LEAD, ELEVATED BLOOD LEAD LEVELS (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 1/31/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force (USPSTF) Recommendation
In 1996, the U.S Preventive Services Task Force recommended that clinicians screen children at risk for lead exposure for elevated blood lead levels. Given the availability of new evidence, the USPSTF has decided to update its 1996 recommendation. This work is currently in progress.

CDC Recommendation
The Centers for Disease Control and Prevention (CDC) recommends blood lead testing for children at high risk for exposure from lead paint, from house dust and soils contaminated by lead paint, from industrial sources of lead (e.g., smelters), and from imported cosmetics, traditional remedies, and cultural items that contain lead.1



Condition / Disease Specific Information

Epidemiology of Condition/Disease
The dangers of lead are well-documented for all age groups. High levels of lead exposure produce serious neurologic complications that can result in permanent disability or death. Lead affects multiple organ systems such as the cardiovascular, renal, and hepatic systems.3,4 Lead can also reduce growth, resulting in restricted height.5,6 Among children, elevated blood lead levels (BLLs) are associated with behavioral and reaction (attention) deficits 7-11 and intellectual impairments (lowered IQ).12-17 Neurologic complications associated with lead exposure and lead poisoning are irreversible, even with treatment. The association between elevated BLLs and reduced intellectual capacity is strong and has a dose-response relation, meaning that the more lead present in the blood, the more severe the impairments become.18,19 For example, a rise in blood lead from 10 to 20 µg/dL reduces a child's score on an IQ test by an average of 2 points.18 No "safe" BLL in children has been specified.13,15,19

It is estimated that 310,000 children between the ages of 1 and 5 years have elevated BLLs.20 An estimated 24 million housing units have significant lead-based paint hazards, including 1.2 million homes occupied by low-income families with children under the age of 6 years. These units pose a serious threat to children's health.20

The prevalence of elevated BLLs among young children in the United States has declined 98% since 1976-1980.20 A critical factor in reducing children's BLLs has been the reduction in the number of homes with lead-based paint, which fell from 64 million in 1990 to approximately 38 million in 2000.20 Despite the dramatic reduction in elevated BLLs, lead exposure and lead poisoning remain serious public health problems in the United States, especially for young children, who are most susceptible to the harmful effects of lead.

Reducing BLLs and eliminating BLLs higher than 10 µg/dL in children are two of the nation's Healthy People 2010 objectives.21

Condition/Disease Risk Factors
Racial and ethnic minorities (particularly African-Americans), individuals with low incomes, children living in housing built before 1950, and those living in urban centers and in the Northeast bear the highest rates of lead exposure.22,23

Major sources of lead exposure include dilapidated housing with lead-based paint (commonly used until 1950) and paint dust, lead-soldered pipes, and lead found in dust or soil from peeling paint, leaded gasoline, or industrial emissions. Other sources of lead exposure include lead waste brought into the home from industry,24 ethnic remedies,25-27 or from lead in consumer products.28-31



The Value of Prevention

Economic Burden of Condition/Disease
The costs of providing medical care and public health services to treat adverse health outcomes constitute the immediate direct costs of lead exposure and lead poisoning. Between 1988 and 1992, childhood lead poisoning was estimated to result in 53,400 hospitalization days and $41 million in inpatient treatment costs.32 The longer term burden to taxpayers includes the costs of special education and lost tax revenues from the lower wages of workers with intellectual deficits due to childhood lead exposure or lead poisoning. The total economic burden would be much higher if lifetime productivity losses due to cognitive impairment and premature mortality were included in cost analyses.

Workplace Burden of Condition/Disease
Lead poisoning results in dose-related reductions in IQ which, in turn, contributes to lower wages and diminished lifetime earning power. The present value of economic losses attributable to lead exposure in the birth cohort of current 5-year-olds was estimated to be $43.4 billion in 1997.33

Economic Benefit of Preventive Intervention
Reducing lead exposure yields economic benefits by avoiding healthcare and special education costs and by preventing reductions in children's intelligence, academic achievement, and future productivity. A recent study quantified economic benefits from projected improvements in worker productivity that resulted from the reduction in children's exposure to lead in the United States since 1976. It was estimated that, because of falling BLLs in the United States, preschool-aged children in the late 1990s had IQs that were, on average, 2.2 to 4.7 points higher than they would have been if they had the blood lead distribution observed among United States preschool-aged children in the late 1970s. It was also estimated that each IQ point raises worker productivity 1.76% to 2.38%. With discounted lifetime earnings of $723,300 for each 2-year-old in 2000 dollars, the estimated economic benefit for each year's cohort of 3.8 million 2-year-old children ranges from $110 billion to $319 billion.34

