North Dakota Health Department 1 Lead Screening in North Dakota To do or not to do that is the question...

North Dakota Health DepartmentNorth Dakota Health Department 11

Lead Screening Lead Screening in North Dakotain North Dakota

““To do or not to do that is the To do or not to do that is the question...”question...”


Lead Screening - Lead Screening - GeneralGeneral

Changes in Pb intoxication Changes in Pb intoxication definition levels definition levels – 1985 - 25 ug /dL1985 - 25 ug /dL– 1991 - 10 ug /dL1991 - 10 ug /dL

ND has no official statewide Pb ND has no official statewide Pb screening planscreening plan

Should we have one? CDC says Should we have one? CDC says “Yes”“Yes”


Lead Screening - Lead Screening - GeneralGeneral

US Screening in children 12-72 mo US Screening in children 12-72 mo in the since 1991 (CDC in the since 1991 (CDC recommendation for universal recommendation for universal screening)screening)– 25% (generally)25% (generally)– 33% (poor children)33% (poor children)


Lead Screening - Lead Screening - ClinicalClinical 900,000 (1997) US children have lead levels 900,000 (1997) US children have lead levels

high enough to cause adverse effects on high enough to cause adverse effects on learninglearning

1991-941991-94– 1-2 yo - 5.9% (Note this!!)1-2 yo - 5.9% (Note this!!)– 3-5 yo - 3.5%3-5 yo - 3.5%– 6-11 yo - 2%6-11 yo - 2%

Greater risk - inner city, living in older Greater risk - inner city, living in older houseshouses– 0% Alaskan poor children had levels > 11 ug / dL 0% Alaskan poor children had levels > 11 ug / dL – 10% with levels > 25 ug / dL10% with levels > 25 ug / dL– 21.9% black children living in houses built before 194621.9% black children living in houses built before 1946– 66% with levels > 15 ug / dL66% with levels > 15 ug / dL


Lead Screening - Lead Screening - ClinicalClinical

Characteristic % of children, 1-5 yo with BLL > 10Race / ethnicityBlack / non-hispanic 11.2%Mexican - American 4.0%White, non-HIspanic 2.3%IncomeLow 8.0%Middle 1.9%High 1.0%All children 4.4%



Year housewas built

% with BLL >10

Geometricmean BLL

Before 1946 8.6% 3.8 ug / dL1946-1973 4.6% 2.8 ug / dL> 1973 1.6% 2.0 ug / dL



Internationally adopted children Internationally adopted children (MMWR 49:5;97-100, Feb 11, (MMWR 49:5;97-100, Feb 11, 2000)2000)– China - 38% > 10 ug / dLChina - 38% > 10 ug / dL– Russia - 58% > 10 ug / dLRussia - 58% > 10 ug / dL



Calcium and iron deficiency Calcium and iron deficiency increase the amount of Pb increase the amount of Pb absorbedabsorbed

Neurologic consequences of Neurologic consequences of chronic exposure are irreversiblechronic exposure are irreversible

Screening - serum lead levels Screening - serum lead levels (capillary or venous) not FEP or (capillary or venous) not FEP or ZPPZPP


Lead Levels - ChildrenLead Levels - ChildrenLead Level Problems

10 ug / dL Decreased IQ, hearing, growth

10 - 20 ug / dL Developmental toxicity

10-20 ug / dL Increased FEP, decreased vit D metabolism?

20 ug / dL Decreased nerve conduction

30 ug / dL Decreased vit D metabolism

40 ug / dL Decreased Hgb

50 - 100 ug / dL Colic, anemia, nephropathy, encephalopathy

100-150 ug / dL Death


Lead Screening - IQ Lead Screening - IQ EffectsEffects

707580859095

100105110115120

5 10 15 20 25 30 35 40

Fulton '87

WHO/CEC '90

Hawk '86

Schroeder '85


Lead Levels - AdultsLead Levels - Adults

Lead Level Problem10 ug / dL Hypertension10-20 ug / dL FEP increases in women20-30 ug / dL FEP increases in men30 ug / dL Increased systolic bp in men, hearing40 ug / dL Peripheral neuropathy, infertility (men),

nephropathy50 ug / dL Decreased Hgb50-100 ug / dL Decreased longevity, anemia100 ug / dL Encephalopathy



Association with ADHD / ADD - all Association with ADHD / ADD - all should be screenedshould be screened

Aggressive / delinquent behavior / Aggressive / delinquent behavior / violent crime associated with bone violent crime associated with bone lead levels - Nevin R. Environ-Res. lead levels - Nevin R. Environ-Res. 2000 may; 83(1): 1-22.2000 may; 83(1): 1-22.


