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What Impact Has the Pandemic Had on Childhood Blood Lead Testing?

  • Authors: News Author: Lucy Hicks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/8/2022
  • Valid for credit through: 7/8/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for pediatricians, internists, family medicine and primary care clinicians, public health and prevention officials, nurses, obstetricians/gynecologists, family medicine practitioners, nurses, pharmacists, physician assistants, public health officials, and other members of the healthcare team involved in childhood blood lead level (BLL) testing.

The goal of this activity is for learners to be better able to describe BLL testing trends among young children during the COVID-19 pandemic, according to a Centers for Disease Control and Prevention (CDC) analysis of data reported from 34 state and local health departments about BLL testing among children aged < 6 years conducted during January to May 2019 and January to May 2020.

Upon completion of this activity, participants will:

  • Describe BLL testing trends among children aged < 6 years during the COVID-19 pandemic, according to a CDC analysis of data reported from 34 jurisdictions about BLL testing among children conducted during January to May 2019 and January to May 2020
  • Identify clinical and public health implications of BLL testing trends among children aged < 6 years during the COVID-19 pandemic, according to a CDC analysis of data reported from 34 jurisdictions about BLL testing among children conducted during January to May 2019 and January to May 2020
  • Outline implications for the healthcare team


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News Author

  • Lucy Hicks

    Freelance writer, Medscape, LLC


    Lucy Hicks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC


    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

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What Impact Has the Pandemic Had on Childhood Blood Lead Testing?

Authors: News Author: Lucy Hicks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/8/2022

Valid for credit through: 7/8/2023, 11:59 PM EST


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

The Centers for Disease Control and Prevention (CDC) identify no safe blood lead levels (BLLs) in children and considers a blood lead reference value (BLRV) of 5 μg/dL sufficient to warrant clinical and public health intervention. Among children aged < 6 years, BLLs (> 70 μg/dL) can cause neurologic problems, organ failure, and death.

In the United States, the most common childhood lead exposures are from lead-based paint used in pre-1978 housing, lead-contaminated soil or lead-containing pollutants from industrial sources, and water from old lead pipes and fixtures. Very young children are particularly vulnerable because of their tendency to put fingers or objects in their mouths and their greater absorption of lead as their bodies are rapidly developing.

Study Synopsis and Perspective

Childhood BLL testing rates fell by a third in the period March 2020 through September 2020 compared with the same calendar months from 2017 to 2019. Although 2021 testing rates showed some improvement, they were still significantly below prepandemic levels.

The research was presented earlier this month at the 2022 Epidemic Intelligence Service (EIS) Conference,[1] held virtually. EIS is a 2-year epidemiology training program sponsored by the CDC.

Lead exposure in young children can result in serious health consequences, such as brain and nervous system damage, slowed growth, lower IQ, underperformance in school, behavioral issues, and hearing and vision problems. Some of the most common ways children are exposed to lead is lead-based paint chips or lead-contaminated dust, although other sources include soil, drinking water delivered through degrading lead pipes, consumer products such as toys and jewelry, and medicines. Although there is no safe level of lead exposure, the CDC's blood lead reference value (BLRV), which identifies children with the highest blood lead levels, is 3.5 μg/dL.

Lead exposure continues to be an issue of health equity, as children in low-income housing are at a higher risk for lead exposure, according to the CDC.[2] Most children with elevated blood lead levels are asymptomatic, which is why universal screening is recommended, said Hillary Spencer, MD, MPH, an EIS officer at the Chicago Department of Public Health, who presented the research.[1]

"It's similar to the importance of testing someone's blood pressure, because rarely do people have symptoms because of hypertension," she told Medscape Medical News. "You have to test to know."

To find out how the past 2 years of the COVID-19 pandemic have affected childhood blood lead testing, Spencer and her team tallied the total number of lead tests reported to the Illinois Healthy Homes and Lead Poisoning Surveillance System from Chicago children aged 11 months to 4 years. They compared the average number of tests conducted from March through September in the years 2017 to 2019 as well as the total tests performed in the same months in 2020 and 2021.

Spencer's team found that testing levels had dropped 33% in 2020 from prepandemic years, from a mean of 36,307 tests in 2017 to 2019 to 24,387 in 2020. This is consistent with a 34% national drop in childhood blood lead testing that same year, according to a study in the CDC's Morbidity and Mortality Weekly Report.[3] In 2021, the number of tests from March through September rose to 28,622, which was still 21% below the tests performed in prepandemic years.