Estimated Cost of Preventive Intervention
In 2004, the private-sector cost of blood lead screening (venous sample test) averaged $22 per specimen for shipping, handling, and laboratory analysis; approximately 95% of all paid claims fell within the range of $8 to $55.35 Including the blood draw, which costs an average of $9, the total cost for blood lead level screening averaged $31. Approximately 95% of all paid medical claims fell within the range of $10 to $69.35

Estimated Cost of Treatment
Chelation therapy, the standard treatment, which leeches lead from the body, costs an estimated $2,046 (in year 2001 dollars) for each child treated.36

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
A study based on mathematical simulations of a blood lead screening program, estimated that, compared with no screening, universal screening of all 1-year old children for elevated BLLs would produce economic benefits exceeding program costs in communities where at least 11% to 17% of children had elevated BLLs.37



Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Identifying children with elevated BLLs allows parents to make necessary environmental changes to limit the child's exposure to lead and allows clinicians to begin medical treatment with chelating agents (if necessary), before lead poisoning and its serious complications occur. Environmental changes, such as lead-paint abatement and removal of lead-soldered pipes, can have beneficial effects on both exposed children and other children who live in the home.

Benefits and Risks of Intervention
Risks associated with BLL screening include increased anxiety among parents, discomfort to the child of repeated blood draws, and the inconvenience associated with office visits. As with all screening tests, a false-positive test result can lead to unnecessary treatment. However, the benefits of screening, including early identification of lead exposure and the prevention of lead poisoning, outweigh the costs and risks associated with screening.

Chelating agents can cause adverse effects, which may be severe. Thus, the benefits and risks associated with lead poisoning treatment should be carefully weighed.

Initiation, Cessation, and Interval of Screening
Children at risk for lead exposure should be screened at or before age 12 months. Clinicians should note that, on average, blood levels peak in exposed children between 18 and 24 months of age. Screening for elevated BLLs should cease when the clinician determines the child is no longer at risk for exposure based on age or environmental risk profile.

At a minimum, blood lead testing for at-risk populations should be conducted at the following ages:
  • 12 months
  • 24 months
  • 36-72 months
Children of any age should be screening when deemed medically necessary by a clinician's risk assessment, when clinical signs or symptoms consistent with elevated BLL are present, or when other evidence indicates possible exposure.

Children with symptoms consistent with increased intracranial pressure should also be considered for screening.

Recently resettled refugee, immigrant, and internationally adopted children 6 months to 16 years of age should be tested upon arrival and again 3 to 6 months after resettlement if local conditions warrant.38

State screening plans can be found on the CDC Childhood Lead Poisoning Prevention Branch website (www.cdc.gov/nceh/lead).

Intervention Process
Screening for lead exposure is conducted by measuring the amount of lead circulating in the blood through either a capillary or venous blood sample. Venous samples are more accurate and are thus the preferred method of testing. However, because of the added discomfort and cost of venous samples, clinicians often screen low-risk populations by taking a capillary blood sample and by performing a confirmatory venous blood lead concentration test on samples that show elevated BLLs.

Treatment Information
The main treatment for lead exposure is to stop the exposure by removing environmental or dietary sources of lead. Lead exposure reduction may include full lead abatement in the home, special cleaning techniques, the removal of contaminated objects, or the removal of the child from the home.39 Treatment for lead poisoning (a BLL of 45 µg/dL or higher) requires pharmacologic intervention. Chelation therapy is the most common form of lead poisoning treatment and may prevent further damage by reducing the amount of lead circulating in the blood. Clinicians may choose to begin chelation therapy for children with BLLs lower than 45 µg/dL if the children have persistently elevated BLLs that do not respond to environmental risk reduction.40

Health benefits should include provisions for diagnostic, surveillance, and treatment services.