Lead Screening - Lead Screening - SourcesSources

Pb paint (housing built before Pb paint (housing built before 1978, particularly built before 1978, particularly built before 1950) - greatest risk, residual is a 1950) - greatest risk, residual is a problem (dust, soil)problem (dust, soil)

Gasoline (outside the US)Gasoline (outside the US)


Lead Screening - Lead Screening - SourcesSources Industries , work sites, occupations, etcIndustries , work sites, occupations, etc

– Smelting / refining of nonferrous metalsSmelting / refining of nonferrous metals– Brass / copper foundriesBrass / copper foundries– Firing rangesFiring ranges– Automotive repair shopsAutomotive repair shops– Bridge / tunnel / elevated highway constructionBridge / tunnel / elevated highway construction– Motor vehicle parts / accessoriesMotor vehicle parts / accessories– Storage batteries (lead batteries) / primary batteries (wet / Storage batteries (lead batteries) / primary batteries (wet /

dry)dry)– Valve and pipe fittingsValve and pipe fittings– Plumbing fixures / fittings / trimPlumbing fixures / fittings / trim– PotteryPottery– Chemical / chemical preparationsChemical / chemical preparations– Industrial machinery / equipmentIndustrial machinery / equipment– Inorganic pigmentsInorganic pigments


Lead Screening - Lead Screening - SourcesSources Hobbies / Home activitiesHobbies / Home activities

– Recreational use of firing rangesRecreational use of firing ranges– Home repairs / repainting / remodelingHome repairs / repainting / remodeling– Furniture refinishingFurniture refinishing– Stained glass makingStained glass making– Making fishing weights / sinkers / toy soldiersMaking fishing weights / sinkers / toy soldiers– Using lead solder (electronics)Using lead solder (electronics)– Using lead-containing artists’ paints / ceramic Using lead-containing artists’ paints / ceramic

glazesglazes– Burning lead painted woodBurning lead painted wood– Car / boat repairCar / boat repair


Lead Screening - Lead Screening - SourcesSources

OthersOthers– Calcium supplements - brand name Calcium supplements - brand name

oyster shell derivatives (Ross EA et al: oyster shell derivatives (Ross EA et al: JAMA, Sep 20 2000; 284:1425-1429) - JAMA, Sep 20 2000; 284:1425-1429) - impact likely negligibleimpact likely negligible

– Public playground equipment Public playground equipment (Consumer Product Safety Review, (Consumer Product Safety Review, vol. 1, No. 2, Fall, 1996.vol. 1, No. 2, Fall, 1996.


Lead Screening - Playground Lead Screening - Playground EquipmentEquipment

1978 CPSC banned sale of paint 1978 CPSC banned sale of paint with > 0.06% lead by weightwith > 0.06% lead by weight

1992 - Residential Lead-Based 1992 - Residential Lead-Based Paint Hazard Reduction Act (Title Paint Hazard Reduction Act (Title X) - 0.5% lead by weight - target X) - 0.5% lead by weight - target for lead hazard control measures.for lead hazard control measures.


Lead Screening - Playground Lead Screening - Playground EquipmentEquipment

Cities sampled - 13Cities sampled - 13 Playgrounds inspected - 26Playgrounds inspected - 26 Age of equipment Age of equipment

– 14-15 yo average, 4 cities (25-45 yo)14-15 yo average, 4 cities (25-45 yo) Lead containing paintLead containing paint

– >> 0.06% - 20 playgrounds / 11 cities 0.06% - 20 playgrounds / 11 cities– >> 0.50% - 16 / 20 playgrounds 0.50% - 16 / 20 playgrounds

Median Pb foundMedian Pb found– >> 0.06% - 0.87% (range 0.07-8.76) 0.06% - 0.87% (range 0.07-8.76)– >> 0.05% - 1.47% (range 0.62-8.76) 0.05% - 1.47% (range 0.62-8.76)

Child ingesting 1/10 sq inch /day ( tip of a pencil Child ingesting 1/10 sq inch /day ( tip of a pencil eraser) / 15-20 days would have lead level eraser) / 15-20 days would have lead level >> 10 ug / dL. 10 ug / dL. Assumes 1.47% Pb in paint and 30% absorption. Assumes 1.47% Pb in paint and 30% absorption.


