As Lead Testing Plummets For Cleveland Children, Health Concerns Grow
By Rachel Dissell
State shutdown orders meant to prevent the spread of the coronavirus have created a double whammy of lead poisoning risk for young children in Cleveland.
Many of these children are spending more time in homes with potential lead hazards and fewer are getting tested to see if they’ve been exposed to the toxin.
Tests for lead have plummeted by almost half compared to previous years in Cleveland and across Ohio, driven mostly by a dip in March, when most pediatricians’ offices and labs were closed to non-emergency visits because of the pandemic.
[Cid Standifer for ideastream]
The setback couldn’t have come at a worse time, say local lead safety advocates. For the past year, they have been working to prevent children from being poisoned in their homes, rolling out a new strategy that includes city-mandated lead inspections in rental homes and new grants and loans for hazard clean-up.
Testing children for lead is the main way to identify damaging lead hazards. The tests also allow parents to get help recognizing developmental delays or behavioral issues linked to exposure to the toxin, which can cause irreversible damage to a child’s brain.
The pandemic-related drop in testing means fewer lead-exposed children will receive help from state-supported early intervention programs, which are now offered automatically when a child’s blood test shows exposure.
It also means public health authorities won’t receive as many referrals to investigate potential lead hazards in homes, which are also triggered by a high lead-level test. That could result in prolonged exposure for children to lead dust or paint chips.
“I worry about children who are at home, playing on porches full of lead paint or in the dirt nearby,” said Patricia Barnes, co-chair of the Ohio Lead Free Kids Coalition, which advocates statewide for policies to eliminate childhood lead poisoning.
When schools shut down and Clevelanders self-isolated, children were “probably getting a lot more exposure than they would have if they were in school for part of the day,” said Barnes, who also is the executive director of the Ohio Healthy Homes Network.
An Ohio Department of Health spokeswoman said while test rates have dipped across Ohio during the pandemic, other “lead belt” states have fared even worse. Tests in Ohio have picked up in recent weeks as more parents schedule routine well-child visits, said state lead poisoning prevention advocates.
“There is nothing we are doing to make up on the missed testing,” ODH spokeswoman Rachel Feeley wrote in an email.
“This is something the [U.S. Centers for Disease Control and Prevention]is tracking, as it is a national occurrence,” she wrote. “We will continue to monitor the situation and follow CDC guidance on the matter.”
“I feel like we’re almost starting over again,” Kathy Schoch, nurse case manager for Cuyahoga County’s lead poisoning prevention program, said of the interruption in testing.
Schoch and others have wrestled with improving lead testing for years.
Only one in five Medicaid-eligible children entering kindergarten in Cleveland public schools from 2011 to 2016 had federally recommended tests for lead poisoning at both ages 1 and 2, according to research released last year by Case Western Reserve University and Invest in Children, a Cuyahoga County early childhood initiative.
The low percentage was disappointing for researchers because the study also showed that even a “high dose” of 18 months or more of high-quality preschool education failed to help most lead-poisoned children catch up with their peers.
At a recent joint meeting of the Healthy Homes Advisory Council and Lead Safe Cleveland Coalition’s screening and testing committee, medical and public health professionals, insurance providers, policy advocates and parents discussed the curve ball coronavirus has thrown them.
Representatives from CareSource and UnitedHealthcare, two of Ohio’s Medicaid managed care organizations that provide insurance to children in low-income families, said they are collaborating on ways to boost lead testing. Past efforts, like programs that offered incentives for parents, were unsuccessful.
Insurers have focused most of their efforts during the pandemic on making sure children get caught up on missed immunizations, which are often needed to enroll in day care or school.
But they agree lead testing should be just as important.
“While we are pushing so hard for immunizations, we need to be pushing for lead tests, too,” Diana Holtrup, a CareSource nurse who manages women and children’s health programs, said during the video committee meeting.
As lead testing stalled in the spring, so did new referrals to Ohio’s Early Intervention program, said Karen Mintzer, director of Bright Beginnings, formerly known as Help Me Grow.
The Early Intervention program, run through the Ohio Department of Developmental Disabilities, provides parents with support and can assess children for developmental delays linked to lead exposure.
Weekly referrals to the program from Cuyahoga County dropped to zero at one point, but have since rebounded, Mintzer said.
Previously, a child could be referred to the program only after an assessment by a doctor. But a state rule change last year automatically refers any child under 3 with lead in their blood at levels of five micrograms per deciliter or higher.
Safer Than The Grocery Store
When the MetroHealth System resumed well-child visits in late April, many parents were reluctant to bring children to the doctor’s office or a lab because of fears about the virus, said Dr. Abdulla Ghori, vice chair of Pediatrics at MetroHealth Medical Center.
There has been a slight uptick in visits in the past few weeks, he said, though the recent increase in COVID-19 cases could disrupt that trend.
In terms of risk, “coming to the hospital is better than going to the grocery store,” Ghori said. “And certainly much safer than [attending] a birthday party.”
Ghori said it is difficult to increase the rate of lead testing in part because testing practices vary by location – and even by facility within a single health system.
Sometimes blood can be drawn in the doctor’s office. Other times, parents have to wait in line at a lab in a different location, which can be impractical for families with limited time and resources. Ghori gave examples of how the variable testing procedures could cause hardships, such as for a family that may have already taken two buses to get to an appointment or having to juggle multiple cranky children after they get their shots during a wellness visit.
Strategies to increase testing also have hit roadblocks. Nurses can do a fairly simple finger stick blood collection that can help detect lead. But many doctor’s offices responsible for reporting those results to the state don’t have the staff to handle the extra paperwork, said Ghori, who is also a professor of pediatrics at Case Western Reserve University.
At MetroHealth, Ghori said about a quarter of lab orders for lead tests aren’t ever completed.
While long-term solutions continue to be debated, Ghori said MetroHealth took the step of “bulk ordering” lead tests for any children who need them, rather than having doctors order the test individually during visits.
The orders will automatically show up in the mail or on electronic medical records for parents, he said.
Ghori said that’s good, but even better would be free, accessible blood drawing locations in the city.
Barnes said she has yet to hear any “outside the box” thinking about how to identify children who haven’t been tested.
She wondered whether testing could be done in tents, outdoors or at a drive-thru, in the same way testing has been done for the coronavirus or how food banks have arranged for pickups.
An additional worry, Ghori said, is that the number of children with elevated lead levels due to exposure could increase as children spend more time confined in their homes or with grandparents and other relatives.
Not enough is known about that yet, he said, but it appears lead levels are up slightly over last year. State records of all lead tests for Cleveland children show that the rate of high lead levels has gone up about a half of a percent.
Ghori said he understands the focus on catching up on immunizations for children under 2, especially immunizing against highly contagious and dangerous diseases, such as measles.
That doesn’t mean lead testing should be an afterthought, though.
Both are important, Ghori said. But he worries people will de-emphasize lead testing. That, he said, would have dangerous long-term consequences.
“People should not be forgetting this silent disease, which could be getting worse during this lockdown, and the consequences that it could have,” he said.