Module II Video Segment 1: Key Strategy – Testing and Reporting

[Music] the contents of this presentation are those of the authors and do not necessarily represent the official views of nor an endorsement by the Centers for Disease Control and prevention the US Department of Health and Human Services or the US government welcome to module 2 strategic planning and implementation of the four key strategies of a lead prevention program and evaluating its impact segment one a key strategy of testing and Reporting at the top right there are pictures featuring a father with a young daughter in his lap a picture of a mother and child at the doctor's office and a classroom with diverse students in the bottom right is the Centers for Disease Control and prevention logo which also shows that CDC is a part of the Department of Health and Human Services the purpose of today's module is to introduce the Centers for Disease Control and prevention strategic priorities and outline proactive steps that can be be taken to Aid in the elimination of childhood lead exposures this segment is designed to assist trainees in developing and sustaining jurisdictional lead advisory committees and screening plans implementing State blood Le testing recommendations and Reporting requirements and ensuring enhanced blood Le level testing and surveillance practices this segment will guide trainees in developing and sustaining a comprehensive testing and Reporting System by doing the following increasing awareness among providers developing screening plans for implementing state and local jurisdictional blood Le level or BL testing and Reporting requirements and recommendations ensuring enhanced BL testing and surveillance practices are in place and developing a referral to care system fortunately blood Le levels in preschool children in the United States have shown downward Trends this bar graph shows the estimated prevalence or percentage of blood Le levels among United States children ages 1 to 11 as plotted on the log 10 scale the dark gray bars show those with blood lead levels greater than or equal to 10 microgr per deciliter and the hatched bars show those with blood Le levels greater than or equal to 5 micrograms per deciliter the geometric mean blood Le levels in micrograms per deciliter for children ages 1 to 5 years are the solid line and the squares ages 6 to 11 years are represented by the circles in the dashed line as you can see all of the trends are moving in the right direction towards lower blood Le levels in the population however it's important to point out that the last mile the hardest populations to reach are still before us in terms of screening testing and surveillance a bar graph showing the decrease in blood lead levels in American children from 1976 to 2016 ages 1 to 5 years and 6 to 11 years residential lead hazards are still a Public Health Challenge this picture points out that lead can be found throughout a child's environment in homes built before 1978 when lead-based paints were banned when this this paint Peels and cracks it makes lead dust and children can be exposed when they either swallow or breathe in the lead dust certain Plumbing pipes in the home can contain lead and it can be found in some household products including children's toys and toy jewelry lead is sometimes found in imported items from other countries such as candles spices Cosmetics or traditional home remedies certain jobs and hobbies involve working with lead-based products and may cause parents to bring lead from the work site or the hobby into the home for example stained glass window work or construction labor a picture of a room inside a home showing a window a door to the kitchen a child sitting on the floor playing with toys a male adult sitting at a table with candles on it and a woman entering a door returning home from work all are potential lead hazards the CDC has four strategic priorities for lead testing and Reporting among state and local jurisdictional Partners the first priority is to develop and sustain a jurisdictional lead ADV advisory committee the second is to develop or update and Implement an appropriate jurisdictional screening plan based on local data with an emphasis on highly impacted communities a third priority is to increase awareness among Pediatric Health Care Providers and clinical laboratories of state and local blood Le level testing recommendations and Reporting requirements the last strategic priority is to enhance secondary prevention or prevention activities at the earliest after childhood Le exposure through core Public Health functions for example Assurance by ensuring accurate blood Le level testing and Reporting and by improving linkages to recommended services for the children identified as exposed to lead in addition regular assessments should be conducted of Statewide testing and screening plans to review data and systems for quality improvement developing and sustaining a jurisdictional advisory committee is an important consideration this committee should be composed of appropriate stakeholders this list includes pediatricians and others in in the healthcare and child care sectors community-based organizations serving L affected communities representatives of affected communities Academia local housing agencies Community leaders tribes and tribal organizations nonprofit organizations and clinical laboratories developing and implementing a jurisdictional screening plan based on the local data is critical also collaborating with jurisdictional lead advisory committees can help establish or update screening and testing plans with clear guidance for Pediatric Healthcare Providers this will help establish or update a blood test reporting policy to ensure that Laboratories and Healthcare Providers understand and comply with reporting requirements and the collaborators can