McMenamin et al. Respond

Thank you for the opportunity to respond to the letter from Madrigal and Roberts regarding our article. We would like to respond to two points made in the letter.

First, the letter stated, “More than half of the California children at highest risk—those enrolled in Medicaid—do not receive a blood test.” We would like to clarify that per federal Medicaid requirements, Medicaid-enrolled children are required to be screened for elevated blood lead levels.¹ Therefore, extending screening requirements beyond the Medicaid population, in which rates of elevated blood lead levels are considerably lower, will not address the low screening rates in the Medicaid population.

Second, the letter addresses the consequences of failing to identify the entire population of children with elevated blood lead levels without addressing the consequences of implementing universal screening requirements in populations at average risk. Our analysis estimated that universal screening would identify an additional 4777 children with elevated blood lead levels but also estimated that an additional 7500 to 22 500 children would receive false-positive test results, an unknown number of children would receive false-negative results, and the requirement would cost $6.2 million annually.¹ In addition, no literature is available to support universal screening policies, including the most recent US Preventive Services Task Force guideline that “recommends against routine screening for EBLL [elevated blood lead levels] in asymptomatic children who are at average risk,” with a “D” grade.² This was in part based on the harm of universal screening such as false-positive results, anxiety, inconvenience, school and work absenteeism, and the costs of return visits and repeat tests.² An update of this recommendation is in progress and may provide additional guidance to decision-makers.³

Ultimately, the California legislature rejected the universal screening requirement and passed an amended version of Assembly Bill 1316 in 2017,⁴ which instead expands the criteria used to determine children at “high risk” who are required to be screened. Future research will determine to what extent this policy was successful in identifying more children with elevated blood lead levels. As state legislatures grapple with this important and complex issue, we hope that this exchange serves as a call to build the evidence base so that legislators have more comprehensive data regarding the potential benefits and associated costs of universal lead screening requirements.