Eliminating Childhood Lead Poisoning in New York State by 2010

V. Proposed Strategies for New York State

Focus Area One: Surveillance

Screening of blood lead levels is an essential component of prevention strategies. Screening is important for early identification and management of individual cases of lead poisoning. As a safety net, screening may prevent recurrent exposure and exposure of other children by triggering identification and remediation of sources of lead in children's environments. Screening also forms the basis of lead poisoning surveillance, a critical component of public health efforts to design effective prevention programs.

Under New York State Public Health Law and regulations, health care providers are required to screen all children for elevated blood lead at the ages of one and two years. Since 1994, NYS has required reporting of all blood lead tests regardless of blood lead level. Based on the most recent data available, 65% of children in New York State were screened at least once by the age of twenty-four months, and 94% were screened at least once by the age of six years.

Goal 1: Health care providers who care for young children screen all children for lead poisoning by blood lead testing at the ages of one and two years, and by risk assessment with blood lead testing as indicated up to age six years.

Objective 1: To increase provider awareness of NYS screening regulations and the rationale for universal screening.

Action Steps:

  1. NYSDOH, in conjunction with the NYS Chapter of the American Academy of Pediatrics and New York State Academy of Family Physicians, will develop and implement a statewide campaign to increase screening practice by primary care providers. Specific strategies may include:
    • Dissemination of an educational packet to all physicians caring for children in New York State that includes information on recent medical literature demonstrating the adverse mental/developmental effects of low lead levels and the significant burden of lead poisoning in NYS, a summary of the NYS blood lead level screening requirements, and guidance to share with families on safe and effective methods for reducing lead exposure.
    • Establishment of a website to promote ongoing dissemination of up to date information on lead poisoning and recommended clinical practice
    • Other formal continuing education opportunities, including institutional grand rounds, conferences, and/or satellite broadcasts
  2. NYSDOH Division of Family Health will work with the American College of Obstetricians and Gynecologists and New York State Academy of Family Physicians to reinforce provider awareness of current requirements for lead exposure risk assessment, targeted blood lead screening, and appropriate follow-up during pregnancy. This effort should build on the related work done in the past year by the New York City Department of Health and Mental Hygiene/Mt. Sinai Center for Children's Health and the Environment
  3. Within the Department of Health, the Childhood Lead Poisoning Prevention Program will work with the Office of Medicaid Management and the Office of Managed Care to promote increased awareness of providers regarding the requirements and rationale for universal screening.

Objective 2: To enhance implementation of screening requirements in provider practice

Action Steps:

  1. NYSDOH will expand the Physician Based Immunization Initiative (PBII), which evaluates individual providers' screening practices and gives the provider direct feedback to improve practice. Currently PBII is occurring in thirty-eight counties and has included over 160 providers' offices. Current PBII strategies to improve immunization rates, such as the missed opportunities concept and continuous monitoring of the chart for a lead lab test, can also be applied to screening for lead. Initial expansion will target providers serving high-risk communities, as described under Priority Focus Area 2 below.
  2. NYSDOH, in collaboration with NY professional medical academies, will establish a protocol for enforcing regulations related to lead screening. Enforcement strategies will emphasize provider education, with targeted auditing, citation, or other penalties as needed in cases of significant non-compliance.

Objective 3: To assure that homeless children receive lead screening in all communities

Action Steps:

  1. NYSDOH will work with local health departments, in coordination with local social service departments, to assure that homeless children are covered by lead screening programs, consistent with current regulations.
  2. In counties where homeless children are excluded from Medicaid Managed Care enrollment (currently 11 counties), or are enrolled on a case-by-case basis (currently 27 counties), NYSDOH will work with counties to assure that mechanisms are in place for screening of homeless children.

Goal 2: The public, including families, are aware of the dangers of lead and the importance of lead screening.

Objective: To increase public demand for lead screening.

Action Steps:

  1. The lead program's annual media campaign will be expanded to include a message about the risk of low lead levels and the need for screening. Messages will be focus tested with target audiences. For example, a new "Got Lead?...Find Out" theme could be developed.
  2. The CLPPP will develop culturally competent educational materials about the risk of low lead levels and the need for screening to be distributed through community-based settings, including community health centers, child care providers, local health departments (LHDs), WIC offices, homeless shelters, community health worker programs, social service organizations, pharmacies, and other points of entry.
  3. CLPPP will work with the NYSDOH Office of Managed Care and Office of Medicaid Management to improve lead screening among their patient populations. Building on a recent award-winning immunization project conducted by the Northeast Public Health Leadership Institute (NEPHLI) and MCOs, patient reminders for lead screening could be included in mailings to families around children's first and second birthdays.

Goal 3: All families of children with measurable blood lead levels have basic knowledge about sources of lead and simple methods to reduce lead hazard exposure.

Objective: To increase public awareness of the sources of lead and common methods to decrease lead exposure.

Action Steps:

  1. The CLPPP will develop and disseminate educational materials specific for children with blood lead levels > 0 but below the current action level of 10 mcg / dL. Children with mildly elevated lead levels have demonstrated that they are exposed in some way to environmental lead. Under current guidelines, lead levels in this range do not usually prompt complete medical or environmental assessments. New materials will emphasize the importance of identifying sources of potential lead exposure, and describe effective methods of minimizing exposure, to be implemented by families. Educational materials can be mailed directly to families via either the county or the state, and/or can be distributed through health care providers' offices, to all children with blood lead levels in this range.
  2. The CLPPP will evaluate the effectiveness of this intervention through surveying a sample of households who have received educational materials, and modify materials as needed to ensure maximum impact.

Goal 4: A surveillance system provides the information needed to advance prevention activities and evaluate ongoing initiatives.

Objective: To ensure the reliability of the existing surveillance system as an effective tool for identification of the nature and scope of the existing childhood lead poisoning problem, high-risk populations, and the effectiveness of interventions.

Action Steps:

  1. CLPPP staff, in cooperation with staff from the Clinical Laboratory Evaluation Program (CLEP) and Electronic Clinical Laboratory Reporting System (ECLRS), CLPPP staff will take steps to improve the quality of lead laboratory data. CLEP is responsible for assuring quality of laboratory tests and reporting, and ECLRS for electronic transmission of test results from laboratories to the Department of Health. Specific strategies will be developed to improve monitoring and quality of data submitted by laboratories, and to provide feedback and education to laboratories that have problems with data quality. Consistency and adequacy of socio-demographic and geographic information on lead laboratory reports will be emphasized for quality improvement.
  2. NYSDOH, in cooperation with local health departments, will utilize surveillance data to help identify gaps in screening practice at provider and/or community level, with an emphasis on application of findings to enhanced outreach and technical assistance to the provider community, and timely feedback of information to providers. Communities with highest prevalence of elevated lead levels and/or high risk housing stock will be targeted for enhanced efforts.
  3. NYSDOH will explore methods for matching the lead screening registry with other available databases, such as Medicaid Fee For Service Database, Managed Care Encounter Database, or Early Intervention Program, to help identify groups of children not receiving blood lead screening.
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