NC Childhood Lead Testing and Follow-Up Manual

Requirements and Recommendations Assessment and Testing Methodology Follow-Up Schedule and Education NC Childhood Lead Testing and Follow-Up Manual NC Department of Health and Human Services Division of Public Health Environmental Health Section Childhood Lead Poisoning Prevention Program Updated November 2012

Table of Contents Websites NC Minimum Recommendations for Lead Poisoning Prevention Quick Reference Guide Chapter 1 Chapter 2 Chapter 3 Chapter 4 Introduction Background Sources and Pathways of Lead Exposure in Children Staff Roles Training Required Alternative Cosmetics, Food Additives, and Medicines that Contain Lead Chart Requirements and Recommended Guidelines Medicaid Refugee Children International Adoptees Use of State Lab of Public Health for Blood Lead Analysis Point-Of-Care (POC) Lead Analyzers NC General Statutes Assessment and Testing Methodology Reporting Blood Lead Results Who and When to Test State Laboratory Procedures About Blood Lead Ordering Supplies Specimen Identification, Collection and Shipment Receiving Results of Blood Lead Tests Case Management and Follow Up Follow-Up Schedule For Diagnostic/Confirmed Lead Levels: Table 1 Reporting and Follow-up Procedures Clinical Evaluation Referrals Chelation Education Helpful Tips TOC/APP Page 1 of 3 Revised November 2012

Appendix A. Glossary B. Contact Information Childhood Lead Poisoning Prevention Staff State Laboratory Staff Other Lead Contacts Regional Environmental Health Specialists C. Memos D. Forms Memo Re: Point of Care Lead Analyzers Memo Re: State Lab Changes: We re Moving Memo Re: Revised Follow-up Schedule for Blood Lead Testing Memo Re: WIC North Carolina County Codes Form 3651: Evaluation of Child with Elevated Blood Lead Level Form 3958: Lead Risk Assessment Questionnaire DHHS Form 3707: Blood Lead Analysis E. Educational Materials Lead Poisoning Do s and Don ts: English/Spanish Facts About Lead (English / Spanish) Lead and Eating Habits (English / Spanish) Lead Safe Toys for NC Children (English / Spanish) Are You Pregnant? 5 Steps to a Healthy Home (English/Spanish) Green Cleaning (English/Spanish) CDC Coloring Book: Ethan s House Gets Healthier With a Visit from the Lead Poisoning Prevention Team (English) F. Nutritional Material Prelude to Nutritional Focus Article Nutrition Focus Article: Childhood Lead Poisoning and the Role of Nutrition Nutrition Assessment Form TOC/APP Page 2 of 3 Revised November 2012

G. Refugee Children References Refugee Children and Lead Screening Recommendations Lead Screening During The Domestic Medical Examination for Newly Arrived Refugees CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children Q&A: CDC Recommendations for Lead Poisoning Prevention in Refugee Children Lead Poisoning Prevention in Newly Arrived Refugee Children: Tool Kit H. NCLEAD I. Other NCLEAD and Clinical Follow-Up Quick Reference Guide to Clinical Print Documents NCLEAD: Attaching a File or Word Document to an Event Quick Reference Guide To Workflows North Carolina Childhood Lead Screening Data by County Outreach Materials TOC/APP Page 3 of 3 Revised November 2012

Distribution of Educational Materials North Carolina Minimum Recommendations Lead Poisoning Prevention Effective Date: October 1, 1999 Revised Date: November 14, 2012 Educational materials regarding lead exposure should be made available to families of all children less than 72 months of age. Distribution of these materials should occur during all well-child visits. Educational materials are available on the web or by calling the NC Childhood Lead Poisoning Prevention Program (NC CLPPP) at (919) 707-5950. Assessment for Risk of Exposure Lead poisoning remains a principle environmental concern for our young children, universal blood lead testing at 12 months and again at 24 months of age (or at first contact between 25 and 72 months if the child has not been previously tested) is strongly encouraged. Immigrant children: Testing for all immigrant children should be considered at the time of arrival to the United States. Internationally adopted children and refugee children are considered high risk as they may be malnourished. Malnourished children may be at increased risk, especially those deficient in iron, calcium and/or zinc. All refugee children 6 months to 16 years of age at the time of arrival to the United States should be tested initially and again after 3-6 months. Coordinated Approach To Testing Note: Local health departments should take the initiative in assuring a coordinated approach to the universal blood lead testing of those young children participating in Health Check (Medicaid), Health Choice, or WIC as well as refugee children. All primary care providers should be included in this process. At a minimum, for children who are not required to be tested, the attached "Lead Risk Assessment Questionnaire" should be administered on all children at 12 months and 24 months of age or at first contact between 25 and 72 months if the child has not been previously assessed or does not meet the above criteria. The questionnaire protocol determines those children who should receive blood lead testing at those ages. Questionnaires are available on the web or by calling the NC CLPPP at (919) 707-5950. Blood lead testing and risk assessment (when indicated) should occur during well-child visits to the child s primary care provider. Referral solely for risk assessment or blood lead testing is strongly discouraged.

Testing Methodology Direct blood lead measurement is the screening test of choice. Fingerstick, capillary blood specimens are adequate for initial testing and re-testing provided that precautions are taken to minimize the risk of contamination. Venous blood specimens should be collected for confirmation of all blood lead test results 5 µg/dl. Please note: Blood lead test results are rounded off to a whole number for comparability with results reported from other laboratories and for submission to the Centers for Disease Control and Prevention, National Surveillance System. For example, test results between 4.5 to 4.9 µg/dl are rounded off to 5 µg/dl. The State Laboratory of Public Health is available to analyze blood specimens on all children less than six years of age as well as refugee children less than 16 years of age collected by all providers at no charge. Point-of-Care (POC) Blood Lead Analyzers The Clinical Laboratory Improvements Amendments (CLIA) designates facilities that use POC blood lead analyzers (e.g. LeadCare II) as laboratories. As such, they are required to report all blood lead test results for children less than six years old to the NC CLPPP per NC General Statute 130A-131.8. Laboratory reports., even if determined in a clinical setting. Medical and Environmental Response to Test Results An outline of medical and environmental responses to test results can be found in the Quick Reference Section or for more detail, Chapter 4 (Case Management and Follow-up). This outline is not intended to replace professional judgment, which must be based on the blood lead level, the presence of symptoms and other circumstances peculiar to an individual child in question. Reference and background information can be found in the CDC publication, Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. The publication is available at http://www.cdc.gov/nceh/lead/casemanagement/casemanage_main.htm.

QUICK REFERENCE GUIDE NORTH CAROLINA DIVISION OF PUBLIC HEALTH FOLLOW-UP SCHEDULE FOR DIAGNOSTIC / CONFIRMED BLOOD LEAD LEVELS FOR CHILDREN UNDER THE AGE OF SIX Blood Lead Level Response <5 µg/dl Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure Perform another blood lead test at age 2, earlier if risk of exposure increases All diagnostic (i.e., confirmation) tests should be performed as soon as possible within the time periods listed below. If diagnostic test result falls into a lower category - follow response for that risk category. If diagnostic or follow-up test result falls in a higher category conduct another diagnostic test based on the higher risk category & follow response for that risk category. 5-9 µg/dl (Diagnostic test within 3 months) 10-19 µg/dl (Diagnostic test within 1 month) Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure If diagnostic test result is 5-9 µg/dl Conduct nutritional assessment Take environmental history to identify lead sources & emphasize the importance of environmental assessment to identify and mitigate lead hazards Continue follow-up testing every 3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 10-19 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for environmental investigation Continue follow-up testing every 1-3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household 20-69 µg/dl (Diagnostic test within 1 week at 20-44 µg/dl within 48 hours at 45-59 µg/dl within 24 hours at 60-69 µg/dl) >70 µg/dl (Diagnostic test immediately as emergency lab test) Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 20-69 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Provide clinical management Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 70 µg/dl Hospitalize child and begin medical treatment immediately Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household *Children s Developmental Service Agency **Care Coordination for Children 08/15/2012

QUICK REFERENCE GUIDE Diagnostic Testing Schedule Initial Test Result (µg/dl) Perform Diagnostic Test on Venous Blood Within: 5-9 3 months 10-19 1 month 20-44 1 week 45-59 48 hours 60-68 24 hours 70 Immediately, as an emergency lab test FAQs about the 3651 Form How do I get the form? You can copy the form located in the Appendix of this manual or print it from the Children s Environmental Health Program s website at the address below. http://www.deh.enr.state.nc.us/children_health/lead/lead.html When do I complete the form? The form should be completed when a child returns for a diagnostic (i.e., confirmation) test. How is the form used? The form is used to take a child s environmental history, document blood lead test results and to identify and educate the family about sources of lead exposure. The form is also used to refer a child for environmental follow-up by sending a copy to Environmental Health at the local health department. All children who meet the legal definition as having an Elevated Blood Lead Level (EBL) or Confirmed Lead Poisoning (CLP) per G.S. 130A- 131.7 should be referred for environmental follow-up. Contact information for local health departments can be found at the link below. http://www.deh.enr.state.nc.us/docs/ehsdir2012.pdf Where do I send the form? If the diagnostic test result confirms that the child has a blood lead level 5 µg/dl, completed forms may be sent via fax to (919) 841-4015 or mail to Children s Environmental Health Program; NC DHHS, Division of Public Health; 1934 Mail Service Center; Raleigh NC 27699-1934. NC LEAD users may also scan and attach the completed 3651 form to the Child Event in the NC LEAD System. If the child meets the legal definition as having an EBL or CLP a copy of the form should be sent to Environmental Health at the local health department to refer the child for environmental follow-up. Still have questions? Please call (888) 251-5543 and ask to speak to the NC CLPPP Surveillance Coordinator.

