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Elevated Blood Lead Levels in Refugee Children --- New Hampshire, 2003--2004

Please note: An erratum has been published for this article. To view the erratum, please click here.

As a result of reductions in lead hazards and improved screening practices, blood lead levels (BLLs) in children aged 1--5 years are decreasing in the United States. However, the risk for elevated BLLs (>10 µg/dL) remains high for certain populations, including refugees (1,2). After the death of a Sudanese refugee child from lead poisoning in New Hampshire in 2000, the New Hampshire Department of Health and Human Services (NHDHHS) developed lead testing guidelines to screen and monitor refugee children (3). These guidelines recommend 1) capillary blood lead testing for refugee children aged 6 months--15 years within 3 months after arrival in New Hampshire, 2) follow-up venous testing of children aged <6 years within 3--6 months after initial screening, and 3) notation of refugee status on laboratory slips for first tests. In 2004, routine laboratory telephone reports of elevated BLLs to the New Hampshire Childhood Lead Poisoning Prevention Program (NHCLPPP) called attention to a pattern of elevated BLLs among refugee children. To develop prevention strategies, NHDHHS analyzed NHCLPPP and Manchester Health Department (MHD) data, focusing on the 37 African refugee children with elevated BLLs on follow-up for whom complete data were available. This report describes the results of that analysis, which indicated that 1) follow-up blood lead testing is useful to identify lead exposure that occurs after resettlement and 2) refugee children in New Hampshire older than those routinely tested might have elevated BLLs. Refugee children in all states should be tested for lead poisoning on arrival and several months after initial screening to assess exposure after resettlement.

Case Series

During October 1, 2003--September 30, 2004, a total of 242 refugee children, 238 (98%) of whom were African, resettled in New Hampshire; of these, 216 (89%) resettled in Manchester*. Of the 242 children, 32 had no lead test, 113 had a first but no follow-up test (17 overdue and 96 either not yet due or too old for follow-up), five had only elevated first tests (i.e., delayed because too young or extenuating circumstances), and 92 had two tests. A refugee child identified with an elevated BLL received the same follow-up care as any other child with the same BLL. Different BLLs trigger different actions. A BLL >15 µg/dL triggers a home visit during which a MHD staff administers parents questionnaires about their children's habits, diet, and potential sources of lead exposure, both inside and outside of the home. For children with BLLs >20 µg/dL, NHCLPPP routinely performs environmental investigations to identify lead hazards in or around the child's home. Lead hazards are defined as surfaces with lead paint present and with at least one of the following properties: chipping or peeling paint, a chewable surface, or a surface that creates friction on impact (e.g., windows and doors), increasing the likelihood that dust is generated. Intact lead paint is not considered a lead hazard.

After noting a pattern of elevated BLLs among refugee children, NHDHHS and NHCLPPP tabulated existing home visit and environmental data on refugee children with elevated BLLs. In addition, MHD abstracted height and weight measurements recorded up to 1 year before immigration on International Office of Migration medical examination forms. A computerized anthroprometry module was used to calculate percentages of children falling below two standard deviations (-2 Z-scores) using growth reference curves for height-for-age (HAZ) and weight-for-height (WHZ). Concern for malnutrition in a population occurs when the prevalence of low HAZ, indicating growth retardation or stunting from chronic malnutrition or chronic illness, or low WHZ, indicating acute malnutrition or wasting, is substantially greater than the expected 2.3% of a population (4).

A total of 92 (38.0%) of the 242 refugee children had both initial and follow-up blood lead testing; of these, 13 (14.1%) had elevated BLLs at both initial screening and follow-up, 10 (10.9%) had elevated BLLs at initial screening but not at follow-up, 27 (29.3%) were not elevated at screening but were elevated at follow-up, and 42 (45.7%) were not elevated at either screening or follow-up. Forty children had elevated BLLs at follow-up. Three children, for whom data were incomplete, were excluded from this analysis; therefore, this report describes the 37 (40.2%) of the 92 children who had elevated BLLs on follow-up testing (Table).

All 37 children (from 19 families) were born in Africa and resettled in Manchester. Seventeen (46.0%) were Somalis; 21 (56.8%) were female. The prevalence for low HAZ was 35.1% (13 of 37) and for low WHZ was 21.6% (eight of 37), indicating chronic and acute malnutrition. No other data from before immigration were available to assess micronutrient sufficiency.

Median age at the time of follow-up testing was 4.9 years (range: 14 months--13 years). Median initial screening BLL was 8.1 µg/dL (range: 2--28 µg/dL), performed 7--77 days (median: 22 days) after arrival. Median follow-up BLL was 18.6 µg/dL (range: 10--63 µg/dL), performed 35--188 days (median: 89 days) after arrival. Follow-up BLLs increased for 35 of 37 children; the average increase was 11 µg/dL (range: 1--59 µg/dL), and 26 (70.2%) became elevated after the initial testing. Three children received chelation therapy for BLLs >45 µg/dL.