incorporate a sustainability plan to ensure a regular review of the data and make updates to the Statewide screening and testing recommendations as required there is guidance for Led testing and Reporting processes are developed by programmatic professionals to inform how testing and Reporting is to be carried out this guides how field professionals promote and Implement testing and Reporting then from the implementation surveillance professionals can track reported data and ensure its accuracy an image of a laboratory machine used to test blood samples CDC and the American Academy of Pediatrics or the AAP have made recommendations regarding screening and testing children for lead the following applies to Physicians treating children in your jurisdiction first a definition of screening versus testing in this context when we say screening that refers to questions and epidemiological data that Define the degree of a child's risk testing is the actual measuring of lead in the blood in a past effort in 2012 The Centers for Disease Control and prevention advisory committee on childhood Le poisoning prevention or a clip issued a report the 2012 AC clip report made the following recommendations for testing criteria in children ages 1 and 2 years old and children 36 6 to 72 months old who had not previously been tested children who receive services from Public Assistance programs such as Medicaid or the women infants and children's supplemental nutrition program more commonly known as Wick should be tested for lead the centers for Medicare and Medicaid services or CMS requires either capillary or Venus blood Le level testing for Medicaid enrolled children at 12 and 24 months of age children who are 72 months of age or less and who missed required testing at a younger age must be tested at presentation the a clip also recommended Universal lead screening for children living in a community where more than 27% of the population lives in pre-1950 housing or when 12% or more of the childhood population up to age 36 months has a blood lead level greater than or equal to 10 microgr per deciliter at the time that was considered a level of concern there's also priority screening for specific groups with higher risk factors in communities even where there is lower prevalence of higher blood Le levels sometimes state and local agencies formulate their own lead screening recommendations based on local data these recommendations may be revised to account for the 2021 updated blood Le reference value the lead exposure and prevention advisory committee also known as leac provides guidance and advice to the Health and Human Services secretary the CDC director and the agency for toxic substances and disease registry administrator regarding reviewing Federal programs and services current research and best practices regarding lead screening in the prevention of lead poisoning most recently leac recommended lowering the reference blood Le level value to 3.5 microgr per deiler this recommendation was based on the 97.5th percentile of two national health and nutrition examination survey Cycles across the country the blood Le level reference value at 3.5 micrograms per deciliter was most recently updated on October 28th 2021 with this new reference value in mind opportunities for improvement include attention to the lower limit of detection of the point of care or po test which is 3.3 microgr per deciliter measurement uncertainty is highest at the limit of detection and the current blrv is only 0.2 microgr per deciliter above its limit of detection the accuracy of measurements is a concern if contaminated materials were used to collect the blood sample for any type of blood test in addition skin contamination or contamin in collection materials can cause falsely high blood lead results regardless of the test used for the measurement there are opportunities for improvements and implications for public health thresholds for inspection and other interventions at the level of the community and the home there are also implications for healthc care providers in confirming and Reporting higher blood L levels the new reference value of 3.5 micrograms per deser has implications for healthcare providers in developing action plans there are some advantages to lowering the reference blood Le level we can reach more children who are at risk it's an opportunity for early identification of children potentially exposed to lead there's also the ability to maximize the potential effectiveness of remediation and intervention with timely linkages to referral and Care the American Academy of Pediatrics Bright Futures program also has issued some recommendations for lead screening and testing the AAP recommends the following that Pediatric Healthcare Providers perform risk assessment that is screening at well child care visits at 6 9 12 18 and 24 months of age and at ages 3 4 5 and 6 years to obtain a blood Le level only if the screening that is the risk assessment of the child and the family is positive there's also a recommendation for the universal blood Le level testing of Medicaid recipients a snapshot of the American Academy of Pediatrics lead poisoning website Wick is a Federal grant program that's been in existence since 1974 it's designed to safeguard the health of low-income women infants and children up to 5 years of age by serving these groups pregnant persons breastfeeding persons non- breastfeeding but postpartum persons infants and toddlers up to age five it includes screening preschool children for nutritional risk testing for anemia is mandatory and testing for a blood Le level is recommended we will now discuss the roles for healthc care providers in screening testing reporting and follow-up of cases Healthcare Providers have a variety of roles screening preschool children to identify those in high-risk groups ordering blood