QUICK REFERENCE GUIDE FAQs about Childhood Lead Poisoning Surveillance Reports What is the purpose of the Surveillance Report? To let you know that these children have at least one blood lead test result 5 µg/dl and need diagnostic (i.e. confirmation) or follow-up testing and to assure that NC CLPPP has received all blood lead test results for each child. The report also lists children who should be referred to Environmental Health at the local health department for environmental follow-up. How do I get a Surveillance Report? NC LEAD users can print a Surveillance Report by clicking the reports icon after logging into the NC LEAD system. If you do not have access to NC LEAD, you can request a surveillance report via email ncleadhelp@lists.ncmail.net or phone toll free at (888) 251-5543 and ask to speak to the NC CLPPP Surveillance Coordinator. What do I do with this report? When you get a report please check the spelling of names and date of birth information for children listed on this report. Records are matched by name and date of birth to produce this and other reports. If there is an error, blood lead records for children may be missing. If a test result is missing from the report, please fax a copy of the missing laboratory report to (919) 841-4015. Do I need to fax/mail laboratory reports for a child who is retested? According to state law, laboratories are required to report all lead test results for children. However, if you know a test result is missing from the surveillance report, please fax a copy of the missing laboratory report to (919) 841-4015 or mail it to Children s Environmental Health Program; NC DHHS, Division of Public Health; 1934 Mail Service Center; Raleigh NC 27699-1934. Why are children listed who have moved or been reported as lost to follow-up? It is not unusual for a child who has moved to return to the state. Likewise, a child reported as lost to follow-up sometimes turns up again. By continuing to list these children on the report, it serves as a reminder that should they show up in the system again, they are still in need of clinical follow-up. If the child shows up in another county or is tested at another clinic, the child s information will move off the report and show up on the other county/clinic surveillance report. If you have notified NC CLPPP that a child has moved or is lost to follow-up, this information should be listed on the report under Additional Comments. How do I get a child listed as lost to follow-up? It is recommended that a certified letter be sent to the child s last known address to document efforts to bring the child back in for followup. You may also try contacting the family s local health department, Social Services or the WIC Program to see if they can provide additional information. If these efforts fail to get the child back in for follow-up services, you can notify the NC CLPPP that the child is lost to followup via fax (919) 841-4015 or mail Children s Environmental Health Program; NC DHHS, Division of Public Health; 1934 Mail Service Center; Raleigh NC 27699-1934. Still have questions? Please call (888) 251-5543 and ask to speak to the NC CLPPP Surveillance Coordinator.

Chapter 1 Introduction Background Page 1 Sources of Lead Exposure in Children Page 2 Staff Roles Page 3 Training Required Page 3 Alternative Cosmetics, Food Additives Page 4-5 and Medicines that Contain Lead Chart

Chapter 1 INTRODUCTION BACKGROUND Childhood lead poisoning is one of the most common environmentally-caused pediatric health problems in the United States today. The persistence of lead poisoning, in light of present knowledge about the sources, pathways and prevention of lead exposure, continues to present a direct challenge to clinicians and public health authorities. According to the US Centers for Disease Control and Prevention (CDC), there are approximately a half million U.S. children ages 1-5 with blood lead levels above 5 micrograms per deciliter (μg/dl), the reference value at which CDC recommends public health actions be initiated. Lead Reference Value In 2012, the CDC established a reference value of 5 µg/dl for which public health interventions are initiated. This value is based on the 97.5th percentile of the BLL distribution among children 1 5 years old in the United States using data generated by the National Health and Nutrition Examination Survey. The reference value will be updated by CDC every four years based on the most recent data. Lead has no known physiological value and children are particularly susceptible to its toxic effects. Although lead poisoning can affect nearly every system in the body, lead is particularly toxic to the developing brains of young children. At low levels of exposure, lead can cause learning disabilities, lowered IQ, attention deficit disorders and anti-social behavior. However, most poisoned children have no apparent symptoms, and as a result, many cases go undiagnosed and untreated. No safe level of lead in a child s body has been identified. At higher levels ( 70 µg/dl), lead exposure is an acute condition and can have devastating health consequences, including encephalopathy, seizures, coma and even death. Blood lead testing is encouraged as an important element of a comprehensive program to eliminate childhood lead poisoning. The goal of such testing is to identify children who need individual interventions to reduce their exposure. The major source of lead exposure among U.S. children is deteriorated lead-based paint and lead-contaminated dust. Other common sources of lead poisoning are drinking water contamination, parental occupations, hobbies, and home health remedies. Although lead-based paint was banned for use in residential housing in 1978, an estimated 4 million households continue to expose children to lead hazards. Children living in older, deteriorating housing or who are living in poverty are at higher risk for lead exposure. Other children living in communities where the risk of lead exposure has been demonstrated to be low may not need to be tested. Our task as public health officials, health care providers, and as parents is to identify those children who will benefit from testing and to ensure that they receive the services that they need. If children are enrolled in Medicaid or live in a high-risk zip code, they should receive blood lead testing at ages 1 and 2 years old. Chapter 1 - Page 1 of 5 Revised November 2012

SOURCES AND PATHWAYS OF LEAD EXPOSURE IN CHILDREN Lead Based Paint. A common source of high-dose lead exposure to young children is deteriorated paint found in older homes. Lead paint is found most commonly in pre-1950 homes. Soil and house dust. Dust contaminated by deteriorated paint, leaded gasoline and industry emissions may contain high concentrations of lead. Soil containing lead is found near the foundations of homes and near major roads. Contaminated dust is common on floors and windows sills and troughs. Vinyl miniblinds. Those manufactured prior to 1996 may contain lead as a stabilizing agent. Exposure to ultra-violet light deteriorates the vinyl, causing lead-contaminated dust to accumulate on the surface of the blinds. Drinking water. Lead pipes or copper plumbing connected with lead solder may contaminate water. Food. Some imported canned foods contain lead, as do foods served from leaded crystal or ceramic dishes with lead-containing glaze. Air. Emissions from active lead smelters and other lead-related industry may be sources of lead contamination. Occupations and hobbies. Workers may bring home lead-contaminated dust on their clothing, or may bring lead home via scrap materials. Hobbies such as reloading or casting ammunition, or making stained glass, pottery, fishing weights and jewelry are common sources of lead. Pottery. Traditional pottery imported from Mexico or other countries may be improperly glazed, and the glaze used to make the pottery may contain large amounts of lead. Lead can leach out of this type of pottery if it is used to hold or store foods. Traditional pottery used in cooking may poison entire families. Medicines. Immigrant families often use traditional medicines and folk remedies. Several of these can cause lead poisoning. Azarcon (also known as Rueda, Coral, Maria Luisa, Alarcon or Liga) and Greta are remedies imported from Mexico that contain 90 to 100 percent lead by weight. Any amount of these products is poisonous to children or adults. Azarcon is a bright orange powder; Greta is a yellow powder. Both are used to treat Empacho (intestinal illness). Children who are given these powders are actually ingesting lead, and they may develop the same symptoms that these medicines are intended to treat. Paylooah is a red powder that contains high levels of lead. Paylooah is used by the Hmong people to treat rash or fever. Lead has also been found in some Chinese herbal medications. Chapter 1 - Page 2 of 5 Revised November 2012

Cosmetics. Another source of lead may be eye cosmetics called Surma or Kohl, which are used by some Indian, African and Middle Eastern immigrants. Lead has also been found in aphrodisiacs imported from India and Africa. Toys. Toys that have been made in other countries and then imported into the U.S. and antique toys and collectibles may put children at risk for lead exposure. Lead may be used in two aspects of toy manufacturing; paints or plastics. To reduce these risks, the U.S. Consumer Product Safety Commission (CPSC) issues recalls of toys that could potentially expose children to lead. Photos and descriptions of recalled toys can be found at http://www.cpsc.gov or call 1-800-638-2772. Candy. Lead has been found in some consumer candies imported from Mexico. Certain candy ingredients such as chili powder and tamarind may be a source of lead exposure. Lead sometimes gets into the candy when processes such as drying, storing, and grinding the ingredients are done improperly. Also, lead has been found in the ink printed on wrappers of some imported candies. People selling these candies may not know whether or not the candy contains lead. You cannot tell by looking or tasting if candy contains lead, so blood lead testing is recommended to determine exposure. More information and advisories on lead in candy can be obtained from the FDA at www.fda.gov or 1-888-463-6332. STAFF ROLES Prevention of and follow-up for childhood lead poisoning is a multidisciplinary activity. Team members may include those with expertise in nursing, medicine, social work, nutrition, child development and environmental health. TRAINING REQUIRED Clinical workshops are offered annually by the NC Childhood Lead Poisoning Prevention Program. These workshops are open to public and private health care providers, and cover topics such as: Basic Information about Lead Health effects from lead exposure Blood lead testing Case management for children with elevated lead exposure Environmental remediation for lead hazards For further information about clinical workshops, contact the NC CLPPP Data Manager. Chapter 1 - Page 3 of 5 Revised November 2012

