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. 2021 Feb 5;70(5):155–161. doi: 10.15585/mmwr.mm7005a2

Decreases in Young Children Who Received Blood Lead Level Testing During COVID-19 — 34 Jurisdictions, January–May 2020

Joseph G Courtney 1,, Stella O Chuke 1, Kelly Dyke 1, Kimball Credle 1, Carolina Lecours 1, Kathryn B Egan 1, Monica Leonard 1
PMCID: PMC7861485  PMID: 33539334

Exposure to lead, a toxic metal, can result in severe effects in children, including decreased ability to learn, permanent neurologic damage, organ failure, and death. CDC and other health care organizations recommend routine blood lead level (BLL) testing among children as part of well-child examinations to facilitate prompt identification of elevated BLL, eliminate source exposure, and provide medical and other services (1). To describe BLL testing trends among young children during the coronavirus disease 2019 (COVID-19) pandemic, CDC analyzed data reported from 34 state and local health departments about BLL testing among children aged <6 years conducted during January–May 2019 and January–May 2020. Compared with testing in 2019, testing during January–May 2020 decreased by 34%, with 480,172 fewer children tested. An estimated 9,603 children with elevated BLL were missed because of decreased BLL testing. Despite geographic variability, all health departments reported fewer children tested for BLL after the national COVID-19 emergency declaration (March–May 2020). In addition, health departments 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. Providers and public health agencies need to take action to ensure that children who missed their scheduled blood lead screening test, or who required follow-up on an earlier high BLL, be tested as soon as possible and receive appropriate care.

CDC identifies no safe BLL in children and considers a blood lead reference value (BLRV) of 5.0 μg/dL* sufficient to prompt clinical and public health intervention (1,2). Among children aged <6 years, very high BLL (>70 μg/dL) can cause neurologic problems (e.g., seizures or coma), organ failure, and death. Lower, but still elevated, BLL can affect the nervous system, causing permanent neurologic damage, behavioral disorders, and cognitive impairment (1). In the United States, the most common childhood lead exposures are from lead-based paint that was used in pre-1978 housing, lead-contaminated soil or lead-containing pollutants from industrial sources, and water from old lead pipes and fixtures (3). Very young children might ingest lead dust or paint because of their tendency to put fingers or objects (toys or paint chips) in their mouths, and they more readily absorb lead because their bodies are rapidly developing. Primary prevention focuses on reducing lead exposures in homes, schools, and communities. Secondary prevention consists of BLL screening as part of routine well-child examinations. Early identification of children with lead exposure can help identify and eliminate lead sources (and future exposures for other children); reduce their BLL over time; and link children with high BLLs to medical, nutritional, and educational services. Medicaid-enrolled children are required to be screened at ages 12 and 24 months; many states have additional screening requirements (4).

In 1995, elevated BLLs became a nationally reportable condition (5). CDC funds 53 state and local childhood lead poisoning prevention programs to conduct ongoing surveillance of BLL testing among children.§ During May and June 2020, CDC received anecdotal reports of declines in BLL testing. To understand BLL testing trends during the COVID-19 pandemic, including after a national emergency was declared in March 2020, CDC requested that state and local health departments report the total number of children aged <6 years with BLL tests by month during January–May 2019 and January–May 2020. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. Health departments could also submit qualitative information. Based on the 2007–2010 National Health and Nutrition Examination Survey (NHANES) data and subsequent trends** (1), an estimated 2.0% of children who did not have a BLL test were conservatively assumed to have levels exceeding the BLRV.

Data for the period of interest for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City.†† Overall, the number of children aged <6 years who had BLL tests during January–May 2020 (948,844) was lower by 33.6% (480,172) than the number who had BLL tests during January–May 2019 (1,429,016) (Figure), resulting in an estimated 9,603 children with elevated BLLs being missed. During the analysis period, the number of children with BLL testing was lower during every month during January–May 2020 compared with the number with testing during the same period in 2019; the largest proportional decrease (66.4%) occurred 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 variation, all 34 responding state and local health departments reported decreased BLL testing during March–May 2020 compared with testing during 2019 (Table). Several health departments reported difficulties in conducting home nursing visits and environmental investigations following identification of children with BLL above the reference value because of staffing shortages and difficulties conducting home visits. In addition, some families whose children had elevated BLLs were no longer in the listed residence.

FIGURE.

Figure is a line graph showing the number of children under the age of six that received blood lead level tests, by month, across 34 U.S. jurisdictions during 2019–2020.

Number of children aged <6 years who received blood lead level (BLL) tests,* by month — 34 U.S. jurisdictions, 2019–2020

* CDC requested that state and local health departments report the total number of children with BLL tests by month during January–May 2019 and January–May 2020. Data for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City.

