Childhood lead poisoning continues to be a persistent, environmentally mediated pediatric health problem in New Hampshire. In this small state located in the Northeast, 55% of the housing stock was built before the 1978 ban on lead in residential paint. In several of the state's high-risk communities, the percentage of housing stock built before 1978 is greater than 83% according to the 2012-2015 American Community Survey.1 In 2015, 660 (4.9%) New Hampshire children younger than 6 years were reported to have blood lead levels of 5 μg/dL or more, the recommended level for public health action by the Centers for Disease Control and Prevention (CDC) and an estimated 40% of school-aged children were reported to have had a blood lead elevation of 5 μg/dL or more at some point in their lives. Yet, statewide, only 52.6% of 1-year-olds and 26.3% of 2-year-olds were tested for blood lead levels in 2015, meaning that the actual number of children younger than 6 years with elevated blood lead levels is likely much higher.2 In 2015, as the tragic news of lead poisoning in Flint, Michigan, spread across the country, New Hampshire's legislators made changes to the RSA 130-A Lead Paint Poisoning Prevention and Control that impacted all pediatric health care providers, setting the stage for changing the blood lead level testing climate statewide.3 The New Hampshire Department of Health and Human Services, Division of Public Health Services, Healthy Homes and Lead Poisoning Prevention Program (HHLPPP) was positioned to capitalize on these events, developing and dedicating resources to a 5-part integrated strategy to increase blood lead level testing rates for 1- and 2-year-olds statewide.
New Hampshire's 5-Part Strategy
The HHLPPP reviewed the state blood lead surveillance data and worked with health care providers to identify barriers to blood lead level testing and opportunities to improve testing rates for 1- and 2-year-olds. Through collaboration with providers, the HHLPPP discovered 2 major obstacles to blood lead level testing of young children: (1) a heavy reliance on venous blood lead level testing and (2) a lack of understanding in the medical community about the importance of blood lead level testing. In addition, the New Hampshire Chapter of the American Academy of Pediatrics (AAP) was no longer sponsoring its annual statewide medical educational conference, and pediatricians and other providers spread across the state had limited opportunities to collectively learn about changes in the understanding of lead poisoning and the importance of blood lead level testing.
To respond to these identified obstacles while also recognizing the realities of engaging pediatric health care providers, the HHLPPP developed and implemented a 5-part strategy with the goal of increasing blood lead level testing rates for 1- and 2-year-olds statewide. This 5-part strategy included the following: (1) increasing provider awareness of blood lead point-of-care (POC) testing equipment; (2) implementing a medical education program for pediatric providers; (3) creating and distributing medical reference materials; (4) developing reminders for parents to have their child's blood lead levels tested; and (5) increasing availability of POC testing equipment in the community.
Increasing provider awareness of blood lead POC testing
POC testing is an effective and efficient means of increasing blood lead level testing rates. Magellan Diagnostics LeadCare II (LC II) instrument is based on anodic stripping voltammetry technology with disposable screen-printed sensors.4 In 2004, Magellan Diagnostics developed the LC II instrument in conjunction with the CDC to address health care providers' needs to rapidly screen young children for elevated blood lead levels. The instrument determines a screening blood lead level through a 50-μL capillary sample, using just 2 drops of blood obtained from a finger stick. If the health care provider finds the child's blood lead level to be elevated above 4 μg/dL, it allows the provider to collect a confirmatory venous sample during the same office visit. The Food and Drug Administration and the CDC have determined that the LC II instrument is simple to operate with little risk of error. The LC II instrument does not require highly skilled laboratory personnel to operate it, and most federal requirements for certification of medical laboratories, including proficiency testing, are waived for LC II users under the provisions of the Comprehensive Laboratory Improvement Amendments (CLIA).5 As a result, implementation of POC testing in the health care provider office or clinic is relatively straightforward. The LC II instrument is the only POC blood lead level testing instrument available on the market with a CLIA Certificate of Waiver.6 Staff members using an LC II instrument need to be trained in the operation of the instrument and the careful preparation and cleansing of the finger-stick site with soap and water prior to the use of an alcohol wipe. This is an important step to prevent sample contamination, as an alcohol wipe does not remove ambient lead from the finger. Procedures for reporting test results to the state health department must also be in place. Proper sample collection technique, instrument operation, and reporting of tests results are explained during the medical educational sessions described in the following text.
Implementing a medical education program
The most crucial step of the 5-part strategy was designing an education program to be delivered face-to-face to pediatric providers at health care sites across the state. The education program designed was 1-hour long and most frequently presented in a “lunch-and-learn” format at the pediatric or family medicine office. The health care professionals who completed the 1-hour educational session received continuing medical education credits from the HHLPPP. The content of the medical education program included common sources of lead exposure for children in New Hampshire, the negative impact on the developing brain, lead's long-term consequences for a child, and the economic burden of children affected by lead poisoning on communities statewide. Additional educational content included statewide blood lead surveillance data, including prevalence of children with elevated blood lead levels of 5 μg/dL or more and data on New Hampshire's low blood lead level testing rates. The educational session reviewed various blood lead level testing methodologies, pointing out the efficiency of a POC testing instrument within the pediatric health care office as an effective means of improving blood lead level testing rates.