Guidelines for the Identification & Management of Pregnant Women with Elevated Lead Levels Alternative Cosmetics, Food Additives, and Medicines that Contain Lead Exposure Source Albayalde or albayaidle Al Kohl (Middle East, India, Pakistan, some parts of Africa) Al Murrah Anzroot Description/Exposure Pathway Used by mainly by Mexicans and Central Americans to treat vomiting, colic, apathy and lethargy. A gray or black eye cosmetic applied to the conjunctival margins of the eyes for medicinal and cosmetic reasons. Can contain up to 83% lead. It is believed to strengthen and protect the eyes against disease and may be used as an umbilical stump remedy. Also known as simply as kohl. Used as a remedy for colic, stomach aches and diarrhea in Saudi Arabia. A remedy from the Middle East used to treat gastroenteritis. Azarcon Ayurvedic medicine (Tibet) Ba-Baw-San or Ba-Bow- Sen (China) Bali goli Bint Al Zahab (Iran) Also known as alarcon, coral, luiga, maria luisa, or rueda. Bright orange powder used to treat empacho (an illness believed to be caused by something stuck in the gastrointestinal tract, resulting in diarrhea and vomiting). Azarcon is 95% lead. Traditional medicines that may contain lead. Some examples include: guglu, sundari kalp, jambrulin Herbal medicine used to detoxify fetal poisoning and treat colic pain or to pacify young children. A round, flat black bean which is dissolved in gripe water and used within Asian Indian cultures for stomach ache. Rock ground into a powder and mixed with honey and butter given to newborn babies for colic and early passage of meconium after birth. Bint Dahab (Saudi A yellow lead oxide used by local jewelers and as a home remedy Arabia; means "daughter for diarrhea, colic, constipation and general neonatal uses. of gold") Bokhoor (Kuwait) A traditional practice of burning wood and lead sulfide to produce pleasant fumes to calm infants. Cebagin Used in the Middle East as a teething powder. Chuifong tokuwan Cordyceps Deshi Dewa Farouk Ghasard Greta (Mexico) Hai Ge Fen (Concha cyclinae sinensis) Henna A pill imported from Hong Kong used to treat a wide variety of ailments. Used in China as a treatment for hypertension, diabetes and bleeding. A fertility pill used in Asia and India. A teething powder from Saudi Arabia. Brown powder used in Asian Indian cultures as a tonic to aid in digestion. Yellow powder used to treat empacho (see azarcon); can be obtained through pottery suppliers, as it is also used as a glaze for low-fired ceramics. Greta is 97% lead. A Chinese herbal remedy derived from crushed clam shells. Used as a hair dye and for temporary tattoos in the Middle East and India - may contain lead. Chapter 1 - Page 4 of 5 Revised November 2012 169

Guidelines for the Identification & Management of Pregnant Women with Elevated Lead Levels Jin Bu Huan (China) An herbal medicine used to relieve pain. Kandu Koo Sar A red powder from Asia and India used to treat stomach ache. Red pills from China used to treat menstrual cramps. Kushta Used for diseases of the heart, brain, liver, and stomach and as an aphrodisiac and tonic in India and Pakistan. Litargirio A yellow or peach-colored powder used as a deodorant, a foot fungicide and a treatment for burns and wound healing particularly by people from the Dominican Republic. Lozeena An orange powder used to color rice and meat that contains 7.8% 8.9% lead. Pay-loo-ah (Vietnam) A red powder given to children to cure fever or rash. Po Ying Tan (China) Santrinj (Saudi Arabia) Surma (India) Tibetan herbal vitamin Traditional Saudi medicine An herbal medicine used to treat minor ailments in children. An amorphous red powder containing 98% lead oxide used principally as a primer for paint for metallic surfaces, but also as a home remedy for "gum boils" and "teething." Black powder used as an eye cosmetic and as teething powder or umbilical stump remedy. Used to strengthen the brain. Orange powder prescribed by a traditional medicine practitioner for teething; also has an antidiarrheal effect. 170 Chapter 1 - Page 5 of 5 Revised November 2012

Chapter 2 Requirements and Recommended Guidelines Medicaid Page 1 Refugee Children Page 1 International Adoptees Page 1 Use of State Lab for Blood Lead Analysis Page 2 Point-Of-Care (POC) Lead Analyzers Page 2 NC General Statutes Page 3 Assessment and Testing Methodology Page 4 Reporting Blood Lead Results Page 4 Who and When to Test Page 5

Chapter 2 Requirements And Recommended Guidelines Requirements and recommended guidelines for specific groups of children at high risk are below. Medicaid All Medicaid-enrolled children are required to have a blood lead test at 12 and 24 months of age. Children between 36-72 months must be tested if they have not previously been tested. Capillary blood lead samples are adequate for the initial blood lead test. Venous blood lead samples should be collected for confirmation of all blood lead test results 5 µg/dl. Refugee Children The prevalence of elevated blood lead levels among newly resettled refugee children is higher than that for US children. This is attributed to several possible factors: (1) exposures in their previous country of residence, (2) malnutrition and deficiencies in iron, calcium and zinc, (3) living and playing in high-risk U.S. areas such as in and around homes built before 1978, and (4) exposure to lead-containing foods, candies, ceramics, utensils, cosmetics, and traditional remedies. All refugee children 6 months to 16 years of age are to be tested at the time of arrival to the United States. Repeat testing: Blood lead testing should be repeated again 3 to 6 months after placement in a permanent residence regardless of initial test results. See Refugee Children Tab G in the Appendix for more details. Repeat testing has revealed elevated blood lead levels in some refugee children even when initial test results were not elevated. Chronic malnutrition and pica, which is common among certain refugee populations, put some of these children at greater risk of lead poisoning after placement in permanent residences. Therefore, this repeat blood test is considered to be a medical necessity. Refugee children younger than 6 years should undergo nutritional assessments as well as testing for hemoglobin or hematocrit level. Provide daily pediatric multivitamins with iron for refugee children 6-59 months of age. See Refugee Children Tab G in the Appendix for more details. International Adoptees CDC recommends that all internationally adopted children have a blood lead test during their first medical examination in the U.S. and at 12 and 24 months of age. Children immigrating to the United States through international adoptions may have health issues as diverse as the cultures into which they were born. Although recent research is sparse, evidence suggests that a significant proportion of immigrant and Chapter 2 - Page 1 of 5 Revised November 2012

adopted children have elevated blood lead levels. Risk of elevated blood lead levels varies by country of origin. Use of State Laboratory of Public Health for Blood Lead Analysis The State Laboratory Services of Public Health will analyze blood lead specimens for all children less than six years of age (and refugee children through 16 years) at no charge. Providers requesting analysis of specimens from children outside of this age group will need to contact the State Laboratory of Public Health at 919-807-8878. The Medicaid program encourages all providers to utilize the State Laboratory of Public Health for this service because it will: Contribute to the creation of a central database on blood lead testing Help assess the extent of North Carolina's lead problem Be less expensive for the Medicaid program Facilitate Medicaid reporting of blood lead testing on Medicaid recipients. Point-Of-Care (POC) Lead Analyzers A growing number of health care providers in North Carolina are using point-of care (POC) lead analyzers (e.g. LeadCare II) to test children for lead poisoning. Use of these analyzers provides the advantage of an immediate test result reading and unnecessary delays in conducting diagnostic (i.e., confirmation) testing based on a child s blood lead test result. The Clinical Laboratory Improvement Amendments (CLIA) designates facilities that use a POC lead analyzer as a laboratory. As such, they are required to report all blood lead test results for children less than six years old, even if determined in a clinical setting, to the North Carolina Childhood Lead Poisoning Prevention Program (NC CLPPP). To arrange for reporting blood lead test results, please contact Tena Ward at (919) 707-5933 or at tena.ward@dhhs.nc.gov. Because current POC lead analyzers appear to provide optimal performance around 10 µg/dl NC CLPPP recommends that all diagnostic test specimens be analyzed at a reference laboratory. Same day test results obtained using the POC lead analyzer cannot be accepted as a diagnostic test. Please note: Blood lead test results are rounded off to a whole number for comparability with results reported from other laboratories and for submission to the Centers for Disease Control and Prevention, National Surveillance System. For example, test results between 4.5 to 4.9 µg/dl are rounded off to 5 µg/dl. Chapter 2 - Page 2 of 5 Revised November 2012

NC General Statutes TABLE 1 130A-131.7. Definitions. (3) "Confirmed lead poisoning" means a blood lead concentration of 20 micrograms per deciliter or greater determined by the lower of two consecutive blood tests within a six-month period. (5) "Elevated blood lead level" means a blood lead concentration of 10 micrograms per deciliter or greater determined by the lower of two consecutive blood tests within a six-month period. 130A-131.8. Laboratory Reports of blood levels in children. (a) All laboratories doing business in this State shall report to the Department all environmental lead test results and blood lead test results for children less than six years of age and for individuals whose ages are unknown at the time of testing. Reports shall be made by electronic submission within five working days after test completion. (b) Reports of blood lead test results shall contain all of the following: (1) The child's full name, date of birth, sex, race, ethnicity, address, and Medicaid number, if any; (2) The name, address, and telephone number of the requesting health care provider; (3) The name, address, and telephone number of the testing laboratory; (4) The laboratory results, whether the specimen type is venous or capillary; the laboratory sample number, and the dates the sample was collected and analyzed. 130A-131.9A. Investigation to identify lead poisoning hazards. (a) When the Department learns of confirmed lead poisoning, the Department shall conduct an investigation to identify the lead poisoning hazards to children. The Department shall investigate the residential housing unit where the child with confirmed lead poisoning resides. The Department shall also investigate the supplemental addresses of the child who has confirmed lead poisoning. (a1) When the Department learns of an elevated blood lead level, the Department shall, upon informed consent, investigate the residential housing unit where the child with the elevated blood level resides. When consent to investigate is denied, the child with the elevated blood lead level cannot be located, or the child's parent or guardian fails to respond, the Department shall document the denial of consent, inability to locate, or failure to respond. 130A-131.9C. Abatement and Remediation. (a) Upon determination that a child less than six years of age has a confirmed lead poisoning of 20 micrograms per deciliter or greater and that child resides in a residential housing unit containing lead poisoning hazards, the Department shall require remediation of the lead poisoning hazards. The Department shall also require remediation of the lead poisoning hazards identified at the supplemental addresses of a child less than six years of age with a confirmed lead poisoning of 20 micrograms per deciliter or greater. Chapter 2 - Page 3 of 5 Revised November 2012