Alabama, Alaska, Arizona, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, New York (excluding New York City), New York City, Ohio, Oregon, Rhode Island, Tennessee, Texas, Washington, West Virginia, and Wisconsin.

TABLE. Number of children aged <6 years with blood lead level (BLL) tests,* absolute change, and percentage change, by jurisdiction — 34 U.S. jurisdictions, 2019–2020.

Jurisdiction Month No. of children tested
Absolute change, no. % Change
2019 2020
U.S. totals (for programs reporting data)
Jan
287,343
286,261
−1,082
−0.4
Feb
260,861
244,384
−16,477
−6.3
Mar
282,150
171,298
−110,852
−39.3
Apr
301,380
101,388
−199,992
−66.4
May
297,282
145,513
−151,769
−51.1
5-month totals
Jan–May
1,429,016
948,844
480,172
33.6
Alabama
Jan
3,376
3,060
−316
−9.4
Feb
2,914
2,219
−695
−23.9
Mar
2,972
1,928
−1,044
−35.1
Apr
3,563
1,328
−2,235
−62.7
May
2,732
1,097
−1,635
−59.8
Alaska
Jan
701
561
−140
−20.0
Feb
544
526
−18
−3.3
Mar
659
325
−334
−50.7
Apr
627
334
−293
−46.7
May
581
417
−164
−28.2
Arizona
Jan
5,571
5,278
−293
−5.3
Feb
4,701
4,501
−200
−4.3
Mar
5,278
3,060
−2,218
−42.0
Apr
5,470
1,819
−3,651
−66.7
May
5,233
2,300
−2,933
−56.0
California
Jan
41,972
39,719
−2,253
−5.4
Feb
36,939
35,170
−1,769
−4.8
Mar
41,215
24,210
−17,005
−41.3
Apr
43,778
12,746
−31,032
−70.9
May
43,734
21,006
−22,728
−52.0
Colorado
Jan
1,994
1,406
−588
−29.5
Feb
1,882
1,113
−769
−40.9
Mar
1,826
803
−1,023
−56.0
Apr
1,963
716
−1,247
−63.5
May
2,060
609
−1,451
−70.4
Delaware
Jan
1,177
885
−292
−24.8
Feb
1,068
759
−309
−28.9
Mar
1,166
517
−649
−55.7
Apr
1,358
126
−1,232
−90.7
May
1,319
270
−1,049
−79.5
District of Columbia
Jan
1,411
1,109
−302
−21.4
Feb
1,126
1,186
60
5.3
Mar
1,357
828
−529
−39.0
Apr
1,465
264
−1,201
−82.0
May
1,408
567
−841
−59.7
Florida
Jan
17,839
16,928
−911
−5.1
Feb
16,001
14,444
−1,557
−9.7
Mar
15,165
11,667
−3,498
−23.1
Apr
17,473
8,061
−9,412
−53.9
May
16,993
11,385
−5,608
−33.0
Georgia
Jan
9,079
9,401
322
3.5
Feb
8,104
7,302
−802
−9.9
Mar
8,059
4,905
−3,154
−39.1
Apr
8,154
3,818
−4,336
−53.2
May
8,222
4,490
−3,732
−45.4
Hawaii
Jan
1,593
1,456
−137
−8.6
Feb
1,378
1,315
−63
−4.6
Mar
1,437
976
−461
−32.1
Apr
1,627
578
−1,049
−64.5
May
1,688
980
−708
−41.9
Illinois
Jan
17,426
18,219
793
4.6
Feb
18,094
16,693
−1,401
−7.7
Mar
19,265
11,326
−7,939
−41.2
Apr
21,269
5,760
−15,509
−72.9
May
21,014
8,700
−12,314
−58.6
Indiana
Jan
6,349
7,801
1,452
22.9
Feb
5,920
6,586
666
11.3
Mar
6,503
4,592
−1,911
−29.4
Apr
6,622
2,285
−4,337
−65.5
May
6,487
3,911
−2,576
−39.7
Iowa
Jan
5,396
5,241
−155
−2.9
Feb
5,066
4,361
−705
−13.9
Mar
5,616
3,567
−2,049
−36.5
Apr
5,937
2,472
−3,465
−58.4
May
5,969
3,277
−2,692
−45.1
Kansas
Jan
2,462
2,485
23
0.9
Feb
2,104
2,083
−21
−1.0
Mar
2,317
1,603
−714
−30.8
Apr
2,670
1,163
−1,507
−56.4
May
2,580
1,523
−1,057
−41.0
Louisiana
Jan
2,837
2,808
−29
−1.0
Feb
2,576
2,307
−269
−10.4
Mar
2,675
1,639
−1,036
−38.7
Apr
2,718
1,145