Strength of Evidence

The evidence supporting the recommendations contained in this section is described below.
Recommended Guidance:
Centers for Disease Control and Prevention's (CDC) Advisory Committee on Childhood Lead Poisoning Prevention
Strength of Evidence: Not Specified
  • The CDC supports routine blood lead testing for children at high risk for exposure from lead paint, from house dust and soils contaminated by lead paint, from industrial sources of lead (e.g., smelters), and from imported cosmetics, traditional remedies, and cultural items that contain lead.1
Center for Medicare and Medicaid Services (CMS)
Strength of Evidence: CMS Mandate
  • The Centers for Medicare/Medicaid Services (CMS) requires blood lead testing of all Medicaid enrolled children at 1 and 2 years of age or at 3 years of age if not previously tested.2


Summary Plan Description

Covered Screening
Covered screening tests for lead exposure include blood lead concentration measured from capillary or venous samples.

Initiation, Cessation, and Interval
Screening is a covered benefit for children at risk for lead exposure at the following ages: 12 months, 24 months, and 36-72 months, or at any age when deemed medically necessary by a risk assessment, clinical signs or symptoms consistent with elevated BLL, or when other evidence indicates possible lead exposure. Secondary venous blood lead concentration tests, taken for confirmation, are covered for all children identified as having an elevated BLL through a capillary blood lead concentration screen.



CPT Codes

Elevated Blood Lead Levels (Screening)
83655 Lead



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Brown MJ, Chattopadhyay S. Lead, elevated blood lead level evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.