Assessment and Testing Methodology Health care providers are encouraged to conduct a blood lead test on all children at 12 months and again at 24 months of age. However, at a minimum, North Carolina children are to be assessed for lead poisoning at 12 months and again at 24 months of age. Children under six years of age who first enter the health care system between 25 and 72 months of age should have lead screening (via blood lead test or risk assessment questionnaire) at their first visit if record of prior lead testing is not available. Although it is preferred that the assessment occurs at 12 and 24 months of age, there are acceptable ranges of ages during which screening may occur. For the 12-month screening, the acceptable range is from 11 through 18 months of age. For the 24- month screening, the acceptable range is from 18 through 30 months of age, with the goal being to conduct the screening as close as possible to 24 months of age. Research has shown little value to screenings done prior to one year of age, due to children s developmental stages with respect to mobility and hand-to-mouth behaviors. Assessment of potential lead exposure may be accomplished by performing a blood lead test (preferred) or by administering a risk assessment questionnaire. All children participating in Health Check (Medicaid), Health Choice or the Special Nutrition Program for Women, Infants and Children (WIC Program) are required to receive a blood lead test at 12 and 24 months. Other children living in low-risk ZIP codes may be assessed using the risk assessment questionnaire starting when the child is 12 months old. If all of the answers on the risk assessment questionnaire are No and the child lives in a low-risk ZIP code, the child is to be reassessed at 24 months of age. Any Yes or I don t know response on the questionnaire indicates the need to perform a blood lead test. When 18 and 30 month-old children present for WIC (re) certification, WIC staff are to assess whether blood lead testing was performed in the child s medical home. If the lead test was not done or if the test result is not available, a blood lead test should be performed only when children are having a hemoglobin or hematocrit test done at the local agency during the WIC (re) certification visit. Otherwise, the child should be referred to the agency s lead program staff or to the child's medical home, depending on the agency s protocol. Reporting blood lead test results Report all blood lead test results to parents/guardians and document notification. Reporting blood lead test results not only informs the parent of the child s blood lead status and facilitates the lead educational process, but may stimulate questions from the parent providing feedback to the medical provider as to what the parent/guardian understands about the potential health effects of lead and how lead exposure may affect their child. It also provides the parent with the knowledge to seek further testing options. Chapter 2 - Page 4 of 5 Revised November 2012

Indications for Additional Testing Blood lead testing should be done at times other than the routine testing schedule if it is suspected that a child faces increased risk for lead exposure. Indications for additional testing include: Increased likelihood of exposure due to housing. A child's risk for lead exposure may increase because the family has moved to older housing or to a geographic area with a higher prevalence of lead poisoning or older housing, or because the child lives in an older home that has recently been repaired, remodeled or renovated. Parental request. Parents may express concern about their children s potential lead exposure because of residence in older housing, nearby construction or renovation, an elevated blood lead level (EBL) in a neighbor s child, or other possible exposures. Such information may be valuable in highlighting potential exposure. A blood lead test should be performed if there is reason to suspect that lead exposure has occurred. Immigrant, foreign adoption, and foreign travel. Immigrant children, foreign child adoption, and children traveling often to and from foreign countries less than 6 years of age may be at a potentially greater lead exposure risk. Who and When to Test All children seen at local health departments for health maintenance visits (Baby and Child Health Check Clinics; Pediatric Supervisory Clinics; WIC Children etc.) and all children receiving services through private providers should receive a blood lead test at 12 and 24 months of age. Ideally, children should be tested between 12 and 24 months of age, or upon their first entry to the health care system at a later age. Children identified as high risk should be retested in 12 months. Blood lead specimens should be collected by the child's primary care provider. Referral to a provider solely for the purpose of blood lead testing is discouraged. Chapter 2 - Page 5 of 5 Revised November 2012

Chapter 3 State Laboratory Procedures About Blood Lead page 1 Odering Supplies page 2 Specimen Identification, Collection and Shipment page 2-3 Receiving Results of Blood Lead Tests page 4 Shipping Specimen to NCSLPH Power Point Presentation page 5-18

Chapter 3 State Laboratory Procedures About Blood Lead Childhood lead poisoning is a major, preventable environmental health problem. The persistence of lead poisoning, in light of present knowledge about the sources, pathways and prevention of lead exposure, continues to present a direct challenge to clinicians and public health authorities. As a result of industrialization, lead is common in the environment. Lead has no known physiological value and children are particularly susceptible to its toxic effects. Most poisoned children have no apparent symptoms, and consequently, many cases go undiagnosed and untreated. Lead poisoning is widespread and is not solely a problem of inner city or minority children. No socioeconomic group, geographic area, racial or ethnic population is spared its effects. Blood lead testing is encouraged as an important element of a comprehensive program to eliminate childhood lead poisoning. The goal of such testing is to identify children who need individual interventions to reduce their exposure. New data indicate adverse effects of lead exposure in children at blood lead levels previously believed to be safe. No safe level of lead in a child s body has been identified. At higher levels ( 70 μg/dl), lead exposure is an acute condition and can have devastating health consequences, including encephalopathy, seizures, coma and even death. As a result, the Centers for Disease Control (CDC) 1993 intervention level of 10 ug/dl has been lowered to 5 ug/dl. The newest methodologies including ICP/MS (Inductively Coupled Plasma Mass Spectometer) are now performed at the North Carolina State Laboratory of Public Health (NCSLPH). In addition, a multi-tier approach to follow-up has been adopted with an overall goal of reducing children's blood lead levels below 5 μg/dl, effective July, 2012. Attention: The North Carolina State Laboratory of Public Health will not process blood lead specimens collected on patients who are not residents of North Carolina. If any serious elevations were detected, the North Carolina Childhood Lead Poisoning Prevention Program would not have any jurisdiction in another state. Ordering Supplies The NCSLPH furnishes, at cost, mailers for collection and shipment of samples and specimens. These mailers are carefully selected by the Laboratory to meet U.S. Postal Service/DOT diagnostic specimen shipping and packaging regulations to minimize problems such as leakage or breakage, and to identify the Chapter 3 - Page 1 of 18 Revised November 2012

type of specimen or sample through color coding. Color coding speeds up the process of sorting and routing thousands of specimens and samples received daily. The mailers are provided for shipping specimens or samples only to the State Lab. The NCSLPH Online Supply Ordering System must be used to order supplies. You can access supplies by going to this website: http://slph.ncpublichealth.com/ You must have an account to access the system. To set up a new account please call 919-807-8617 or follow the instructions for setting up a new account on the website. Specimen Identification, Collection and Shipment A. DHHS form #3707 Blood Lead Analysis Form and specimen collection device kit are available from The NCSLPH website at: http://slph.ncpublichealth.com/forms/dhhs-3707.pdf or the NCSLPH Mailroom (919-807-8575). It is imperative that all of the following information be given: last name, first name, patient number or social security number, address, date of birth, race, sex, Medicaid number, submitter name, address and tax identification number (EIN#), specimen collection date, initial or follow-up blood lead test and microtainer or EDTA blood specimen (full, unopened tube). Tips on filling out Form 3707 Completely 1. Use Social Security and Medicaid numbers. DO NOT substitute other patient numbers. 2. County should be coded as child s county of residence, not the county in which the specimen was obtained. 3. Print or type information clearly. 4. Place labeled microtainer in a plastic bag, keeping Form 3707 separate from specimen. Place sample and Form 3707 into approved mailing canister. Do not mail in envelopes or other mailing devices. 5. Send specimen to NCSLPH as soon as possible. If transport is delayed, refrigerate specimen. Specimen MUST BE RECEIVED by the NCSLPH within four weeks (28 calendar days) from date of collection. B. Collection of Finger Stick Sample 1. Wash child s hand with soap and water. Rinse well. Dry. 2. Grasp the child s hand so that the thumb of the blood drawer is across the top of the child s fingers. 3. Hold the child s hand so that the palm faces up. 4. Use child s middle or ring finger for sample collection. 5. Using an alcohol wipe, briskly scrub the child s fingertip for 20 seconds. 6. Using dry gauze, wipe scrubbed area once. Chapter 3 - Page 2 of 18 Revised November 2012

7. Use lancet to stick finger slightly left of center. 8. Use dry gauze to wipe off the first drop of blood. 9. After specimen collection, care of puncture site should be consistent with your institution s procedures. C. Collection of Blood Sample 1. Continuing to grasp the finger, touch the tip of the capillary of collection device to the beaded drop of blood. 2. Capillary must be held continuously in a horizontal position during specimen collection to prevent air bubbles from forming in the capillary tube. 3. After 3-4 drops of blood fall from the full capillary into the microtainer, you have enough blood (150-250 ug/l). 4. Turn capillary/tube unit immediately to a vertical position to allow the blood in the capillary into the tube. 5. Remove capillary with holder at the same time. Close microtainer with attached cap. 6. Agitate the specimen to mix the anticoagulant through the blood. 7. Properly label with patient s first and last name. Place in a refrigerator until specimen is shipped. D. Shipment The NCSLPH must receive the specimen within 28 days of collection; however, immediate shipping is recommended to ensure specimen integrity and suitability for analysis. If not shipped immediately, store in refrigerator. The kit consists of two containers, one that fits inside the other. Place the specimen in either 1) Plastic bag with separate pouch for requisition or 2) Absorbent material such as: tissues, kimwipes, etc Place into the inner can of mailing container, then wrap the requisition (if not in plastic bag) around the inner container and place into the outer container securing the lid tightly. Place return address label on outside of outer container. Receiving Results of Blood Lead Tests Specimens are usually analyzed and reported on the day received by the NCSLPH Online results are available from The NCSLPH website at: https://slphreporting.ncpublichealth.com/lims/clinicallims/login Results are reported in micrograms per deciliter (ug/dl) of whole blood. The range of results reported is 1 ug/dl to >70ug/dL. Requisition forms are retained by the NCSLPH for two years plus the current and are filed according to laboratory accession number. Occasionally, results are given as one of several Unsatisfactory Specimen Codes. These require submission of another specimen for analysis. Chapter 3 - Page 3 of 18 Revised November 2012