Le level tests when indicated confirming a blood Le level which exceeds the blood Le reference value by a finger stick with a Venus test obtained in a timely fashion ensuring that all blood Le level results are shared with local and state level Public Health agencies following up on interpreting blood Le level results and counseling families about the interpretation of those results initiating follow-up management for the future referral as needed to other resources and working with families in prevention counseling there are some populations who are at risk for lead exposure for example pregnant persons and therefore fetal exposure is a high risk children living in households at or below the federal poverty level children living in dwellings built before 1978 or residing in ZIP codes with a high prevalence of lead Expos exposure children living with housing inequity which would include substandard housing immigrants and refugees children adopted from locals outside of the United States children with developmental disabilities who often have abnormal habits such as Pica Pica is the putting of non-food items in their mouths and chewing sucking on or swallowing them and adults participating in lead related occupations or Hobbies also known as take-home Le and their children these are all populations at risk for lead exposure the following are some typical screening questions about housing that might be asked of families does this child live in or regularly visit a home built before 1978 in the past year has this child been exposed to repairs repainting or Renovations of a home built before 1978 at any time has this child lived near a factory where lead is being used for example near a lead smelter does this child reside in a high Le prevalence zip code other screening questions for clinicians involve the child or the family is this child an immigrant or Refugee from some less developed countries do any of this child's Playmates have a Venus blood Le level at or above the blood Le reference value of 3.5 microgram per deciliter does this child have a sibling with a Venus blood Le level greater than or equal to 3.5 microgr per deciliter family screening questions include does this child live with someone whose job or hobby may involve lead or has this child been to any country where exposure to Le in certain items could have occurred other risk-related questions include is this child in foster care with numerous housing transitions does this child have persistent Pica habit that is oral exploratory behaviors of non-food items such as those seen in children with developmental disabilities is this child an international adoptee does this child or adolescent engage in Marksmanship or other Hobbies or occupations that may involve lead and finally does this family use important spices Cosmetics religious powders cookware Pottery or ethnic remedies it's important in public health to enhance secondary prevention of childhood Le poisoning this is accomplished through the core Public Health functions of assurance and assessment Assurance means ensuring access to blood Le level testing reporting accurately and improving linkages to recommended Services assessment means to monitor lead exposure by enhancing blood lead level surveillance what do we mean by secondary prevention secondary prevention is screening to identify diseases at the earliest stages before the onset of signs and symptoms in terms of the goal for lead poisoning prevention we screen children at early ages to identify exposure eliminate the source remediate the environment and Link affected children to critical medical and Behavioral Services these are the ideal pieces of secondary prevention the rationale for testing children involves two intervention targets primary PR vention the elimination of sources of lead contamination in a child's environment before any possible exposure can occur secondary prevention a measure to identify children exposed to lead and reduce hazardous impact each state has its own requirements for secondary prevention in addition to Medicaid requirements a picture of a child in a doctor's office having blood drawn now we will move on to assessing sample types for blood Le testing finger stick also known as capillary testing versus V sampling a finger stick also known as capillary blood testing for lead has some advantages as well as challenges the advantages are that the capillary blood can be tested by Any Lab Test type but it's mainly tested on point of care instruments it's easier to collect thereby leading to increased rates of blood Le testing one of the challenges of capillary blood testing is that during collection the sample is easily contaminated from lead on the skin which can give false positive results compliance in reporting blood results by point of Care staff members to state and federal authorities may be lower than compliance in reporting by labs in addition to these advantages and challenges there are some recommendations that are made when capillary blood testing is done one is that higher capillary blood blood level results should be confirmed by Venus blood Le testing in a timely fashion providers and families may choose to use capillary blood sampling for blood Le screening but should have access to confirmatory Venus blood Le level testing as well one example is from a Minnesota study of 3,898 children aged less than 6 years from 2011 to 2017 in this study capillary blood Le levels greater than or equal to 5 microgr per deciliter were followed by a Venus blood Le test within 90 days of the children tested 60% had a confirmatory Venus blood Le level less than 5 microG per deciliter in other words they had a false positive 73% of the elevated capillary screening tests or 2 . 