The results of the study are not particularly surprising, said Alan Woolf, MD, MPH, the director of the Pediatric Environmental Health Center at Boston Children's Hospital, Boston, Massachusetts. He was not involved with the research. "I think it was unreasonable to expect that the level of testing would rise to prepandemic levels in terms of its frequency, at least right away," he told Medscape Medical News.

The pandemic led to a drop-off in people seeking out primary care, which resulted in a decline in BLL testing in Chicago and nationally. There was some improvement in 2021, but in May of that year, a major diagnostic company announced the recall of its point-of-care blood lead test due to unreliable results.[4]

Without that point-of-care testing available in pediatric offices, fewer children ended up getting their BLLs checked.

Beyond prioritizing BLL testing, Woolf said providers can also counsel families to lower risk for lead exposures by:

  • Maximizing dietary sources of iron, calcium, and vitamin D, which discourage gut absorption of lead
  • Removing shoes when entering the house
  • Frequent dusting and damp mopping of baseboards, windowsills, and tabletops
  • Washing toys with soap and water
  •  Frequent handwashing

"We call lead an 'old adversary' but it's still a threat to young children, especially because of its potential effects on their intelligence, learning ability, and behaviors," Woolf said. "Even in 2022, we need to be vigilant and take action to try to lower [exposure]."

Spencer is an officer of the Epidemic Intelligence Service, a program sponsored by the US Centers for Disease Control and Prevention. Woolf reports funding by the Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry.

Study Highlights

  • The CDC analyzed data reported from 34 state and local health departments about BLL testing among children aged < 6 years conducted during January to May 2019 and January to May 2020.
  • During January to May 2020, 480,172 (34%) fewer US children had BLL testing compared with during January to May 2019, with an estimated 9603 children with elevated BLLs missed.
  • The number of children with BLL testing was lower during every month during January to May 2020 compared with the number with testing during the same period in 2019, with the largest proportional decrease (66.4%) in April 2020.
  • During the early pandemic period (March-May 2020), the number of children with BLL tests (481,199) decreased by 52.5% compared with the same period in 2019 (880,812).
  • Despite geographic variability, all 34 reporting jurisdictions reported that fewer children were tested after COVID-19 was declared a national emergency in March.
  • Health departments also reported difficulty conducting medical follow-up and environmental investigations for children with elevated BLLs because of staffing shortages and constraints on home visits associated with the pandemic.
  • The investigators concluded that the pandemic adversely affected identification of children with elevated BLLs, exposure elimination, and linkage to critical services.
  • Clinicians should ensure that young children receive appropriate lead testing and care management.
  • Providers and public health agencies should take action to ensure that children who missed their scheduled BLL screening test or who needed follow-up on an earlier high BLL be tested as soon as possible and receive appropriate care.
  • Although socioeconomic data were not collected, the investigators anticipated disproportionate impact among children at risk for increased lead exposure, including children from racial or ethnic minority groups, from economically or socially marginalized families, and/or living in older housing with lead-based paint.
  • These groups were also disproportionately affected by the pandemic, with lead testing trends among young children mirroring declines in emergency department visits, well-child visits and screenings, and vaccination coverage.
  • Lockdowns and school closures create concern that children spending more time in contaminated environments could have ongoing or increased exposure.
  • American Academy of Pediatrics recommends that well-child examinations occur in person whenever possible and within the child’s medical home where continuity of care can be established.
  • CDC guidance recommends that clinicians identify children who have missed well-child visits or vaccinations and contact them to schedule in-person appointments, prioritizing infants, children aged < 24 months, and school-aged children.
  • Collaborations among health departments; Special Supplementation Nutrition Program for Women, Infants, and Children programs; immunization programs; Medicaid; refugee health organizations; and other health service providers for children at risk, including outreach to parents and providers and reminders to test children at risk for lead exposure, can help ensure needed examinations.
  • States and local childhood lead poisoning prevention programs can examine data from blood lead surveillance and Medicaid to identify children needing BLL testing.
  • Childhood lead poisoning prevention programs can collaborate with federal and local housing and environmental health agencies to address priority housing hazards.
  • Study limitations include reliance on preliminary surveillance data and use of laboratory and health department resources for COVID-19 activities, which could have affected these data.

Clinical Implications

  • The COVID-19 pandemic hindered identification of children with elevated BLLs, exposure elimination, and linkage to critical services.
  • Clinicians should ensure that young children receive appropriate lead testing and care management.
  • Implications for the Healthcare Team: In-person visits are still necessary for childhood BLL testing and other essential health examinations. Collaboration among the child’s extended medical home interprofessional care team is essential for coordination of care.


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