Unsatisfactory Descriptions BROKEN IN TRANSIT - NEEDS TO BE REPEATED QUANTITY NOT SUFFICIENT - NEEDS TO BE REPEATED GREATER THAN 14 DAYS OLD - NEEDS TO BE REPEATED RECEIVED CLOTTED - NEEDS TO BE REPEATED NO SPECIMEN RECEIVED - NEEDS TO BE REPEATED APPEARS TO BE DENATURED - NEEDS TO BE REPEATED NO COLLECTION DATE - NEEDS TO BE REPEATED NAME ON SPECIMEN AND FORM DO NOT MATCH-NEEDS TO BE REPEATED NO NAME ON SPECIMEN-NEEDS TO BE REPEATED LABORATORY ACCIDENT - NEEDS TO BE REPEATED INSTRUMENT PROBLEMS-NEEDS TO BE REPEATED OTHER - NEEDS TO BE REPEATED OUT OF STATE RESIDENT, INELIGIBLE FOR TESTING APPEARS TO BE CONTAMINATED IMPROPER SPECIMEN FOR TEST REQUESTED PERSON IS PAST THE AGE LIMIT AND INELIGIBLE FOR TEST UNCAPPED, LEAKED IN TRANSIT NEEDS TO BE REPEATED NO SUBMITTER ADDRESS PATIENT ID QUESTIONABLE Please call for any questions or concerns: Kate Mason Hemachemistry Supervisor 919-807-8878 Chapter 3 - Page 4 of 18 Revised November 2012

Shipping Blood Lead Specimens to the North Carolina State Laboratory of Public Health Using U.S. Postal Service Chapter 3 - Page 5 of 18 Revised November 2012

Supplies Needed SLPH Blood Lead kit State Lab Blood Lead kit pack of 50 microtainers 90 labels for microtainers 10 green mailing labels 10 mailing boxes Chapter 3 Page 6 of 18 Revised November 2012

Supplies not included in SLPH Blood Lead kit Leak proof secondary container* such as ziptype baggie Biohazard sticker* *not provided with kit Chapter 3 Page 7 of 18 Revised November 2012

Supplies Needed cont. Correctly completed Blood Lead requisition forms* Absorbent material such as tissue or paper towels* * Not provided with kit Chapter 3 Page 8 of 18 Revised November 2012

Requisition forms Fill out the form completely When using computer generated labels or If hand written please make sure information is legible. Medicaid eligible Medicaid number is NECESSARY SS# - Social security number is REQUIRED Submitter name/ein return address is REQUIRED Chapter 3 Page 9 of 18 Revised November 2012

Packing instructions for blood lead specimens US Postal Service Guidelines Updated 11/1/2006 Chapter 3 Page 10 of 18 Revised November 2012

Step 1 Place microtainer or venous tube with unique identifiers in a leak-proof zip type baggie marked with a biohazard symbol Microtainers with labels attached Chapter 3 Page 11 of 18 Revised November 2012

Step 2 Place enough absorbent material to soak up all of the liquid inside the zip type baggie. Paper towels or tissues can be used. Absorbent material inside zip type baggie Chapter 3 Page 12 of 18 Revised November 2012

Step 3 Place the zip type baggie with specimens into the outer shipping box Chapter 3 Page 13 of 18 Revised November 2012

Step 4 Place all requisition forms inside the shipping box The requisitions should NOT be inside the zip type baggie with the specimens Chapter 3 Page 14 of 18 Revised November 2012

Step 5 Place enough cushioning material inside the box to hold the zip type baggie securely during transit. Chapter 3 Page 15 of 18 Revised November 2012

Step 6 Seal the shipping box. Affix the green NCSLPH shipping label Affix Your return address label Mailing label Chapter 3 Page 16 of 18 Revised November 2012

Biohazard Symbol DO NOT place the biohazard symbol on the outside of the shipping container. According to shipping regulations the biohazard symbol goes on the secondary container. Chapter 3 Page 17 of 18 Revised November 2012

If you have any questions About packaging specimens for transport: please contact Kristy Osterhout @ (919) 807-8755 or kristy.osterhout@dhhs.nc.gov About Blood Lead testing at the NCSLPH, please call the Newborn Screening/Clinical Chemistry Office @ (919) 807-8617 Kit ordering information: State Lab website: http://slph.state.nc.us Chapter 3 Page 18 of 18 Revised November 2012

Chapter 4 Case Management and Follow Up Follow-Up Schedule Table 1 Page 1 Reporting and Follow-up Procedures Page 2 Clinical Evaluation Page 3 Referrals Page 4 Chelation Page 5 Education Page 5 Helpful Tips Page 6

Chapter 4 Table 1 NORTH CAROLINA DIVISION OF PUBLIC HEALTH FOLLOW-UP SCHEDULE FOR DIAGNOSTIC / CONFIRMED BLOOD LEAD LEVELS FOR CHILDREN UNDER THE AGE OF SIX Blood Lead Level Response <5 µg/dl Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure Perform another blood lead test at age 2, earlier if risk of exposure increases All diagnostic (i.e., confirmation) tests should be performed as soon as possible within the time periods listed below. If diagnostic test result falls into a lower category - follow response for that risk category. If diagnostic or follow-up test result falls in a higher category conduct another diagnostic test based on the higher risk category & follow response for that risk category. 5-9 µg/dl (Diagnostic test within 3 months) 10-19 µg/dl (Diagnostic test within 1 month) Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure If diagnostic test result is 5-9 µg/dl Conduct nutritional assessment Take environmental history to identify lead sources & emphasize the importance of environmental assessment to identify and mitigate lead hazards Continue follow-up testing every 3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 10-19 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for environmental investigation Continue follow-up testing every 1-3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household 20-69 µg/dl (Diagnostic test within 1 week at 20-44 µg/dl within 48 hours at 45-59 µg/dl within 24 hours at 60-69 µg/dl) >70 µg/dl (Diagnostic test immediately as emergency lab test) Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 20-69 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Provide clinical management Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 70 µg/dl Hospitalize child and begin medical treatment immediately Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household *Children s Developmental Service Agency **Care Coordination for Children 08/15/2012 Chapter 4 - Page 1 of 7 Revised November 2012

Reporting and Follow-Up Procedures Children are classified according to the risk for adverse effects of lead based solely on blood lead measurement. The urgency and type of follow-up required are based on a child's risk classification. Diagnostic testing should be conducted according to the schedule listed below. The urgency and type of follow-up required are based solely on a child's blood lead level. Always report blood lead test results to parents. DIAGNOSTIC TESTING SCHEDULE Initial Test Result (µg/do) Perform Diagnostic test on venous blood within: 5-9 3 months 10-19 1 months 20-44 1 week 45-59 48 hours 60-69 24 hours 70 Immediately, as an emergency lab test. Form EHS 3651: Evaluation of Child with Elevated Blood Lead Level. (Environmental History) This form should be used by the health care provider to assist in the determination of potential sources of lead exposure for a child with a confirmed blood lead level 5 µg/dl and to educate the family about lead poisoning. This form should be completed when the child comes in for the confirmatory test (preferably venous) and faxed or mailed when BOTH tests results are known to (919) 841-4015 or NC CLPPP, 1934 Mail Service Center, Raleigh NC 27699-1937. NCLEAD users may scan and attach the 3651 form to the Child Event in the NCLEAD System. Form EHS 3651 is also used as a referral form to Environmental Health for a Lead Investigation. For a child with a confirmed blood lead level (10-19 µg/dl), the following apply: 1. Fill in the entire form and check all appropriate answers. 2. Obtain the name and address of the owner of the child's primary residence. 3. Retain the original copy of the form at the local health department or provider office with the child's medical record. Send a copy of the form to the address listed above. For a child with a confirmed lead poisoning ( 20 µg/dl), the following apply: 1. Fill-in the entire form and check all appropriate answers. 2. Obtain the name and address of the owner of the child's primary residence. 3. Retain the original copy of the form at the local health department or provider office with the child's medical record. Send a copy to the local lead investigator as a referral for an environmental investigation. Chapter 4 - Page 2 of 7 Revised November 2012

Clinical Evaluation Medical History Environmental History (EHS Form 3651) Nutritional History (Nutritional Assessment CLPPP form) Physical Examination Referrals Ask about symptoms, developmental history, mouthing activities, pica, previous blood lead level measurements and family history of lead poisoning. Ask about age, condition, and on-going remodeling or repainting of primary residence and other places where the child spends time (including secondary homes and child care centers). Determine whether child is being exposed to lead-based paint hazards at any or all of these places. Ask about occupational and hobby histories of adults with whom the child spends time. Determine whether the child is being exposed to lead from an adult's workplace or hobby. Ask about other sources of potential lead exposure, including dust or soil in or outside of dwelling. Take a diet history, including the frequency of the child s meals, snacks and beverages. Assess the child s intake of iron, vitamin C, calcium and zinc-rich food sources. Ask about the source of water used for cooking, drinking and for preparing infant formula. Ask about pica, or possible ingestion of non-food items. Evaluate the child's iron status using appropriate laboratory tests. Ask about participation in Food and Nutrition Services (food stamps) and WIC. Pay particular attention to the neurologic examination and to the child's psychosocial and language development. A standardized developmental screening test is recommended. Developmental progress should be monitored carefully. If there are delays or lags, the child should be referred to the appropriate agency for further assessment. See Section on Referrals in this Chapter Comments: Environmental history. State and local health departments may provide additional questions about local exposure sources. Nutritional status. Identified nutritional problems should be corrected. Ensure that children are eating at least 3 meals and 2 snacks daily. Smaller and more frequent meals may be helpful since absorption of lead may be increased when the stomach is empty. Deficiencies of iron, calcium and zinc may increase lead absorption or toxicity. A diet high in fat may result in increased lead absorption. A low hemoglobin or hematocrit may predispose the child to absorb lead easier. Chapter 4 - Page 3 of 7 Revised November 2012