2% of all capillary screening tests in this study were false positives an image of a finger stick blood draw there is currently only one POC blood Le analyzer approved by the Food and Drug Administration to be used as a waved test according to Clinical Laboratory Improvement amendments or CLIA regulations a PO blood Le test reduces barriers to Patient compliance and provides bloodle results within the same office visit the current POC test requires only 50 microl of blood and takes only 3 minutes it's suitable for office use with a simple technique for training office staff challenges for the pocc blood Le test include that it's limited to testing only capillary blood samples less than 24 hours old and it can report only in the range of 3.3 to 65 microgr per deciliter POC blood test locations are not required by Clea to demonstrate accuracy of their blood Le testing by participating in proficiency testing as our Labs from 201 21 to early 2022 most lead care 2 test kits on the market were recalled as part of an FDA class 1 recall which greatly reduced the availability of blood Le testing the recall Ended as of March 30th 2022 and distribution of the lead care 2 testing product resumed a picture of a laboratory blood Le testing machine here are a few of the details regarding testing Venus blood for lead Venus blood Le tests are approved by Clea certified High complexity Laboratory evacuated blood tubes pre-tested for lead contamination are commercially available these tests represent the gold standard for reliability in results and minimize lead contamination concerns a picture of a gloved hand holding a blood-filled test tube showing it is for a lead test there are challenges to Venus blood lead testing for example there are barriers to compliance it's not currently approved for point of care blood L testing untrained staff members in a practice May collect the specimen in the wrong tube the highly complex laboratory tests used to analyze Venus blood require extensive training these tests are limited to Laboratories with the appropriate cleia certificate and to staff that meet higher requirements of qualification and training the result of Venus blood Le level testing may not be immediately available it may take up to four to 5 days to get a report back from the laboratory a picture of an adult man's arm having blood drawn by a FLOTUS in terms of reporting lead level results there are are some jurisdictional reporting requirements jurisdictions receiving CDC funding are required to report bloodle data from Laboratories to the CDC quarterly jurisdictions should strive to submit data to the CDC that are free of errors or missing information so why is such reporting important it allows Health departments to collect and track data for improved surveillance it helps to identify high-risk populations in areas it's used to support funding opportunities and it alerts health departments to cases that need public healthare management there are also recommendations from the American Academy of Pediatrics the AAP says that state and local governments should work with pediatricians and other Primary Care Providers to ensure that a comprehensive environmental inspection is conducted in the housing units of children who have blood Le concentrations at or above the current blood Le reference value and that they receive appropriate case management a snapshot of the American Academy of Pediatrics recommend Commendation report on childhood Le toxicity and so there are some important linkages to care it's important to connect children with blood Le levels at or above the reference value to appropriate medical environmental social and Behavioral Services this helps to establish a sustainable referral system to establish and maintain relationships with medical service providers to establish and maintain relationships with social and behavioral service providers to identify and work with providers of environmental remediation services and to identify state and local resources for the provision of services the following map shows the 2022 childhood lead poisoning prevention funding recipients in terms of national lead program surveillance coverage this map shows testing reporting and linkage to care in specific counties and state Departments of the environment or Departments of Public Health as well as targeted population-based policy intervention throughout the United States a map of the United States showing areas with childhood poison poisoning prevention programs in summary of Segment 1 module 2 lead contamination of water and housing is still an important Public Health concern in the USA both the CDC and AAP have set guidance for screening and testing children for lead healthare providers have important roles for screening and testing Children at Risk or exposed to lead and in reporting the results of such screening and testing there are important differences between finger stick that is capillary and Venus blood L levels this presentation was developed in collaboration with the American Academy of Pediatrics and Dr Alan wolf associate chief medical education officer at Boston Children's Hospital and a professor of pediatrics at Harvard Medical School he's the director of the Pediatric Environmental Health Center at Boston Children's Hospital the contents of this presentation are those of the authors and do not necessarily represent the official views of nor an endorsement by the Centers for Disease Control and prevention the American Academy of Pediatrics the UN Department of Health and Human Services or the US government the use of trade names is for identification only and does not imply endorsement by the CDC the Public Health Service or the US Department of Health and Human Services thank you for viewing module 2 Segment 1 for questions or comments regarding this segment please send an email to the following address lead info@ cdc.gov and indicate a training question for module 2 segment one in the subject line thank you