The HHLPPP also used these educational sessions as an opportunity to review the New Hampshire's Childhood Lead Poisoning Screening and Management Guidelines and the 2015 changes to New Hampshire's lead law that affected all pediatric health care providers.7 To prevent 1- and 2-year-old children from missing a blood lead level testing opportunity and to provide children the treatment and protection they need, the 2015 changes to New Hampshire's lead law established an 85% testing rate goal for those 1 and 2-year-olds insured by Medicaid, receiving WIC benefits, enrolled in HeadStart, or living in one of state's high-risk communities (57% of the state) designated for “Universal Testing.” The changes also required that if this 85% blood lead level testing rate goal was not reached by 2017, the Department of Health and Human Services would be required to change the current regulations to enforce provider compliance. In addition, changes to the lead law mandated that any medical provider conducting blood lead level testing for a child younger than 6 years provide parents with the Lead and Children factsheet, prepared by the HHLPPP, if the test indicated an elevated blood lead level of greater than 5 μg/dL.8
To further augment the medical education program, the HHLPPP developed and disseminated educational resources that included childhood lead poisoning medical “Quick Guides” and parent education reminders that focused on the importance of blood lead level testing at the age of 1 year and again at the age of 2 years.
Creating and distributing medical “Quick Guides” reference materials
During the medical educational training sessions, health care providers received childhood lead poisoning medical reference “Quick Guides” handouts to help them understand and implement lead testing. The “Quick Guides” are double-sided, laminated, and part of a 3-piece “ringed” set of educational material distributed to pediatric health care providers (see Figure 1—Supplemental Digital Content, available at http://links.lww.com/JPHMP/A531). The “Quick Guides” allow health care providers to quickly review guidelines for testing, treatment, evaluation, and medical management of lead poisoning developed by the CDC and the AAP. The “Quick Guides” also provide the contact information for the HHLPPP and the Region I Pediatric Environmental Health Specialty Unit at Boston Children's Hospital.
Developing parent reminder for blood lead tests at the age of 1 year and at the age of 2 years
The HHLPPP also developed and disseminated educational material to remind parents and health care providers to test children at both 1 and 2 years of age. An educational poster was developed for providers to post in their waiting areas and examination rooms with the following message: “At one and two testing for lead is what to do ... Ask your doctor about having YOUR child tested for lead at their first birthday and again at their second birthday” (see Figure 2—Supplemental Digital Content, available at http://links.lww.com/JPHMP/A532).9
Parents were also provided a message to take home from the provider's office. The HHLPPP placed a blood lead level testing reminder sticker on the back cover of the children's board book, Sleep Baby: Safe and Snug, to remind parents of the importance of testing their children at 1 and 2 years of age (see Figure 2—Supplemental Digital Content, available at http://links.lww.com/JPHMP/A532).9 This bedtime story book, produced exclusively by Charlie's Kids Foundation and written by pediatrician Dr John Hutton, reviews the AAP's safe sleep recommendations. The board books, available in both English and Spanish, are a cost-effective, durable vehicle for the “test reminder” message that are placed directly into the hands of parents by providers, with whom they have a valuable, trusting relationship.
Increasing availability of POC testing equipment
With funding from the CDC Preventative Health and Health Services Block Grant, the HHLPPP purchased 10 Magellan Diagnostics LC II POC blood lead level testing instruments and 30 boxes of blood lead level testing kits. These materials were provided to 10 community health centers across the state that lacked these resources. Any community health center interested in receiving one of the LC II instruments was required to host the “lunch-and-learn” education program for its clinical team, as well as additional “go live training” provided by the HHLPPP on capillary sample collection, the importance of hand washing, operation of the POC instrument, and reporting of test results to the state health department.
Community health centers with very low testing rates were eager to obtain the POC instruments once they understood the prevalence of elevated blood lead levels for young children in their catchment areas. The “go live training” prevented the community health centers from failing to use the analyzer due to unfamiliarity with its operation and ensured that the staff understood the HHLPPP's legal blood lead test result reporting requirements.
Cost and Resource Needs
The HHLPPP's health educator conducted the review of statewide blood lead surveillance data and collaborated with pediatricians to identify both barriers to blood lead level testing rates and opportunities for improvement. From this assessment, the health educator developed and implemented the 5-part strategy described, spending an estimated 30% of the position's time on this project. Over the course of 12 months, the health educator was able to complete 25 medical education sessions across the state that educated a total of 332 pediatric health care participants. A health educator with strong communication and presentation skills, and the ability to develop medical training materials and guides, was critical in successful implementation of the strategy. In addition to 30% of the health educator's salary/benefits and associated travel costs, additional project expenses included purchase of Sleep Baby: Safe and Snug board books and printing of educational posters for pediatric medical practices, medical reference “Quick Guides” for providers, and reminder stickers.