Physical examination. Findings of language delay or other neurobehavioral or cognitive problems should prompt referral to appropriate programs. Children may need early intervention programs and further examinations during the early school years to facilitate entry into an appropriate educational program. Referrals: Nutritional Services: Referral to the WIC Program should be considered for children under five years of age with elevated lead exposure. WIC Program eligibility criteria include: Being a resident of North Carolina or receiving health care in North Carolina. Aliens are eligible to apply as long as they reside in the state. Having a family income less than 185% of the U.S. Poverty Income Guidelines. A person receiving Medicaid, Work First Temporary Assistance to Needy Families (TANF), or Food and Nutrition Services (Food Stamps) automatically meets the income eligibility requirement. Being at nutritional risk. A nutritionist or other health professional conducts a nutritional assessment at no cost to the participant, usually at the local WIC Program office. Examples of nutritional risk conditions are listed below. Anthropometric measurements that indicate or put a child at risk for being underweight or overweight A hemoglobin or hematocrit level that indicates iron-deficiency anemia Documented nutrition-related medical conditions Inadequate dietary intake Conditions that predispose a child to inadequate nutritional patterns such as elevated blood-lead levels, dental conditions, or having a parent or caretaker who has limited ability to make feeding decisions and/or prepare food (e.g. mental retardation, or having a history of alcohol or drug abuse). Information about the North Carolina WIC program is available from your county health department or by accessing information on the following website: http://www.nutritionnc.com. Early Intervention. Children with confirmed lead poisoning ( 20 µg/dl) are eligible for Early Intervention Services. Children birth to 36 months of age should be referred to the Children s Developmental Service Agency (CDSA) for Early Intervention as an entitlement of the Individuals with Disabilities Act. The CDSA contact information may be found at http://www.beearly.nc.gov/index.php/contact/cdsa. Care Coordination for Children (CC4C). Children birth to age three who are at risk for developmental delay or disability, long term illness and/or social, emotional disorders and children ages birth to five who have been diagnosed with developmental delay or disability, long term illness and/or social, emotional disorder may be eligible for the program. For referral information, contact the local health department. Lead Team. Comprehensive services are best provided by a team that includes the health-care provider, care coordinator, community health nurse or health advisor, environmental specialist, social services liaison, and housing specialist. Coordination of care, environmental services (i.e., identifying and controlling sources of lead exposure) and relocation to safe housing are typically provided or coordinated by the health department. Chapter 4 - Page 4 of 7 Revised November 2012

Housing/Social Services/Educational Services. Refer children to appropriate services if problems such as inadequate housing, lack of routine health care, or need for early intervention educational services are identified. Because childhood lead exposure is often associated with poverty, children with EBLs may also have problems such as inadequate housing, lack of routine medical care, and poor nutrition. Children may also need educational services, and the team may be instrumental in ensuring that children with a history of EBLs receive early intervention or special education services for which they are eligible. The health department may also provide referral sources, such as social service agencies, parent support groups and housing services. Chelation Chelation Therapy: Children with confirmed blood lead levels 45 µg/dl may be candidates for chelation therapy. Providers wishing to discuss medical treatment and follow-up of specific children with lead poisoning may contact physicians associated with the Childhood Lead Poisoning Prevention Program: ECU School of Medicine Dr. Dale Newton 252-744-3041 Department of Pediatrics Greenville, NC 27858 ECU School of Medicine Dr. David L. Eldridge 252-744-2535 Department of Pediatrics Greenville, NC 27858 Education The first opportunity to educate families about the causes and consequences of a child s elevated blood lead level (EBL) usually occurs in the health-care provider s office. Anticipatory guidance should be provided prenatally and again when children are 3-6 months of age. Parental guidance at these times might prevent some lead exposure and the EBLs that often occur during a child s second year of life. When children are 12 and 24 months of age, parental guidance should be provided at well-child visits when the personal-risk questionnaire is administered and/or the blood lead test is performed. Anticipatory guidance on lead poisoning covers many of the same areas as the Family Lead Education provided to children with elevated blood lead levels. Discuss with families: Their child's blood lead level (if testing has taken place) and what it means. Potential adverse health effects of lead exposure. Sources of lead and suggestions on how to reduce exposure. (See Chapter 1 Sources and attached list Alternative Cosmetics, Food Additives, and Medicines that Contain Lead ) Include discussion of ceramic dishes and traditional remedies as possible sources of lead. Chapter 4 - Page 5 of 7 Revised November 2012

Wet cleaning to remove lead-contaminated dust on floors, windowsills and other surfaces. Discuss the ineffectiveness of dry methods of cleaning, such as sweeping or vacuuming (unless a HEPA vacuum is used) for lead removal. The importance of good nutrition in reducing the absorption of lead. If there are poor eating habits and dietary patterns, discuss ways to improve the diet, and in particular ensure there is adequate intake of iron, vitamin C, calcium and zinc. Encourage regular meals and snacks. The need for follow-up blood lead testing to monitor the child's blood lead level, as appropriate. Results of environmental investigation, as appropriate. Hazards of improper removal of lead-based paint. Particularly hazardous are open-flame burning, power sanding, water blasting, methylene chloride-based stripping, and dry sanding or scraping. Other information on remediation is available in the Do's and Don'ts brochure (available in English and Spanish), and from EPA publications. Health departments may provide printed materials, flipcharts and videos to assist in the family education process. Health care providers should discuss short-term repercussions of elevated blood lead levels (e.g., the need for follow-up testing / treatment and the need to control lead hazards in the child s environment) and long-term repercussions (e.g., the potential for future learning problems and the availability of early intervention services). Helpful Tips When testing children for blood lead levels, try to obtain multiple telephone numbers for followup contact. Lead follow-up is easiest to do when using computerized tickler files. In the absence of these, a double-tickler file system has been used successfully by many health care providers. In this system, first file children's cards/record by name, in order to respond to questions from providers, schools, etc. A second file should be kept by dates, to keep track of testing and follow-up schedules. D A E B F C Jun May Apr Mar Feb Jan Lead Files by Name Lead Files by Month Coordinate WIC Program appointments and lead testing whenever possible to repeat blood tests. When reviewing WIC PROGRAM charts for immunization status, look for blood lead levels. Communication between the Medical Home and the Environmental Health Specialist is critical to ensure that children are not lost to appropriate follow-up. This may be facilitated by meeting at least quarterly to review state surveillance reports. Chapter 4 - Page 6 of 7 Revised November 2012

Be sure to use Medicaid numbers on lab slips for children who are on Medicaid! Omission of the Medicaid number means that the State Laboratory cannot be reimbursed for processing a specimen. The Two-Bucket Method is recommended for lead cleaning, to ensure that lead debris is not re-deposited onto cleaned surfaces, walls, and floors. 1. Place sponge or mop into bucket of detergent or cleaning solution. 2. Wipe surface. 3. Place contaminated sponge or mop into second bucket of rinse water, allowing debris to fall to the bottom. Do not rinse surfaces with this water. 4. Repeat Steps 1-3. 5. Change rinse water often. Chapter 4 - Page 7 of 7 Revised November 2012

Appendix A. Glossary A-1 B. Contact Information Childhood Lead Poisoning Prevention Staff B-1 Regional Environmental Health Specialists B-1 State Laboratory Staff B-2 Other Lead Contacts B-3 C. Memos D. Forms Memo Re: Point of Care Lead Analyzers C-1 Memo Re: State Lab Changes: We re Moving C-2 Memo Re: Revised Follow-up Schedule for Blood Lead Testing C-3 Memo Re: WIC C-5 North Carolina County Codes D-1 Form 3651: Evaluation of Child with Elevated Blood Lead Level D-2 Form 3958: Lead Risk Assessment Questionnaire D-4 DHHS Form 3707: Blood Lead Analysis D-6 E. Educational Materials Facts About Lead (English) E-1 Facts About Lead (Spanish) E-2 Lead and Eating Habits (English) E-3 Lead and Eating Habits (Spanish) E-4 Lead Safe Toys for NC Children (English) E-5 Lead Safe Toys for NC Children (Spanish) E-7 Are You Pregnant? E-9 5 Steps to a Healthy Home (English) E-11 5 Steps to a Healthy Home (Spanish) E-13 Green Cleaning (English) E-15 Green Cleaning (Spanish) E-17 CDC Coloring Book: Ethan s House Gets Healthier With a Visit E-19 -from the Lead Poisoning Prevention Team (English) Lead Poisoning Do s and Don ts: (English) Lead Poisoning Do s and Don ts: (Spanish)

F. Nutritional Material Prelude to Nutritional Focus Article F-1 Nutrition Focus Article: Childhood Lead Poisoning and the Role F-2 - of Nutrition Nutrition Assessment Form F-10 G. Refugee Children References Refugee Children and Lead Screening Recommendations G-1 Lead Screening During The Domestic Medical Examination G-2 - for Newly Arrived Refugees CDC Recommendations for Lead Poisoning Prevention in Newly G-9 - Arrived Refugee Children Q&A: CDC Recommendations for Lead Poisoning Prevention G-11 - in Refugee Children Lead Poisoning Prevention in Newly Arrived Refugee Children: G-14 - Tool Kit H. NCLEAD I. Other NCLEAD and Clinical Follow-Up H-1 Quick Reference Guide to Clinical Print Documents H-2 NCLEAD: Attaching a File or Word Document to an Event H-3 Quick Reference Guide To Workflows H-4 North Carolina Childhood Lead Screening Data by County I-1 Outreach Materials I-2

Glossary Care Coordination for Children (CC4C). Provides formal care coordination and case management services at no charge to eligible children birth to five at risk for or diagnosed with special needs and their families. Services are provided by local health departments, Sickle Cell Agencies, Federally Qualified Health Centers and Rural Health Centers to children not enrolled in the Infant Toddler Program. For more information, call your local health department or the Children with Special Health Care Needs Help Line, 1-800-737-3028. Children s Developmental Services Agency (CDSA). Provides evaluation and intervention services primarily birth to age three. Serves as the local head agency for the Early Intervention Infant Toddler Program. Contact information may be found at http://www.beearly.nc.gov/index.php/contact/cdsa Clinical Management. Comprehensive follow-up care, usually given by a health care provider to a child with an elevated blood lead level. Clinical management includes: 1. Clinical evaluation for complications of lead poisoning (Chap 4-Table 3) 2. Family lead education and referrals. 3. Chelation therapy, if appropriate. 4. Follow-up testing at appropriate intervals. Confirmed lead poisoning. A blood lead concentration of 20 μg/dl or greater, determined by the lower of two consecutive blood tests within a six-month period. Diagnostic Test. A laboratory test for lead that is performed on the blood of a child who has a screening blood level of 10 μg/dl or greater. The diagnostic test is usually the first venous blood lead test performed within six months of the screening test. Early Intervention. Identification of young children who have a developmental delay or may be at risk for developing problems and providing different types of services to support the family and the child. Early Intervention services are provided by many agencies under the leadership of the local CDSA. Elevated Blood Lead Level (EBL). A blood lead concentration of 10 μg/dl or greater determined by the lower of two consecutive blood tests within a six-month period. Family Lead Education. This service provides families with prompt and individualized education regarding: 1. Their child's blood lead level, and what it means. 2. Potential adverse health effects of lead exposure. 3. Sources of lead and suggestions on how to reduce exposure. GLS - Page 1 of 2 Revised November 2012

