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State Activities for Prevention of Lead Poisoning Among Children -- United States, 1992

In 1990, an estimated 3 million children aged less than 6 years had blood lead levels (BLLs) greater than 10 ug/dL (1) -- levels associated with decreased intellectual performance and other adverse health events (2,3). During October 1991, CDC revised its childhood lead poisoning prevention policy statement (4); the recommendations included lowering the BLL of concern from 25 ug/dL to 10 ug/dL. To characterize efforts of state health agencies in lead-poisoning prevention and to assess the extent of implementation of the recommendations in the 1991 lead statement, in June 1992, the Lead Task Force of the Association of State and Territorial Health Officials (ASTHO) conducted a questionnaire survey of directors of public health in each of the 50 states. This report summarizes findings of the survey regarding screening issues, funding mechanisms, and follow-up of children with elevated BLLs.

In addition to lowering the BLL of concern, CDC's 1991 revised lead statement introduced a multitiered approach for environmental management (i.e., investigation of lead exposure and reduction of lead hazards) and medical follow-up based on an affected child's BLL; recommended a phase in of "virtually universal" screening (i.e., screening of all young children except those in communities where large numbers of children were previously screened and found not to have lead poisoning); and emphasized the importance of primary prevention (i.e., identification and remediation of lead hazards before children's BLLs increase). Because the erythrocyte protoporphyrin (EP) test that had been previously recommended for screening is not sufficiently sensitive for BLLs less than 25 ug/dL, measurement of blood lead was identified as the screening test of choice.

Although 48 states responded to the survey, not all respondents answered every question. Of 48 respondents, 21 (44%) had implemented or were planning to implement the revised guidelines within 1 year, 18 (38%) planned to phase in the guidelines over several years, and nine (19%) had no plans to implement the guidelines. Thirty-seven (80%) of 46 states are coordinating prevention activities with housing and environmental agencies. Of 47 respondents, 19 (40%) maintain a system at the state level for monitoring health and environmental follow-up of children with elevated BLLs.

Major barriers to establishing virtually universal screening were a lack of financial support for blood lead screening (67%); inadequate funding for abatement (65%); insufficient resources for environmental follow-up (40%); a lack of interest in and/or support for the CDC guidelines by the health-care community (38%); absence of a state law mandating screening (35%); and insufficient laboratory capacity for analyzing blood lead samples (29%).

Approaches for statewide screening included use of well-child clinics, community health centers, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and Head Start programs. Thirty-seven (86%) of 43 states reported that the Early and Periodic Screening, Diagnostic, and Treatment program was important for providing statewide screening.

Primary screening methods reported by 44 states were blood lead testing (70%), both blood lead testing and EP (23%), and EP only (7%). Of 35 respondents, 22 (63%) reported the primary screening test used by pediatricians was blood lead tests, 12 (34%) reported that pediatricians used both blood lead testing and EP, and one (3%) reported that pediatricians used EP.

Twenty-eight (58%) of 48 states provided information on their ability to assure medical and environmental follow-up of children consistent with the multitiered approach outlined in the 1991 statement. Eighty-six percent of respondent states reported that medical and environmental management as recommended by CDC was provided for more than half of children with BLLs greater than or equal to 20 ug/dL. One fourth reported that more than 50% of children with BLLs 10-19 ug/dL received follow-up activities consistent with CDC recommendations.

States used multiple financial mechanisms to fund lead poisoning prevention activities. Among 45 states reporting information on funding for blood lead screening, 91% used federal funds; 53%, state funds; and 29%, local funds. Among 40 states providing information on financial mechanisms to support environmental investigations, 70% used federal funds and 58% used state funds. Among 37 states reporting funding information on medical follow-up, 92% used federal funds; 49%, state funds; 41%, client copayment; and 35%, reimbursement from private insurance. Only 23 (48%) states provided information on sources of funding for lead abatement. The principal methods of supporting these activities were local funds and "other" resources (e.g., money spent by owners of property with lead hazards).

Reported by: DB Fischer, JD, A Boyer, Lead Poisoning Task Force, Association of State and Territorial Health Officials. Lead Poisoning Prevention Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: The lead survey conducted by ASTHO is the first systematic assessment of lead poisoning prevention activities at state health agencies since the October 1991 lead statement. However, the survey focused on statewide programs and activities, and the findings may not reflect prevention efforts conducted by local health departments.

The 1991 lead statement underscored the need for state and local health departments to implement virtually universal screening and to assure follow-up at BLLs lower than previously recommended. The findings in this report indicate that most states are implementing the new guidelines and identifying aspects that require strengthened efforts or resources.

When the 1991 lead statement was released, EP testing was widely used to screen children. Although most public and private health-care providers appear to be screening children with blood lead tests, the findings in this report indicate EP testing is still being performed and underscore the need for continued efforts to phase in blood lead testing.

Collection of state-level data to monitor health-care and environmental management of children with elevated BLLs was reported by only 40% of respondents. However, such data are useful for facilitating coordination and allocation of resources and assuring implementation of prevention programs. Case-management software, such as CDC-developed System for Tracking Elevated Lead Levels and Remediation (STELLAR), can facilitate data management. Additional information about STELLAR is available from CDC's Lead Poisoning Prevention Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Mailstop F-42, 4770 Buford Highway, NE, Atlanta, GA 30341-3724.

CDC is providing resources to assist with the development of "balanced" programs at the state and local level; such programs integrate activities for screening, environmental inspections, health-care case-management and environmental follow-up, education, and data collection and management. Primary and secondary prevention of childhood lead poisoning relies on funding for lead-hazard reduction; during fiscal year 1992, the U.S. Department of Housing and Urban Development awarded funds to 10 state and local agencies for abatement activities.

CDC plans to revise the 1991 lead statement to incorporate new scientific data and to account for recent changes in approaches to environmental hazard reduction. The findings in this report have assisted in identifying potential barriers to the implementations of recommendations in the lead statement.


  1. US Environmental Protection Agency. Strategy for reducing lead

exposures. Washington, DC: US Environmental Protection Agency, 1992.

2. Baghurst PA, McMichael AJ, Wigg NR, et al. Environmental exposure to lead and children's intelligence at the age of seven years. N Engl J Med 1992;327:1279-84.

3. Mushak P, Davis JM, Crocetti AF, Grant LD. Prenatal and postnatal effects of low-level lead exposure: integrated summary of a report to the U.S. Congress on childhood lead poisoning. Environ Res 1989;50:11-36.

4. CDC. Preventing lead poisoning in young children: a statement by the Centers for Disease Control, October 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

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