North Dakota HousingNorth Dakota Housing1990 Census1990 Census

Total housing units 276,340Built < 1979 230,501 (83%)

Built < 1949 85,128 (30.8%)


Oregon - December, Oregon - December, 19971997Risk Factors NHANES III US

(1991-94)OCLPP Oregon(1993-97)

Private LabsOregon(1993097)

Year house built<1946 8.6% 7.4% NA1946-1973 4.6% 4.2% NA1974 onward 1.6% 4.5% NAIncomeLow 8.0% NA NAMiddle 1.9% NA NAHigh 1.0% NA NAAge1.2 yo 5.9% 6.0% 3.6%3-5 yo 3.5% 4.2% 2.6%1-5 combined 4.4% 5.2% 3.3%


Oregon Oregon 1991 CDC recommendations widely 1991 CDC recommendations widely

ignoredignored 26.5% of homes built < 195026.5% of homes built < 1950 < 5 % of children 12-72 mo have been < 5 % of children 12-72 mo have been

screenedscreened Estimated 6000 intoxicated children in the Estimated 6000 intoxicated children in the

state. Only 1042 have been identified.state. Only 1042 have been identified. Targeted strategy to identify most at risk Targeted strategy to identify most at risk

childrenchildren– Young age (1-2 yo)Young age (1-2 yo)– Living in pre-1950 housingLiving in pre-1950 housing


Oregon - Participation Oregon - Participation PlanPlan

Developed a coalition to identify Developed a coalition to identify target communities for childhood target communities for childhood lead screeninglead screening– local health departmentslocal health departments– private practicesprivate practices– managed care organizationsmanaged care organizations– MedicaidMedicaid– private insurance organizationsprivate insurance organizations– general community (any interested)general community (any interested)


Oregon - Revised Oregon - Revised Screening Screening

RecommendationsRecommendations BLL’s should be determined at 1-2 yo BLL’s should be determined at 1-2 yo (or if not previously screened, at least (or if not previously screened, at least once between the ages of 3-6 yo), if once between the ages of 3-6 yo), if they meet any of the following criteria:they meet any of the following criteria:– Live in a high risk zip code area (where Live in a high risk zip code area (where >>

27% of housing was built < 1950.27% of housing was built < 1950.– Live in poverty (receive public assistance - Live in poverty (receive public assistance -

WIC or Medicaid)WIC or Medicaid)– Have a parent or guiardian who answers yes Have a parent or guiardian who answers yes

to any of the three magic questions:to any of the three magic questions:– Have a parent or guardian with a job or Have a parent or guardian with a job or

hobby where lead is used.hobby where lead is used.


Oregon Magic Oregon Magic QuestionsQuestions

Does your child live in or regularly visit Does your child live in or regularly visit (e.g. a home day-care) a house built (e.g. a home day-care) a house built before 1950?before 1950?

Does your child live in or regularly visit Does your child live in or regularly visit a house built before 1978 with recent a house built before 1978 with recent (within the last 6 months) or ongoing (within the last 6 months) or ongoing renovations or remodeling?renovations or remodeling?

Does your child have a sibling or Does your child have a sibling or playmate who has had lead poisoning?playmate who has had lead poisoning?


Missouri - 2000Missouri - 2000

Missouri is the #1 lead producing state in Missouri is the #1 lead producing state in the US.the US.

29% of Missouri housing was built < 1950.29% of Missouri housing was built < 1950. 80% of housing was built < 197880% of housing was built < 1978 Estimated 12% of children < 6yo have Estimated 12% of children < 6yo have

BLL BLL >> 10 ug / dL 10 ug / dL 9% of children < 6 yo were screened in 9% of children < 6 yo were screened in

1995. Goal was to increase to 11% in 1995. Goal was to increase to 11% in 1999.1999.


Missouri - 2000Missouri - 2000 Universal BLL testing of all children at least twice Universal BLL testing of all children at least twice

during the 1st 24 months of life during the 1st 24 months of life (e.g. 12 and 24 mo). (e.g. 12 and 24 mo). Risk assessment may indicate the need for BLL testing at Risk assessment may indicate the need for BLL testing at an earlier age (e.g. 6 mo) and more frequently.an earlier age (e.g. 6 mo) and more frequently.– BLL may be done by venipuncture or capillary methodsBLL may be done by venipuncture or capillary methods– Confirm capillary results with a venous sample if the Confirm capillary results with a venous sample if the

results are: results are: >> 10 ug / dL or questionable. 10 ug / dL or questionable. Immediate BLL testing of any child 12-72 mo who Immediate BLL testing of any child 12-72 mo who

has not had a documented BLL test.has not had a documented BLL test. Re-evaluation of all children < 6 yo for risk of lead Re-evaluation of all children < 6 yo for risk of lead

poisoning at health care visits (at least annually). Use the poisoning at health care visits (at least annually). Use the lead risk assessment tool. lead risk assessment tool. BLL tests should be done for BLL tests should be done for all those found at risk.all those found at risk.