−1,573
−57.9
May
3,086
1,931
−1,155
−37.4
Maine
Jan
1,231
1,862
631
51.3
Feb
1,013
1,420
407
40.2
Mar
1,207
988
−219
−18.1
Apr
1,271
766
−505
−39.7
May
1,361
1,137
−224
−16.5
Maryland
Jan
6,300
6,153
−147
−2.3
Feb
5,662
5,004
−658
−11.6
Mar
6,498
3,535
−2,963
−45.6
Apr
6,876
1,626
−5,250
−76.4
May
7,271
2,726
−4,545
−62.5
Massachusetts
Jan
18,682
18,470
−212
−1.1
Feb
15,917
14,996
−921
−5.8
Mar
18,170
10,012
−8,158
−44.9
Apr
18,868
5,594
−13,274
−70.4
May
19,852
8,007
−11,845
−59.7
Michigan
Jan
12,006
13,224
1,218
10.1
Feb
12,242
11,201
−1,041
−8.5
Mar
13,421
7,181
−6,240
−46.5
Apr
13,093
3,008
−10,085
−77.0
May
13,400
2,266
−11,134
−83.1
Minnesota
Jan
7,551
8,040
489
6.5
Feb
6,877
6,717
−160
−2.3
Mar
7,180
4,803
−2,377
−33.1
Apr
8,272
3,323
−4,949
−59.8
May
8,096
4,198
−3,898
−48.1
Missouri
Jan
6,860
6,252
−608
−8.9
Feb
5,881
4,851
−1,030
−17.5
Mar
6,415
3,154
−3,261
−50.8
Apr
6,886
1,350
−5,536
−80.4
May
6,666
2,012
−4,654
−69.8
Nevada
Jan
663
691
28
4.2
Feb
617
701
84
13.6
Mar
699
409
−290
−41.5
Apr
761
206
−555
−72.9
May
726
279
−447
−61.6
New Hampshire
Jan
1,900
1,974
74
3.9
Feb
1,627
1,551
−76
−4.7
Mar
1,887
1,175
−712
−37.7
Apr
1,932
853
−1,079
−55.8
May
1,979
1,278
−701
−35.4
New Mexico
Jan
1,276
1,162
−114
−8.9
Feb
1,117
881
−236
−21.1
Mar
1,152
781
−371
−32.2
Apr
1,365
357
−1,008
−73.8
May
1,255
398
−857
−68.3
New York (excluding New York City)
Jan
19,553
20,385
832
4.3
Feb
18,130
17,293
−837
−4.6
Mar
20,463
12,771
−7,692
−37.6
Apr
20,351
8,806
−11,545
−56.7
May
21,633
13,088
−8,545
−39.5
New York City
Jan
26,415
27,190
775
2.9
Feb
23,736
23,026
−710
−3.0
Mar
26,556
13,618
−12,938
−48.7
Apr
26,970
3,703
−23,267
−86.3
May
27,779
10,286
−17,493
−63.0
Ohio
Jan
14,382
15,154
772
5.4
Feb
13,440
12,865
−575
−4.3
Mar
13,533
9,555
−3,978
−29.4
Apr
14,878
6,377
−8,501
−57.1
May
14,243
6,938
−7,305
−51.3
Oregon
Jan
1,817
1,843
26
1.4
Feb
1,644
1,710
66
4.0
Mar
1,566
1,153
−413
−26.4
Apr
1,880
968
−912
−48.5
May
1,707
1,330
−377
−22.1
Rhode Island
Jan
N/A
N/A
N/A
N/A
Feb
N/A
N/A
N/A
N/A
Mar
1,360
711
−649
−47.7
Apr
1,425
227
−1,198
−84.1
May
1,547
512
−1,035
−66.9
Tennessee
Jan
7,350
8,379
1,029
14.0
Feb
6,616
7,338
722
10.9
Mar
7,179
5,968
−1,211
−16.9
Apr
8,256
4,629
−3,627
−43.9
May
7,634
4,451
−3,183
−41.7
Texas
Jan
30,459
27,570
−2,889
−9.5
Feb
26,647
24,147
−2,500
−9.4
Mar
27,352
16,441
−10,911
−39.9
Apr
30,569
13,107
−17,462
−57.1
May
26,280
18,833
−7,447
−28.3
Washington
Jan
2,521
1,876
−645
−25.6
Feb
1,802
1,701
−101
−5.6
Mar
2,343
1,328
−1,015
−43.3
Apr
2,200
1,010
−1,190
−54.1
May
2,649
943
−1,706
−64.4
West Virginia
Jan
1,604
1,484
−120
−7.5
Feb
1,569
1,328
−241
−15.4
Mar
1,782
1,049
−733
−41.1
Apr
1,876
624
−1,252
−66.7
May
1,861
930
−931
−50.0
Wisconsin Jan
7,590
8,195
605
8.0
Feb
7,907
7,089
−818
−10.3
Mar
7,877
4,720
−3,157
−40.1
Apr
8,957
2,239
−6,718
−75.0
May 8,237 3,438 −4,799 −58.3

Abbreviation: N/A = not available.

