1 type of medical intervention is initiated at confirmed BLLs of ≥5 µg/dL by mandate in 49% of states and by practice in 82% of states.
Nutritional assessments and interventions include diet evaluation, referrals to Women, Infants, and Children programs, and referrals to nutritionists. At least 1 nutritional assessment or intervention is initiated at confirmed BLLs of ≥5 µg/dL by mandate in 35% of programs and by practice in 55% of programs.
Developmental assessments and interventions include referrals to diagnostic evaluations and early intervention/stimulation programs. At least 1 type of developmental assessment or intervention is initiated at confirmed BLLs of ≥5 µg/dL by mandate in 18% of programs and by practice in 41% of programs.
1.6 Medicaid Reimbursement
Sixteen programs (32%) responded that their health department receives reimbursement from Medicaid. Table 2 shows the types of actions for which programs reported being reimbursed. The most common activities that were reimbursed were inspecting the child’s home and other sites (9.6%), obtaining an exposure history (6.1%), measuring environmental lead levels (6.1%), and follow-up blood lead testing (6.1%).
Types of Public Health Actions That Are Reimbursed by Medicaid That Were Mentioned by Programs, CDC Awardee Lead Profile Assessment (ALPA), 2022
Action . | Number (%) . |
---|---|
Inspection of the child's home and other sites | 11 (9.6%) |
Obtain exposure history | 7 (6.1%) |
Measure environmental lead levels | 7 (6.1%) |
Follow-up blood lead monitoring and testing | 7 (6.1%) |
Phone call | 6 (5.3%) |
Coordination of services | 6 (5.3%) |
Educational interventions to reduce ongoing exposure | 6 (5.3%) |
Caregiver lead education (nutritional and environmental) | 6 (5.3%) |
Mail letter and brochure | 5 (4.4%) |
Refer patient for services | 5 (4.4%) |
Referral to WIC | 5 (4.4%) |
Referral to nutritionist | 5 (4.4%) |
Refer for early intervention/stimulation programs | 5 (4.4%) |
Diet evaluation | 5 (4.4%) |
Conduct developmental assessment | 4 (3.5%) |
Complete history and physical exam | 4 (3.5%) |
Temporary measures for lead hazard reduction | 3 (2.6%) |
Refer for diagnostic evaluation | 3 (2.6%) |
Permanent measures for lead hazard reduction | 3 (2.6%) |
Neurodevelopmental monitoring | 3 (2.6%) |
Abatement interventions to reduce ongoing exposure | 2 (1.8%) |
Complete neurologic exam | 2 (1.8%) |
Chelation therapy | 2 (1.8%) |
Laboratory work | 1 (0.9%) |
Abdominal x-ray with bowel decontamination | 1 (0.9%) |
Total | 114 |
Action . | Number (%) . |
---|---|
Inspection of the child's home and other sites | 11 (9.6%) |
Obtain exposure history | 7 (6.1%) |
Measure environmental lead levels | 7 (6.1%) |
Follow-up blood lead monitoring and testing | 7 (6.1%) |
Phone call | 6 (5.3%) |
Coordination of services | 6 (5.3%) |
Educational interventions to reduce ongoing exposure | 6 (5.3%) |
Caregiver lead education (nutritional and environmental) | 6 (5.3%) |
Mail letter and brochure | 5 (4.4%) |
Refer patient for services | 5 (4.4%) |
Referral to WIC | 5 (4.4%) |
Referral to nutritionist | 5 (4.4%) |
Refer for early intervention/stimulation programs | 5 (4.4%) |
Diet evaluation | 5 (4.4%) |
Conduct developmental assessment | 4 (3.5%) |
Complete history and physical exam | 4 (3.5%) |
Temporary measures for lead hazard reduction | 3 (2.6%) |
Refer for diagnostic evaluation | 3 (2.6%) |
Permanent measures for lead hazard reduction | 3 (2.6%) |
Neurodevelopmental monitoring | 3 (2.6%) |
Abatement interventions to reduce ongoing exposure | 2 (1.8%) |
Complete neurologic exam | 2 (1.8%) |
Chelation therapy | 2 (1.8%) |
Laboratory work | 1 (0.9%) |
Abdominal x-ray with bowel decontamination | 1 (0.9%) |
Total | 114 |
Multiple actions could be selected per state. WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
2. BLRV Implementation Update
As of March 2023, 37 (71%) programs have implemented CDC’s updated BLRV, 11 (21%) programs have not changed their BLRV, and status was unknown for 4 (8%) programs. This sample included all 50 states, DC, and PR. Most programs (n = 24, 65%) that implemented CDC’s updated BLRV did so via guidance for health care providers and laboratories for when to initiate case management and other services for lead-exposed children. Eleven programs (30%) changed their state laws on case management, and 2 programs (5%) have a mechanism in place where their childhood blood lead laws are automatically updated to align with CDC’s BLRV. Information on month and year of implementation was available for 32 (86%) of the programs that implemented CDC’s updated BLRV. The highest number of programs updated their BLRV in January 2022 and July 2022 (n = 6, 19%, each), followed by October 2022 (n = 4, 13%).