Missouri - 2000Missouri - 2000

A statewide advisory committee A statewide advisory committee developed the testing plan.developed the testing plan.

Guidelines used to develop the Guidelines used to develop the plan: CDC and AAPplan: CDC and AAP

Missouri Dept of Health and Social Missouri Dept of Health and Social Services endorsed the plan.Services endorsed the plan.


North Dakota - Pb North Dakota - Pb ScreeningScreening

CDC (Screening of Young Children for CDC (Screening of Young Children for Lead Poisoning, Nov 1997) “Exercise Lead Poisoning, Nov 1997) “Exercise caution in using BLL data to assess caution in using BLL data to assess risk for lead exposure, because these risk for lead exposure, because these data may not reflect the risk of the data may not reflect the risk of the entire populationentire population. If BLL data are . If BLL data are not thought to be reliable, other data not thought to be reliable, other data should be used until improved BLL should be used until improved BLL data are available”.data are available”.


North Dakota - FargoNorth Dakota - Fargo

October - December, 1991October - December, 1991 Average age of housing 67.8 yoAverage age of housing 67.8 yo Children from Head Start and kindergarten Children from Head Start and kindergarten

in older neighborhoodsin older neighborhoods SamplesSamples

– 202 capillary samples (9 duplicates)202 capillary samples (9 duplicates)– 193 children and adults tested (24 193 children and adults tested (24

unaatisfactory specimens, 169 successfully unaatisfactory specimens, 169 successfully screened)screened)

– 12 were over 6 yo with 157 from 1-6 yo.12 were over 6 yo with 157 from 1-6 yo.


North Dakota - FargoNorth Dakota - Fargo

ResultsResults– 6.3% (10) with BLL 6.3% (10) with BLL >> 10 10– 20% (2/10) with abnormal BLL (capillary) 20% (2/10) with abnormal BLL (capillary)

had BLL (venipuncture) had BLL (venipuncture) >> 10 - both < 14 10 - both < 14– 1.3% (2/157) had BLL 1.3% (2/157) had BLL >> 10 10– No correlation of BLL with housingNo correlation of BLL with housing– Average age of children 1-6 yo - 5.2 yoAverage age of children 1-6 yo - 5.2 yo– Average age of housing - 67.8 yoAverage age of housing - 67.8 yo


Grand ForksGrand Forks

May, 1994May, 1994 Children from large day care Children from large day care

centers and included children centers and included children living in housing built prior to 1970living in housing built prior to 1970


Grand Forks - ResultsGrand Forks - Results

198 samples (161 adequate to 198 samples (161 adequate to test)test)

2.4% (4/161) with levels 10-15 ug / 2.4% (4/161) with levels 10-15 ug / dLdL


EPSDT - 1995EPSDT - 1995

510 tests completed510 tests completed 3.5% (18/510) were 3.5% (18/510) were >> 10 10


EPSDT - 1996EPSDT - 1996

572 tests done572 tests done 3.8% (22/572) had BLL 3.8% (22/572) had BLL >> 10 with 0.5% 10 with 0.5%

(3/572) > 20(3/572) > 20 45% (10/22) would have been picked up 45% (10/22) would have been picked up

via risk CDC questionnaire.via risk CDC questionnaire. Elevated lead levels due to: Elevated lead levels due to:

– lead based paintlead based paint– mini-blindsmini-blinds– pool cue chalkpool cue chalk


Crude SummaryCrude Summary

3.3% (46/1400) children screened 3.3% (46/1400) children screened had BLLs had BLLs >> 10 ug / dL 10 ug / dL

Confidence intervals for each ND Confidence intervals for each ND study (CDC charts, 1997)study (CDC charts, 1997)– Fargo (157 children) <1% - 4%Fargo (157 children) <1% - 4%– Grand Forks (161 children) 1% - 5%Grand Forks (161 children) 1% - 5%– EPSDT 1995 (510 children) 2% - 6%EPSDT 1995 (510 children) 2% - 6%– EPSDT 1996EPSDT 1996 (572 children) 2% - 6%(572 children) 2% - 6%


CDC RecommendationsCDC Recommendations Develop a statewide plan (targeted or universal) Develop a statewide plan (targeted or universal)

for lead screeningfor lead screening– May need to divide the state into different areas with May need to divide the state into different areas with

different recommendationsdifferent recommendations– Develop specific screening recommendations for each Develop specific screening recommendations for each

areaarea– Dissemination of screening recommendationsDissemination of screening recommendations– EvaluationEvaluation

““Screening policy should be based on data Screening policy should be based on data representative of the entire population”.representative of the entire population”.