References

1 Centers for Disease Control and Prevention. Screening young children for lead poisoning: guidance for state and local public health officials. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC; 1997. Available from: www.cdc.gov/nceh/lead.
2 Centers for Medicare and Medicaid Services. Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit. Updated December 2005. [cited 2006 Oct 17]. Available from: http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.
3 Agency for Toxic Substances and Disease Registry. The nature and extent of lead poisoning in children in the United States: a report to Congress. Atlanta, GA: Agency for Toxic Substances and Disease Registry; 1988.
4 Lidsky TI, Schneider JS. Lead neurotoxicity in children: basic mechanisms and clinical correlates. Brain 2003;126:5-19.
5 Schwartz J, Angle C, Pitcher H. Relationship between childhood blood lead levels and stature. Pediatrics 1986;77:281-8.
6 Shukla R, Bornschein RL, Dietrich KN, Buncher CR, Berger OG, Hammond PB, Succcop PA. Fetal and infant lead exposure: effects on growth in stature. Pediatrics 1989;84:604-12.
7 Bellinger D, Leviton A, Allred E, Rabinowitz M. Pre- and postnatal lead exposure and behavior problems in school-aged children. Environ Res 1994;66:12-30.
8 Wasserman GA, Staghezza-Jaramillo B, Shrout P, Popovac D, Graziano J. The effect of lead exposure on behavior problems in preschool children. Am J Public Health 1998;88:481-6.
9 Burns JM, Baghurst PA, Sawyer MG, McMichael AJ, Tong SL. Lifetime low-level exposure to environmental lead and children's emotional and behavioral development at ages 11-13 years. The Port Pirie Cohort Study. Am J Epidemiol 1999;149:740-9.
10 Kahn C, Kelly P, Walker W. Lead screening in children with attention deficit hyperactivity disorder and developmental delay. Clin Pediatr 1995;34:498-501.
11 Bellinger D, Hu H, Titlebaum L Needleman HL. Attentional correlates of dentin and bone lead levels in adolescents. Arch Environ Health 1994;49:98-105.
12 Bellinger D, Leviton A, Waternaux C, Needleman H, Rabinowitz M. Longitudinal analyses of prenatal and postnatal lead exposure and early cognitive development. N Engl J Med 1987;316:1037-43.
13 Needleman H, Gatsonis C. Low-level lead exposure and the IQ of children. JAMA 1990;263:673-8.
14 Wasserman GA, Liu X, Lolacono NJ, Factor-Litvak kP, Kline JK, Popovac D, et al. Lead exposure and intelligence in 7 year old children: the Yugoslavia Prospective Study. Environ Health Perspect 1997;105:956-62.
15 Lanphear BP, Dietrich K, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations <10 µg/dL in U.S. children and adolescents. Public Health Rep 2000;115:521-9.
16 Canfield RL, Henderson CR, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 10 µg/dL. N Engl J Med 2003;348:1517-26.
17 Chen A, Dietrich KN, Ware JH, Radcliffe J, Rogan WJ. IQ and blood lead from 2 to 7 years of age: Are the effects in older children the residual of high blood lead concentrations in 2-year olds? Environ Health Perspect 2005;113:597-601.
18 National Research Council. Measuring Lead Exposure in Infants, Children and Other Sensitive Populations. Washington, DC: National Academy Press: 1993.
19 Schwartz J. Low-level lead exposure and children's IQ: A meta-analysis and search for a threshold. Environ Res. 1994;65:42-55.
20 Blood lead levels-United States 1999-2002. MMWR 2005;54:513-6.
21 Jacobs DE, Clickner RP, Zhou JY, Viet SM, Marker DA, Rogers JW, et al. The prevalence of lead-based paint hazards in U.S. Housing. Environ Health Perspect 2002;110:A599-A606.
22 Brody DJ, Pirkle JL, Kramer RA, Flegal KM, Matte TD, Gunter EW, Paschal DC. Blood lead levels in the US Population: Phase 1 of the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1991). JAMA 1994;272:277-283.
23 Pirkle JL, Kaufmann RB, Brody DJ, Hickman T, Gunter EW, Paschal DC. Exposure of the U.S. population to lead, 1991-1994. Environ Health Perspect 1998;106:745-750.
24 Roscoe RJ, Gittleman JL, Deddens JA, Petersen MR, Halperin WE. Blood lead levels among children of lead-exposed workers. A meta-analysis. Am J Ind Med 1999;36:475-81.
25 Centers for Disease Control and Prevention. Folk remedy-associated lead poisoning in Hmong children- Minnesota. MMWR 1983;32:555-6.
26 Centers for Disease Control and Prevention. Lead poisoning associated with use of traditional ethnic remedies-California 1991-1992. MMWR 1993; 42:531-4.
27 Centers for Disease Control and Prevention. Lead poisoning from Mexican folk remedies-California. MMWR 1983;32:554-5.
28 Centers for Disease Control and Prevention. Childhood lead poisoning from commercially manufactured French ceramic dinnerware—New York City, 2003. MMWR 2004;53:584.
29 Centers for Disease Control and Prevention. Brief report: Lead poisoning from ingestion of a toy necklace—Oregon, 2003. MMWR 2004;53;509.
30 Norman EH, Hertz-Picciotto I, Salmen DA Ward TH. Childhood lead poisoning and vinyl miniblind exposure. Arch Pediatr Adolesc Med 1997;151:1033-7.
31 Centers for Disease Control and Prevention. Death of a child after ingestion of a metallic charm. MMWR Dispatch 2006;55.
32 Vergara AE, Pertowski CA, Rosenblum LS. Lead poisoning: costs of care in the United States, 1988-1992. JAMA 1996;276(15):1221.
33 Landrigan PJ, Schechter CB, Lipton JM, Fahs MC, Schwartz J. Environmental pollutants and disease in American children: estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer and developmental disabilities. Environ Health Perspect 2002;110(7):721-728.
34 Grosse SD, Matte TD, Schwartz J, Jackson RJ. Economic gains resulting from the reduction in children's exposure to lead in the United States. Environ Health Perspect 2002;110:563-9.
35 Thomson Medstat. Marketscan. 2004.
36 Brown MJ. Costs and benefits of enforcing housing policies to prevent childhood lead poisoning. Med Dec Making 2002;22:482-92.
37 Briss PA, Matte TD, Schwartz J, Rosenblum LS, Binder S. Costs and benefits of a universal screening program for elevated blood lead levels in 1-year-old children. In: Centers for Disease Control and Prevention. Screening young children for lead poisoning; guidance for state and local health officials. Atlanta. GA: US DHHS. CDC, National Center for Environmental Health; 1997.
38 Centers for Disease Control and Prevention. Elevated blood lead levels in refugee children--New Hampshire, 2003-2004. MMWR January 21, 2005.
39 Lane WG, Kemper AR. American College of Preventive Medicine Practice Policy Statement. Screening for elevated blood lead levels in children. Am J Prev Med 2001;20(1):78-82. As cited by the National Guidelines Clearinghouse. Agency for Healthcare Research and Quality. Available from: http://www.guideline.gov/summary/summary.aspx?doc_id=3155&nbr=2381&string=lead+AND+poisoning.
40 Centers for Disease Control and Prevention. Managing elevated blood lead levels among young children: recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1997. Available from: www.cdc.gov/nceh/lead.