Current Trends Impact of the 1985 CDC Lead Statement -- Savannah, Georgia

In January 1985, CDC published a statement of revised recommendations on screening children for lead poisoning (1). The statement recommended that children at high risk for lead poisoning be screened as frequently as every 3 to 6 months, using a two-step screening process consisting of an initial erythrocyte protoporphyrin (EP) test followed by a second EP test and a blood lead (BL) test if the initial test indicated an EP level greater than or equal to35 ug/dl. The statement also recommended that children less than 6 years of age with BL concentrations greater than or equal to25 ug/dl and EP concentrations greater than or equal to35 ug/dl be considered to have lead toxicity and to require medical follow-up. In contrast, the previous CDC statement, published in 1978, had recommended medical follow-up if children had BL concentrations greater than or equal to30 ug/dl and EP concentrations greater than or equal to50 ug/dl.

On January 23, 1985, the Lead Screening Program in Chatham County, Georgia, adopted the new CDC guidelines. Even though there was a similar number of screenings in 1984 and 1985 (greater than 5,000), the program identified many more children in the Savannah area as having lead toxicity in 1985. Fifty-nine children with lead toxicity had a total of 68 hospitalizations in 1985, compared with 25 children with 42 hospitalizations in 1984. The differences represent a 140% increase in the number of children treated and a 60% increase in overall hospitalizations for treatment.

Test results were evaluated to determine whether this increase was attributable to the new criteria for medical referral or whether more children had lead toxicity. Researchers calculated the number of children who would not have received follow-up testing and referral under the 1978 guidelines and compared that number to the number receiving such care under the new guidelines. In 1985, 862 children (15% of 5,828 screenings) required follow-up because their EP levels were greater than or equal to35 ug/dl. However, only 366 (6%) had EP levels greater than 50 ug/dl and would have received follow-up under the 1978 guidelines. Using the new guidelines resulted in the evaluation of 150% more children in 1985.

The quarterly trends of the mean EP and BL levels of children screened in 1985 were also studied. The mean EP level declined for each 3-month period in 1985 (30 ug/dl, 25 ug/dl, 23 ug/dl, and 22 ug/dl). The proportion of children requiring follow-up BL and EP testing also declined (22%, 16%, 12%, and 11%).

Seven hundred fifty-seven of the 862 children with EP levels greater than or equal to35 ug/dl were available for retesting. The highest BL level was 64 ug/dl, and the mean BL level was 17 ug/dl. Of those retested, 139 had BL levels greater than or equal to25 ug/dl and were referred for medical follow-up. If the 1978 CDC guidelines had been in effect, only the 67 children with BL levels greater than or equal to30 ug/dl would have been referred. The difference represents a 110% increase in the number of medical referrals because of the revised guidelines.

Reported by: S Brown, Chatham County Lead Poisoning Prevention Program, Savannah, Georgia. Surveillance and Programs Br, Div of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: Although children's lead exposure appears to be declining in the United States, researchers suggest that BL levels lower than the current cutoff for retesting may have deleterious effects on the developing child (2). The greatest potential harm appears to be in neurobehavioral abnormalities and intellectual impairment. In the revised statement on lead poisoning published by CDC in 1985, the EP screening guidelines were unchanged--only those relating to the BL and EP levels for medical follow-up were changed. The recommendations reflected current knowledge concerning screening, treatment, follow-up, and environmental intervention for children with elevated BL levels.

The American Academy of Pediatrics recently published its recommendations for pediatric lead screening (2), which closely follow those of the 1985 CDC statement. Some researchers and public health officials, however, have proposed that the CDC guidelines be further revised because the current criteria for medical referral allow children to have BL concentrations up to 24 ug/dl, levels that may be unsafe. Lowering the cutoff will identify additional children who may be at risk for lead toxicity. This may necessitate finding an alternative to the EP test, which is not a good predictor of lead exposure at low BL levels (3). EP levels become elevated as the result of many conditions--iron deficiency is often the cause (4). While EP is recommended as a screening test for both iron deficiency and lead toxicity, it is not recommended for identifying children with BL levels less than 18 ug/dl (3). At this level, mass screening may require BL instead of EP analysis.

References

1. CDC. Preventing lead poisoning in young children: a statement by the Centers for Disease Control. Atlanta: US Department of Health and Human Services, Public Health Service, 1985.

2. American Academy of Pediatrics. Statement on childhood lead poisoning. Pediatrics 1987;79:457-65.

3. Piomelli S, Seaman C, Zullow D, Curran A, Davidow B. Threshold for lead damage to heme synthesis in urban children. Proc Natl Acad Sci USA 1982;79:3335-9.

4. Yip R, Schwartz S, Deinard AS. Screening for iron deficiency with the erythrocyte protoporphyrin test. Pediatrics 1983;72:214-9.

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