The distribution of percentages of the following risk factors were not statistically different at an alpha level of 0.05 by the 3 categories of implementation status: Housing built before 1980 (P = .31), foreign-born population (P = .93), adults aged <25 with a high school diploma (P = .38), children <6 years of age receiving Medicaid (P = .36), and population who were Black (P = .50) (data not shown).
Discussion
Programs with strong policies on testing and reporting are more likely to identify children with high BLLs who can be connected to services to mitigate the adverse health effects of lead.7 Almost all programs have laws requiring reporting of BLLs, and about half of the programs require BLLs be reported electronically to their respective jurisdictional health department. All programs in the Northeast and more than half of the programs in the Midwest regions require electronic reporting.
Most programs prioritize both areas and populations that are at high risk for exposure for lead poisoning prevention activities. About a third of the programs reported receiving any reimbursement from Medicaid for lead poisoning prevention activities. Programs may be more likely to provide additional case management and abatement services to mitigate lead exposure and its negative health impacts if these services are covered by Medicaid.8 It is important to recognize that most of these activities are performed by clinicians or local health departments.
More than half of the programs surveyed have a formal lead elimination plan or goal. Thirty-nine percent of the programs have already implemented policies, laws, or regulations to achieve lead elimination, and most of these are located in the Northeast and Midwest regions of the country. In addition to protecting children’s health, a 2017 report found that eliminating lead hazards from the places where children live, learn, and play could generate ≈$84 billion in long-term benefits per birth cohort.9 Savings would be expected to grow over time because permanently removing lead hazards from the environment would benefit future birth cohorts.
In the United States, remarkable progress has been made on identifying children with higher BLLs so that prompt actions can be taken to reduce lead’s harmful effects.10 About two-thirds of the programs have implemented CDC’s updated BLRV, with most programs doing so via updating their case management guidance for health care providers and laboratories. Distribution of known risk factors for childhood lead poisoning did not appear to influence state decisions on implementing CDC’s updated BLRV. This uptake rate could be because of CDC’s employment of a broad communications campaign. CDC issued a press release and published a policy note in the Morbidity and Mortality Weekly Report. Additionally, communication products (such as e-mails to funded programs and partners; communication briefs to state/local health departments, laboratories, and health care providers; Web site updates; and social media messages) were shared across a variety of channels to reach all relevant audiences. This extensive level of outreach likely contributed to successful implementation of the BLRV by many state health departments as demonstrated in other public health settings.11,12
Limitations of the ALPA analysis include that it was administered in June 2022 and did not include response options for reporting actions occurring at BLLs ≥3.5 µg/dL (the BLRV as of October 2021). Therefore, responses to questions that asked what BLLs trigger various case management activities are likely outdated and do not fully reflect lead poisoning prevention activities in funded programs. Beginning in 2023, the ALPA will have response options that reflect the updated BLRV. Limitations of the BLRV analysis include missing information on the status (8%) and month and year of implementation of CDC’s updated BLRV (14%), inability to include data on states that were in the process of updating their BLRV, and the analysis only including data through March 2023. Additional programs may have updated their BLRV since that time.
Conclusions
Almost all programs have laws requiring reporting of BLLs, and about two-thirds of the programs have used CDC’s updated BLRV as the BLL that triggers public health action. Results of this analysis will be shared with funded programs and widely distributed. Additionally, CDC will use the results of this analysis to help develop strategies and best practices for implementing childhood lead poisoning prevention activities in the United States. Results of the 2022 ALPA serve as a baseline from which progress toward national implementation of the BLRV is benchmarked at state and local levels.
Acknowledgments
We thank Shannon Omisore for her help in reviewing state health department Web sites to gather information about implementation of the BLRV, and Nick Hatch for his help in formatting the manuscript.
Dr Ruckart conceptualized the work, oversaw the data abstraction efforts, analyzed data, and drafted the manuscript; Dr Schondelmeyer analyzed data and contributed to an earlier draft of this manuscript; Ms Allen had primary responsibility for abstracting data from state health department Web sites, and helped analyze data; Dr Allwood shaped the final draft of the manuscript by reviewing and providing thoughtful comments; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
References
Competing Interests
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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