During 2016, the first year in which the 5-part strategy was implemented, 25 medical education training sessions were conducted in pediatric health care sites statewide, with an emphasis on reaching those sites in New Hampshire's 21 highest-risk areas.2 These training sessions were well received, with a total of 332 pediatricians, nurses, medical assistants, and other staff members attending over the 12-month period.
A total of 2040 Sleep Baby: Safe and Snug board books with blood test reminder stickers, more than 500 laminated, 3-piece ringed, medical reference “Quick Guides” sets, and 250 parent education posters were distributed to pediatric health care sites.
With this 5-part strategy, New Hampshire was successful in increasing the number of children who had their blood lead levels tested. After many years of relative stability in the number of annual blood lead tests among New Hampshire children younger than 6 years, in 2016, the HHLPPP observed that an additional 2604 children were tested from the previous year, a 19.4% increase. In 2016, 60.4% of 1-year-olds and 33.2% of 2-year-olds statewide were tested, up from 52.6% and 26.3%, respectively, for 1- and 2-year-olds in 2015 (see Figure 3—Supplemental Digital Content, available at http://links.lww.com/JPHMP/A533).10 More importantly, within 6 months of implementing the 5-part strategy, the number of blood lead tests reported increased between 2-fold and 81-fold at pediatric medical sites in 3 of New Hampshire's highest-risk communities (Figure).
This low-cost strategy successfully improved blood lead level testing rates across New Hampshire. Because the majority of New Hampshire is rural, many providers mistakenly believed that their pediatric patients were not at risk for elevated blood lead levels, as they perceived lead poisoning to be a problem unique to urban areas. The 5-part strategy was especially successful at pediatric medical sites in high-risk areas, where within 6 months of provider education and implementation of POC testing, the blood lead tests completed increased significantly, with no other intervention (see the Figure). Given that no other changes or interventions were implemented during this time period, the increase in testing can be attributed to the HHLPPP integrated 5-part strategy. The strategy resulted in a 2016 increase of 19.4% in the number of blood lead tests completed for children younger than 6 years statewide from the previous year. Testing rates statewide for 1- and 2-year-olds increased 7.9% and 7.0%, respectively, from 2015 to 2016, which the HHLPPP found especially encouraging for 2-year-olds. The number of 2-year-olds who had their blood lead tests completed had been relatively stable and even declining prior to 2015, in part, due to the structure of the 2-year-old Well Child Care visit, which does not include any scheduled immunizations or blood draws.11 As a result, the 2-year-old blood lead test was frequently overlooked during this visit. In addition, parents often did not take their 2-year-old child to the laboratory for a venous blood test as a follow-up to the Well Child Check visit due to a low or nondetected blood lead level at their child's 1-year-old Well Child Check visit and reluctance to repeat the experience of drawing a venous sample with their child. After the HHLPPP's medical education session, health care providers understood both the importance of repeated blood lead level testing and how in-office POC testing with a capillary finger-stick sample resolved issues of parent noncompliance with venous draws. With universal testing mandated by New Hampshire state law in 2018, POC testing provides health care professionals an easy-to-use, convenient instrument for maintaining compliance with the new law.
Implications for Policy & Practice
- Health departments can work with local health care providers and state chapters of the AAP to design educational programs that address local conditions. In New Hampshire, in-office education sessions worked best because of the small nature of the state.
- Training materials should provide local- and state-level data on blood lead level testing rates, high-risk populations, and geographic areas that are disproportionately at risk for lead exposure.
- Parental reminders in both the clinical office and for parents to take home ensure that parents are familiar with the need for blood lead level testing in 1- and 2-year-olds and its importance.
- POC blood lead level testing instruments can be an important way to improve blood lead level testing rates in the clinical setting. Health departments can provide training to providers unfamiliar with the instruments and also strengthen the system for reporting results to the state.
The increase in the blood lead tests reported, and especially understanding the barriers of the 2-year-old Well Child Check visit, demonstrates the importance and efficacy of all 5 parts of this combination strategy of education and resources for pediatric health care providers. The combination of face-to-face outreach to pediatric medical providers, introduction of blood lead level POC instrumentation, and development of educational resources for parents and providers enabled New Hampshire's HHLPPP to successfully combat the 2 greatest identified barriers in blood lead level testing for 1- and 2-year-olds statewide: heavy reliance on venous blood lead level testing and lack of understanding in the medical community about the importance of blood lead level testing.
The implementation of the 5-part strategy by a single health educator was successful, in part, due to the small nature of New Hampshire. Its success indicates that similar methods may be effective in other larger, less-rural states, particularly those with more public health resources, such as county public health services and municipal health departments. Education and training materials developed in New Hampshire are available electronically and can easily be modified to meet the needs of other state and local public health departments seeking to improve blood lead level testing rates.12