4. The importance of wet cleaning to remove lead-contaminated dust on floors, windowsills, and other surfaces; the ineffectiveness of dry methods of cleaning, such as sweeping. 5. The importance of good nutrition in reducing the absorption of lead. If there are poor nutritional patterns, discuss adequate intake of calcium, iron and zinc and encourage regular meals and snacks. 6. The need for follow-up blood lead testing to monitor the child's blood lead level, as appropriate. 7. Results of environmental investigation, as appropriate. 8. Hazards of improper removal of lead-based paint. Particularly hazardous are open-flame burning, power sanding, water blasting, methylene chloride-based stripping, and dry sanding or scraping. Follow-up test. A laboratory test for lead that is performed on the blood of a child with an elevated diagnostic test for lead in order to monitor the child s status. Initial Blood Lead Test. A laboratory test for lead that is performed on the blood of an asymptomatic child to determine if the child has an elevated blood lead level. NC CLPPP (North Carolina Childhood Lead Poisoning Prevention Program). Part of the Children s Environmental Health Program in the Division of Public Health, Environmental Health Section - administers the NC CLPPP and Child and School Sanitation Inspection Programs. Reference Value. A value based on the 97.5th percentile of the BLL distribution among children 1 5 years old in the United States (currently 5 μg/dl) to identify children with elevated BLLs using data generated by the National Health and Nutrition Examination Survey (NHANES). Refugee. Refugees are a special group of immigrants who are admitted into the United States because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. These individuals enter the United States legally as a refugee pursuant to Section 207 of the Immigration and Naturalization Act. For the most part, refugees cannot return home because of the danger they would face upon returning. WIC Program. WIC stands for Women, Infants, and Children and is also called the Special Supplemental Nutrition Program. WIC is a federal program for lowincome pregnant, postpartum and breastfeeding women, infants and children until the age of five and provides supplemental foods, nutrition education, breastfeeding support, and referrals for health care. This Program is effective in preventing and improving nutrition-related health problems within its population. GLS - Page 2 of 2 Revised November 2012

NORTH CAROLINA LEAD CONTACTS CHILDHOOD LEAD POISONING PREVENTION PROGRAM (CLPPP) BEVERLY BALDINGER, HUD GRANT MANAGER Division of Public Health 252-200-4664 Department of Health and Human Services FAX: 252-443-4547 email: beverly.baldinger@dhhs.nc.gov HUD Lead Hazard Control Grant, Preventive Maintenance Program DAVID BROWN, SURVEILLANCE COORDINATOR Division of Public Health 919/218-5460 Department of Health and Human Services FAX: 919/841-4015 1934 Mail Service Center Raleigh, NC 27699-1632 email: w.david.brown@dhhs.nc.gov Surveillance, Medical Follow-up, Regional Specialist for Counties: Alamance, Caswell, Chatham, Durham, Lee, Orange, Person, Randolph ED NORMAN, PROGRAM MANAGER Division of Public Health 919/707-5951 Department of Health and Human Services FAX: 919/841-4015 1934 Mail Service Center Raleigh, NC 27699-1934 email: ed.norman@dhhs.nc.gov Overall Contact, Public Outreach, Screening, Surveillance TENA WARD, DATA MANAGER Division of Public Health 919/707-5933 Department of Health and Human Services FAX: 919/841-4015 1934 Mail Service Center Raleigh, NC 27699-1934 email: tena.ward@dhhs.nc.gov Data Management REGIONAL ENVIRONMENTAL HEALTH SPECIALISTS (CLPPP) Kimly Blount (Field Supervisor) PHONE: (252) 903-7925 EMAIL: Kimly.Blount@dhhs.nc.gov COUNTIES: Edgecombe, Greene, Nash, Wake & Wilson Patricia Gilmartin PHONE: (252) 335-2994 EMAIL: Patricia.Gilmartin@dhhs.nc.gov Counties: Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Franklin, Gates, Granville, Halifax, Hertford, Hyde, Jones, Martin, Northampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrell, Vance, Warren, & Washington

Alan Huneycutt (Radiation Safety Officer) PHONE: (704) 681-0138 EMAIL: Alan.Huneycutt@dhhs.nc.gov Counties: Avery, Buncombe, Burke, Cabarrus, Cherokee, Clay, Cleveland, Gaston, Graham, Haywood, Henderson, Jackson, Lincoln, Macon, Madison, McDowell, Mecklenburg, Mitchell, Polk, Rutherford, Stanly, Swain, Transylvania, Union & Yancey Wayne Jones PHONE: (910) 290-3047 EMAIL: Wayne.Jones@dhhs.nc.gov Counties: Bladen, Brunswick, Carteret, Columbus, Cumberland, Duplin, Harnett, Hoke, Johnston, Lenoir, New Hanover, Onslow, Pender, Robeson, Sampson, Scotland & Wayne Warren Richardson PHONE: (336) 312-5069 EMAIL: Warren.Richardson@dhhs.nc.gov Counties: Alexander, Alleghany, Anson, Ashe, Caldwell, Catawba, Davidson, Davie, Forsyth, Guilford, Iredell, Montgomery, Moore, Richmond, Rockingham, Rowan, Stokes, Surry, Watauga, Wilkes & Yadkin STATE LABORATORY KRISTY BREEDLOVE, LAB IMPROVEMENT CONSULTANT State Laboratory of Public Health 919/807-8756 Department of Health and Human Services FAX: P.O. Box 28047 Raleigh, NC 27611-8047 email: Kristy.Breedlove@dhhs.nc.gov clinical workshop coordinator, continuing education hours, technical assistance KATE MASON, HEMACHEMISTRY SUPERVISOR State Laboratory of Public Health 919/807-8878 Department of Health and Human Services FAX: 919/715-7787 P.O. Box 28047 Raleigh, NC 27611-8047 email: Kate.Mason@dhhs.nc.gov Blood Lead Analysis CINDY PRICE, ENVIRONMENTAL SCIENCE UNIT HEAD State Laboratory of Public Health 919/807-8845 Department of Health and Human Services FAX: 919/715-8611 P.O. Box 28047 Raleigh, NC 27611-8047 email: Cindy.Price@dhhs.nc.gov Environmental Sample Analysis

OTHER LEAD CONTACTS JEFF DELLINGER, INDUSTRIAL HYGIENE CONSULTANT Division of Public Health 919/707-5950 Department of Health and Human Services FAX: 919/870-4808 1912 Mail Service Center Raleigh, NC 27699-1912 email: jeff.dellinger@dhhs.nc.gov Worker Protection, Training, Certification, Accreditation DR. DAVID ELDRIDGE, DEPARTMENT OF PEDIATRICS East Carolina University School of Medicine 252/744-2539 or Brody 3E133 252/744-2535 Greenville, NC 27834 FAX: 252/744-5097 email: ELDRIDGED@ecu.edu Pediatric Consultant STEPHANIE FISHER, REGIONAL CHILD HEALTH NURSE CONSULTANT Division of Public Health Department of Health and Human Services 919/266-9524 5601 Six Forks Road Building 2 FAX: 919/266-9527 Raleigh, NC 27699 email: Stephanie.Fisher@dhhs.nc.gov Child Health Services Coordination LEBEED KADY, ENVIRONMENTAL ENGINEER Division of Waste Management 919/707-8229 Department of Environment and Natural Resources FAX: 1646 Mail Service Center Raleigh, NC 27699 email: lebeed.kady@ncdenr.gov Hazardous Waste KATHY LAMB, NUTRITION PROGRAM CONSULTANT Nutrition Services Branch Division of Public Health Department of Health and Human Services 919/707-5756 1914 Mail Service Center FAX: 919/870-4818 Raleigh, NC 27699-1914 email: kathy.lamb@dhhs.nc.gov WIC, Nutrition AMY MACDONALD, ENVIRONMENTAL HEALTH EDUCATOR UNC-Chapel Hill Environmental Resource Program 919/966-2463 CB 1105. FAX: 919/848-9060 Chapel Hill, NC 27599 email: amy.macdonald@.unc.edu CDC Childhood Lead Poisoning Prevention Grant; Healthy Homes training, Educational Materials

JENNIFER MORILLO, NC REFUGEE COORDINATOR NC Refugee Health Program Division of Public Health Department of Health and Human Services 919/733-7286 ext 112 1905 Mail Service Center FAX: 919/733-0084 Raleigh, NC 27699-1905 email: jennifer.morillo@dhhs.nc.gov refugee health program DR. DALE NEWTON, DEPARTMENT OF PEDIATRICS East Carolina University School of Medicine 252/744-3041 Brody 3E139 FAX: 252/744-2398 Greenville, NC 27834 email: NEWTOND@ecu.edu Pediatric Consultant FRANK SKWARA, HEALTH CHECK NURSE CONSULTANT Division of Medical Assistance 919/986-9777 Department of Health and Human Services FAX: 2501 Mail Service Center email: frank.skwara@dhhs.nc.gov Raleigh, NC 27699-2501 Medical Follow-up