““In the absence of a statewide plan or other In the absence of a statewide plan or other formal guidance from health officials, universal formal guidance from health officials, universal screening for virtually all young children should screening for virtually all young children should be carried out”.be carried out”.


Costs and benefits of a universal Costs and benefits of a universal screening program for elevated screening program for elevated blood lead levels in 1-year-old-blood lead levels in 1-year-old-children - Briss PA, Matte TD, et. al.children - Briss PA, Matte TD, et. al. ““When more than 14% (range 11-When more than 14% (range 11-

17%) of children had elevated 17%) of children had elevated blood lead levels, the economic blood lead levels, the economic benefits of universal screening benefits of universal screening exceeded the costs”exceeded the costs”

Targeted screening will likely be Targeted screening will likely be the most cost effective program in the most cost effective program in North Dakota.North Dakota.


Basic Targeted Screening Basic Targeted Screening - CDC- CDC

Use only as an interim measureUse only as an interim measure Screen children at 1-2 years and Screen children at 1-2 years and

children 36-72 mo who have not children 36-72 mo who have not previously been screened, if they previously been screened, if they meet one of the following criteria.meet one of the following criteria.


Basic Targeted Screening Basic Targeted Screening - CDC- CDC Resides in zip code area where Resides in zip code area where >> 27% of the 27% of the

housing was built < 1950housing was built < 1950 Receives public health assistance (e.g. WIC or Receives public health assistance (e.g. WIC or

Medicaid)Medicaid) Child’s parents or guardian answers “yes” or “don’t Child’s parents or guardian answers “yes” or “don’t

know” to any of the following questionsknow” to any of the following questions– Does your child live in or regularly visit a house that was Does your child live in or regularly visit a house that was

built before 1950?built before 1950?– Does you child live in or regularly visit a house built before Does you child live in or regularly visit a house built before

1978 with recent or ongoing renovations or remodeling 1978 with recent or ongoing renovations or remodeling (within the last 6 months)?(within the last 6 months)?

– Does your child have a sibling or playmate who has or did Does your child have a sibling or playmate who has or did have lead poisoning?have lead poisoning?


Efficacy of Targeted Efficacy of Targeted Screening - Rhode IslandScreening - Rhode Island

1995 analysis1995 analysis RI has universal screeningRI has universal screening 92% efficacy - screen all children 92% efficacy - screen all children

with zip codes with a with zip codes with a >> 27% pre- 27% pre-1950 housing.1950 housing.

93% efficacy - screen all in census 93% efficacy - screen all in census tracts with tracts with >> pre-1950 housing pre-1950 housing


North Dakota North Dakota ConsiderationsConsiderations Form an advisory committeeForm an advisory committee

– CompositionComposition Child health providersChild health providers Local health departmentsLocal health departments Managed care organizationsManaged care organizations Private insurance organizationsPrivate insurance organizations CommunityCommunity

– MissionMission Assess lead exposure and screening capacityAssess lead exposure and screening capacity Determine boundaries of recommendation areasDetermine boundaries of recommendation areas Decide on the appropriate screeningDecide on the appropriate screening

– Universal?Universal?– Targeted?Targeted?


North Dakota North Dakota ConsiderationsConsiderations Initial Screening PlanInitial Screening Plan

– Basic Targeted Screening (e.g. based on zip Basic Targeted Screening (e.g. based on zip code or census data for homes built < 1950) - code or census data for homes built < 1950) - should pick up 92-93% of those should pick up 92-93% of those >> 10 10

– Use the basic 3 CDC questionnaire plusUse the basic 3 CDC questionnaire plus Does the child live with an adult whose job or hobby Does the child live with an adult whose job or hobby

involves lead?involves lead? Does the child live near industry likely to release Does the child live near industry likely to release

lead?lead?

– Screen all with significant foreign country Screen all with significant foreign country exposureexposure

Well designed population based research - Well designed population based research - John’s Hopkin’s consultationJohn’s Hopkin’s consultation


North Dakota North Dakota ConsiderationsConsiderations

Adjust Screening Adjust Screening recommendations based on ND recommendations based on ND BLL research and targeted BLL research and targeted screening datascreening data

Recurrent re-evaluation and Recurrent re-evaluation and screening adjustmentsscreening adjustments

North Dakota Health Department 1 Lead Screening in North Dakota To do or not to do that is the question...

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