Of the nine families who received home visits, eight had been placed in multi-unit rental properties constructed before 1978. Paint used in housing before 1978 can contain high levels of lead (5). Six families (66.7%) reported that their children exhibited one or more behaviors that could increase the chance of lead ingestion: frequently putting nonfood items in the mouth (five); picking at loose paint, plaster, or putty (five); and chewing on painted surfaces or items (four). Of eight apartments in which environmental investigations were performed, lead hazards were identified in seven.

Blood lead testing identified five additional refugee children with elevated BLLs, but data for these children were not included in this study because the children did not have both an initial and a follow-up blood lead test. For these five children, median age at time of blood lead test was 2.4 years (range: 11 months--4 years), and tests were performed 117--190 days after arrival in New Hampshire. Median BLL was 33.8 µg/dL (range: 17--72 µg/dL). One child, who had a BLL of 72 µg/dL, received chelation therapy immediately.

Reported by: J Kellenberg, MPH, R DiPentima, MPH, M Maruyama, R Caron, PhD, C Campbell, MD, P Alexakos, MPH, S Gagnon, A Krycki, Manchester Health Dept; M Dembiec, MEd, L Speikers, M Tehan, MPH, Childhood Lead Poisoning Prevention Program; EA Talbot, MD, J Greenblatt, MD, L Bujno, MSN, W Kassler, MD, New Hampshire Dept of Health and Human Svcs. MJ Brown, ScD, T Dignam, MPH, C Thomas, MPA, Emergency and Environmental Health Svcs, National Center for Environmental Health; R Plotinsky, MD, EIS Officer, CDC.

Editorial Note:

The findings in this report indicate that BLLs became elevated after resettlement for nearly 30% of refugee children with two tests, suggesting that lead exposure for these children occurred in the United States. Investigations revealed several risk factors for lead poisoning: living in old homes, the presence of lead hazards, behaviors that could increase the chance of ingesting lead, a lack of awareness of the dangers of lead, and evidence of chronic and acute malnutrition. Malnutrition is common in refugee populations (6); a December 2003 nutritional survey conducted in a refugee camp in Kenya, which was inhabited predominantly by Somalis, indicated that 95% of children aged <6 years were anemic (7). Anemia can enhance lead absorption and thus can increase risk for elevated BLLs, even in housing with minimal lead exposure hazards.

The findings in this report are subject to at least two limitations. First, not all refugee children were tested. Second, not all of those children tested had two tests as recommended by the state guidelines for refugee children. Despite these limitations, these findings demonstrate that lead toxicity can be a substantial risk for refugee children. This investigation highlights the importance of lead testing of this population so children with elevated BLLs can be appropriately identified and managed. To control and prevent lead poisoning, NHDHHS is proposing state adoption of expanded medical and environmental protocols and has implemented active case finding of refugee children who have not had blood lead testing. In addition, CDC and NHDHHS are planning a study to obtain more information about risk factors for elevated BLLs among refugee children, which will help guide lead poisoning prevention strategies for refugee children.

Federal standards stipulate that refugees receive a medical screening within 90 days of arrival in the United States. Federal law does not require that refugee children have a blood lead test; however, some states, including New Hampshire, screen refugee children for lead toxicity. In 2004, a total of 9,333 children aged <7 years, 58.3% of whom were from Africa, were resettled in 49 states. Other states should review their lead testing and care practices for refugee children to help identify problems in this vulnerable population. CDC is working with other federal agencies involved in refugee health to include blood lead testing for refugee children. A blood lead test is the only way to know if a child has been exposed to lead. Other interventions include:

  • pediatric multivitamins with iron for refugee children aged <59 months immediately on arrival in the United States;
  • blood lead tests, hemoglobin or hematocrit tests, and nutritional assessments for children aged <6 years within 90 days of arrival, and another blood lead test 3--6 months after placement in a permanent residence; and
  • consideration of blood lead screening for children aged >6 years if lead hazards are evident.

States should ensure that refugee families receive nutritional counseling and referral to the Supplemental Nutrition Program for Women, Infants, and Children (WIC). Increased lead-hazard training for refugee and resettlement case workers, health-care providers, and other agencies serving this population can help prevent lead poisoning among refugee children who enter the United States.


  1. Binns HJ, Kim D, Campbell C. Targeted screening for elevated blood lead levels: populations at high risk. Pediatrics 2001;108:1364--6.
  2. Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995 to 1999. Pediatrics 2001;108:158--62.
  3. CDC. Fatal pediatric lead poisoning---New Hampshire, 2000. MMWR 2001;50:457--9.
  4. Gorstein J, Sullivan K, Yip R, et al. Issues in the assessment of nutritional status using anthropometry. Bull World Health Organ 1994;72:273--83.
  5. US Consumer Product Safety Commission. Ban of lead-containing paint and certain consumer products bearing lead-containing paint. 16 CFR 1303. Fed Reg 1977;42:44199.
  6. United Nations System/Standing Committee on Nutrition. Nutrition information in crisis situations. Geneva, Switzerland: Secretariat of the UNS/SCN; May 2004. Report no. 2. Available at
  7. Prinzo AW, de Benoist B. Meeting the challenges of micronutrient deficiencies in emergency-affected populations. Proc Nutr Soc 2002;61:251--7.

* Most refugee families were resettled in Manchester because of the availability of affordable housing units that can accommodate larger families.


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