Education Columns

by Ada Celik, DO; Michael Ainbinder, MD, MPH; Alonzo Jalan, MD; Advocate Aurora Health Care, Aurora Family Medicine Program, Milwaukee, WI

Introduction

The state of Wisconsin, and particularly Milwaukee, its largest and most urban hub, has been plagued by lead poisoning for decades. Vulnerable children across all demographics have unfortunately been affected by lead exposure to varying degrees. Even though the CDC recently changed their blood lead reference value (BLRV) to 3.5 micrograms per deciliter to identify children with elevated blood lead levels (representing the top 2.5%); no level of lead in the body has been deemed safe for children according to the American Academy of Pediatrics due to potential neurologic and developmental problems³. Some studies have even linked lead exposure to an increased prevalence of gun violence and victimization⁴. Despite these studies and recommendations, there are still thousands of children in Milwaukee who are exposed to lead each year due to predominantly old housing stock concentrated in areas of poverty. Due to historical redlining, BIPOC (Black, Indigenous, People of Color) communities were forced into these neighborhoods, resulting in a disproportionate impact of lead poisoning on these communities and further perpetuating differences in potential attainment between white and non-white groups ^5,6. It is well known that the main sources of lead include soil, paint chips and dust on older houses, old toys, and tap water from lead-containing pipes. Furthermore, not surprisingly, children under 6 are the most at risk given their developmentally appropriate hand-to-mouth activity and their rapid growth and neurodevelopment during this time. Although the Milwaukee Health Department has made great strides toward reducing the number of children exposed to lead, there has been a tenuous relationship between lead prevention efforts.

Methods

Given the importance of lead monitoring and screening in Milwaukee, there have been efforts across our residency program to improve lead screening capabilities. According to the Wisconsin Department of Health Services; only 47.9% of the required Medicaid assisted children were appropriately tested for lead poisoning in 2019 (Table 1). To increase accessibility to the test, we introduced point-of-care (POC) lead screening at one of our residency clinics. As proven by previous studies, POC testing can substantially increase lead-level screening rates during childhood ^{1, 2}. Although our initial data demonstrated a significant increase in patients who underwent lead screening, our research was later halted due to the COVID-19 pandemic. Moreover, there was a nationwide recall in 2021 for the Magellan POC lead test kits, which further complicated our efforts to screen for lead poisoning.

Table 1: Medicaid Testing Rate by Age

As we are adapting to a life post-pandemic, it is imperative we continue our efforts to expand lead screening. Educating residents and other health care providers on local guidelines regarding lead screening indications is crucial since geography and history may dictate the rate of childhood lead poisoning in different communities. To simplify workflow, we developed a diagram for our residents and other providers to follow in case a child is confirmed to have elevated blood lead levels (Diagram 1). We are also planning on resuming our POC testing at our pilot residency clinic as test kits are becoming increasingly available again and aiming to introduce POC testing to our other residency clinic to increase accessibility to less invasive testing. Furthermore, we are dedicated to collaborating with the Milwaukee Health Department which offers “Lead Safe Kits” which contain various items that can be utilized to minimize lead exposure including water filters, mops, gloves, and educational materials. 

Diagram 1: Lead Screening Flowchart

Conclusion

Ultimately, educating patients, parents, and healthcare workers of the dangers of childhood lead poisoning and ways to prevent it should be a key focus for each family medicine residency program. Incorporating routine screening in infancy into resident workflow, while also collaborating with state or city health departments to stay up to date on local guidelines is absolutely critical. Screening early and frequently is key to preventing long-lasting effects of lead poisoning, and improving the health of our patients.

References

1. Carnahan B, Schaefer EW, Fogel BN. Point-of-Care Testing Improves Lead Screening Rates at 1- and 2-Year Well Visits. J Pediatr. 2021 Jun;233:206-211.e2. doi: 10.1016/j.jpeds.2021.02.067. Epub 2021 Mar 4. PMID: 33675816.
2. Boreland F, Lyle D, Brown A, Perkins D. Effectiveness of introducing point of care capillary testing and linking screening with routine appointments for increasing blood lead screening rates of young children: a before-after study. Arch Public Health. 2015 Dec 29;73:60. doi: 10.1186/s13690-015-0111-y. PMID: 26715987; PMCID: PMC4693436.
3. Sample, Jennifer A, and Lauren Zajac. “Revised Blood Lead Reference Value: Progress, but More Work to Be Done.” Publications.aap.org, American Academy of Pediatrics, 21 Oct. 2021, https://publications.aap.org/aapnews/news/17767?autologincheck=redirected. 
4. Emer LR, Kalkbrenner AE, O'Brien M, Yan A, Cisler RA, Weinhardt L. Association of childhood blood lead levels with firearm violence perpetration and victimization in Milwaukee. Environ Res. 2020 Jan;180:108822. doi: 10.1016/j.envres.2019.108822. Epub 2019 Oct 15. PMID: 31654907.
5. Lynch EE, Malcoe LH, Laurent SE, Richardson J, Mitchell BC, Meier HCS. The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health. SSM Popul Health. 2021 Apr 20;14:100793. doi: 10.1016/j.ssmph.2021.100793. PMID: 33997243; PMCID: PMC8099638.
6. Lynch EE, Meier HCS. The intersectional effect of poverty, home ownership, and racial/ethnic composition on mean childhood blood lead levels in Milwaukee County neighborhoods. PLoS One. 2020 Jun 19;15(6):e0234995. doi: 10.1371/journal.pone.0234995. PMID: 32559243; PMCID: PMC7304591.