* CDC requested that state and local health departments report the total number of children with BLL tests by month during January–May 2019 and January–May 2020. Data for children aged <6 years were received from 34 state and local health departments, including the District of Columbia and New York City.

Discussion

Approximately 500,000 fewer children in the reporting jurisdictions were tested for lead exposure during the first 5 months of 2020 than during the same period in 2019. Estimating from this finding, approximately 10,000 children with elevated BLL were missed because of decreased testing. Reported challenges to conducting follow-up medical visits and environmental investigations indicate delays in exposure elimination and linkage to critical services for these children. Although socioeconomic data were not collected, a disproportionate impact is anticipated among children at risk for increased lead exposure, including children from racial or ethnic minority groups, from families who have been economically or socially marginalized, and those living in older housing with lead-based paint (1,3). These groups have also been disproportionately affected by the COVID-19 pandemic (6,7). Lead testing trends among young children mirror declines in other pediatric medical services during the pandemic, including emergency department visits (8), well-child visits and screenings, §§ and orders for childhood vaccines (9) and vaccination coverage (10). As a result of COVID-19 shelter-in-place orders and school closures, there is also concern that children spending more time in contaminated environments could have ongoing or increased exposure.

Although telemedicine and other remote service delivery strategies provide an alternative to office and clinic visits during the pandemic, in-person visits are still necessary for many essential health examinations, including BLL testing among children. During the pandemic, the 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 health care providers identify children who have missed well-child visits or recommended vaccinations and contact them to schedule in-person appointments, with prioritization of infants, children aged <24 months, and school-aged children.*** It is important that health care providers ensure that all children receive lead testing, including those who missed routine BLL screening, those with prior elevated BLLs who need follow-up testing, and those with possible lead exposure. 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 that these children receive needed health assessments. States and local childhood lead poisoning prevention programs can examine data from blood lead surveillance and Medicaid to identify children in need of lead testing.

The findings in this report are subject to at least two limitations. First, this report is based on preliminary surveillance data. Observed declines could be partially caused by delays in laboratory reporting and data entry backlogs. Second, use of laboratory and health department resources for COVID-19 activities could have also affected these preliminary data. However, given broader national trends for pediatric medical services, it is likely that these BLL testing data reflect actual declines.

CDC has developed guidance for conducting environmental inspections and public health home visits during the COVID-19 pandemic,††† and the Health Resources and Services Administration’s Maternal and Child Health Bureau has developed guidance for conducting home health visits for young children.§§§ Childhood lead poisoning prevention programs can collaborate with federal and local housing and environmental health agencies to address priority housing hazards. CDC will continue to work with health departments and other partners to develop and disseminate strategies for BLL testing during the pandemic. As surveillance data become available, CDC will conduct analyses to guide decision-making and interventions toward ensuring all children receive blood lead screening and appropriate care management during the pandemic.

Summary.

What is already known about this topic?

Lead can affect a young child’s ability to learn and cause other adverse health effects; no safe blood lead level (BLL) is known. Routine testing can detect elevated BLLs.

What is added by this report?

During January–May 2020, 34% fewer U.S. children had BLL testing compared with those during January–May 2019, with an estimated 9,603 children with elevated BLLs missed. All 34 reporting jurisdictions reported that fewer children were tested following the COVID-19 national emergency declaration in March.

What are the implications for public health practice?

COVID-19 has adversely affected identification of children with elevated BLLs, exposure elimination, and linkage to services. It remains important that providers ensure that young children receive appropriate lead testing and care management.

Acknowledgments

State and local lead poisoning prevention programs.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Footnotes

*

CDC uses a BLRV of 5.0 μg/dL to identify children with blood lead levels that are higher than those of most children. The BLRV is based on the 97.5th percentile of the NHANES blood lead distribution in children aged 1–5 years. The current BLRV is based on NHANES data from 2007–2008 and 2009–2010.

The U.S. Consumer Products Safety Commission banned lead-based paints for residential use in 1978.

45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

**

Trends in NHANES blood lead levels are in the National Report on Human Exposure to Environmental Chemicals Updated Tables, January 2019. https://www.cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Volume1_Jan2019-508.pdf

††

Alabama, Alaska, Arizona, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, New York State (excludes New York City), New York City, Ohio, Oregon, Rhode Island, Tennessee, Texas, Washington, West Virginia, and Wisconsin.

***

Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html

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