Beverly Eaves Perdue, Governor Albert A. Delia, Acting Secretary North Carolina Department of Health and Human Services Division of Public Health 1931 Mail Service Center Raleigh, North Carolina 27699-1931 December 9, 2012 Laura Gerald, MD, MPH State Health Director MEMORANDUM FROM: TO: RE: Ed Norman, Manager Childhood Lead Poisoning Prevention Program Environmental Health Section Local Health Directors & Private Medical Providers Point-of-care lead analyzers A growing number of health care providers in North Carolina are using point-of care (POC) lead analyzers to test children for lead poisoning. Facilities using a POC lead analyzer need to be aware that the Clinical Laboratory Improvement Amendments (CLIA) designates them as a laboratory. As such, they are required to report all blood lead test results for children less than six years old, even if determined in a clinical setting, to the North Carolina Childhood Lead Poisoning Prevention Program (NC CLPPP). Use of a CLIA-waived lead analyzer provides the advantage of an immediate test result and unnecessary delays before diagnostic (i.e., confirmation) testing is complete. According to the attached follow-up schedule, a diagnostic test should be performed if the initial result is 5 micrograms per deciliter (µg/dl) and for increasing test results. Because current POC lead analyzers appear to provide optimal performance near 10 µg/dl NC CLPPP recommends that all diagnostic test specimens be analyzed at a reference laboratory. 1 Same day test results obtained using the POC lead analyzer cannot be accepted as diagnostic testing. Please note that blood lead test results are rounded off to a whole number for comparability with results reported from other laboratories and for submission to the Centers for Disease Control and Prevention, National Surveillance System. For example, test results between 4.5 to 4.9 µg/dl are rounded off to 5 µg/dl. For more information, please contact Ed Norman at (919) 707-5951 or at ed.norman@dhhs.nc.gov. To arrange for reporting blood lead test results, please contact Tena Ward at (919) 707-5933 or at tena.ward@dhhs.nc.gov. 1 Recommendations of the Advisory Committee for Childhood Lead Poisoning Prevention. Available at: http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf. Accessed 2012 Nov 9. cc: Danny Staley Layton Long Megan Davies, MD Kevin Ryan, MD Steve Shore, NC Pediatric Society Greg Griggs, NC Academy of Family Physicians Bob Seligson, NC Medical Society Location: 5605 Six Forks Rd. Raleigh, N.C. 27609-3811 An Equal Opportunity Employer

Beverly Eaves Perdue, Governor Albert A. Delia, Acting Secretary North Carolina Department of Health and Human Services Division of Public Health Division of Public Health Section of Epidemiology State Laboratory of Public Health PO Box 28047 Raleigh, NC 27611-8047 Tel 919-733-7834 Fax 919-733-8695 MSC 1918 Laura Gerald, MD, MPH State Health Director TO: Public Health Partners, Customers and Friends FROM: Lou F. Turner, DrPH, HCLD Acting Laboratory Director Re: Changes We re Moving The NC State Laboratory of Public Health is moving! After over 40 years in downtown Raleigh, the Laboratory will be re-locating to a new facility in Raleigh near the NC State Fairgrounds and Interstate 40. The Laboratory will also be co-locating with the Office of the Chief Medical Examiner, which is currently housed in Chapel Hill, NC. The new physical address for both organizations is: 4312 District Drive Raleigh NC 27607 Directions to the new facility may be found at: http://slph.ncpublichealth.com/ The physical address is changing. However: The PO Box remains the same: PO Box 28047 Raleigh NC 27611 The Courier address does not change: MSC 1918 All the e-mail addresses and phone numbers for staff do not change. The only change is the location. There will be no change in how samples are submitted to the State Laboratory; continue to submit them as you do now. Staff may be contacted with the same e-mail address and phone numbers that you currently use. The anticipated start date for the move is December 17, 2012; the move should be completed by January 18, 2013. The move is being coordinated to minimize downtime for testing. However, if during the move, you experience more than a weeks delay in the normal and customary Turn Around Time, please let us know. If you have questions about the move, please contact Vickie Whitaker at Vickie.whitaker@dhhs.nc.gov or by phone at 919-807-8949. Vickie is a former State Laboratory employee; she is working part-time to coordinate communication issues about the move. Thank you for your patience and support during this exciting time. Location: 306 North Wilmington Stree. Raleigh, N.C. 27601 An Equal Opportunity Employer

North Carolina Department of Health and Human Services Division of Public Health 1931 Mail Service Center Raleigh, North Carolina 27699-1931 Beverly Eaves Perdue, Governor Albert A. Delia, Acting Secretary July 5, 2012 Laura Gerald, MD, MPH State Health Director MEMORANDUM FROM: Ed Norman, Manager Childhood Lead Poisoning Prevention Program Environmental Health Section Dr. Lou Turner, Acting Director State Laboratory of Public Health TO: RE: Local Health Directors & Private Medical Providers Revised Follow-up Schedule for Blood Lead Testing As a result of recently revised recommendations from the U.S. Centers for Disease Control and Prevention, the NC Childhood Lead Poisoning Prevention Program and the State Laboratory of Public Health have developed a revised follow-up schedule for diagnostic/confirmed blood lead levels. The most significant revision is the recommendation to begin diagnostic (venous) testing for all children who have an initial blood lead test result equal to or greater than a reference value of 5 micrograms per deciliter (5 µg/dl). The CDC anticipates that this change will increase the need for follow-up testing by four-fold. North Carolina data indicates there may be closer to ten times as many children requiring follow-up under the revised protocol compared to the previous guidelines, which recommended diagnostic testing beginning at 10 µg/dl. Environmental investigation guidelines are not affected by these revised recommendations; however, other revisions to clinical case management are addressed. A chart summarizing these recommendations is attached. We appreciate your assistance in implementing these revised recommendations. For more information, please contact Ed Norman at (919) 707-5951 or at ed.norman@dhhs.nc.gov. cc: Danny Staley Layton Long Megan Davies, MD Kevin Ryan, MD Steve Shore, NC Pediatric Society Greg Griggs, NC Academy of Family Physicians Bob Seligson, NC Medical Society Location: 5605 Six Forks Rd. Raleigh, N.C. 27609-3811 An Equal Opportunity Employer

NORTH CAROLINA DIVISION OF PUBLIC HEALTH FOLLOW-UP SCHEDULE FOR DIAGNOSTIC / CONFIRMED BLOOD LEAD LEVELS FOR CHILDREN UNDER THE AGE OF SIX Blood Lead Level Response <5 µg/dl Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure Perform another blood lead test at age 2, earlier if risk of exposure increases All diagnostic (i.e., confirmation) tests should be performed as soon as possible within the time periods listed below. If diagnostic test result falls into a lower category - follow response for that risk category. If diagnostic or follow-up test result falls in a higher category conduct another diagnostic test based on the higher risk category & follow response for that risk category. 5-9 µg/dl (Diagnostic test within 3 months) 10-19 µg/dl (Diagnostic test within 1 month) Report blood lead test result to parent & document notification Educate family about lead sources, environmental assessment & prevention of lead exposure If diagnostic test result is 5-9 µg/dl Conduct nutritional assessment Take environmental history to identify lead sources & emphasize the importance of environmental assessment to identify and mitigate lead hazards Continue follow-up testing every 3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 10-19 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for environmental investigation Continue follow-up testing every 1-3 months until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household 20-69 µg/dl (Diagnostic test within 1 week at 20-44 µg/dl within 48 hours at 45-59 µg/dl within 24 hours at 60-69 µg/dl) >70 µg/dl (Diagnostic test immediately as emergency lab test) Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 20-69 µg/dl Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Provide clinical management Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household Report blood lead test result to parent & document notification Educate family about lead sources and prevention of lead exposure If diagnostic test result is 70 µg/dl Hospitalize child and begin medical treatment immediately Conduct nutritional assessment and refer to WIC Program Take environmental history to identify sources of lead exposure Refer to local health department for required environmental investigation Refer children to CDSA* Early Intervention or CC4C** as appropriate Refer to Social Services as needed for housing or additional medical assistance Continue follow-up testing every 1 month until 2 consecutive tests are <5 µg/dl Test other children under the age of six in same household *Children s Developmental Service Agency **Care Coordination for Children 08/15/2012

NORTH CAROLINA COUNTY CODES 001 Alamance 026 Cumberland 051 Johnston 076 Randolph 002 Alexander 027 Currituck 052 Jones 077 Richmond 003 Alleghany 028 Dare 053 Lee 078 Robeson 004 Anson 029 Davidson 054 Lenoir 079 Rockingham 005 Ashe 030 Davie 055 Lincoln 080 Rowan 006 Avery 031 Duplin 056 Macon 081 Rutherford 007 Beaufort 032 Durham 057 Madison 082 Sampson 008 Bertie 033 Edgecombe 058 Martin 083 Scotland 009 Bladen 034 Forsyth 059 McDowell 084 Stanly 010 Brunswick 035 Franklin 060 Mecklenburg 085 Stokes 011 Buncombe 036 Gaston 061 Mitchell 086 Surry 012 Burke 037 Gates 062 Montgomery 087 Swain 013 Cabarrus 038 Graham 063 Moore 088 Transylvania 014 Caldwell 039 Granville 064 Nash 089 Tyrrell 015 Camden 040 Greene 065 New Hanover 090 Union 016 Carteret 041 Guilford 066 Northampton 091 Vance 017 Caswell 042 Halifax 067 Onslow 092 Wake 018 Catawba 043 Harnett 068 Orange 093 Warren 019 Chatham 044 Haywood 069 Pamlico 094 Washington 020 Cherokee 045 Henderson 070 Pasquotank 095 Watauga 021 Chowan 046 Hertford 071 Pender 096 Wayne 022 Clay 047 Hoke 072 Perquimans 097 Wilkes 023 Cleveland 048 Hyde 073 Person 098 Wilson 024 Columbus 049 Iredell 074 Pitt 099 Yadkin 025 Craven 050 Jackson 075 Polk 100 Yancey

1. Last Name First Name M I 2. Medicaid No. 3. Date of Birth 4. Hispanic Origin? Yes No 5. Race White Black American Indian Asian Pacific Island. Other 6. Sex 1. Male 2. Female 7. County of Residence: NC Department of Health and Human Services Division of Public Health EVALUATION OF CHILD WITH ELEVATED BLOOD LEAD LEVEL Current Address of Child: Phone: ( ) Length of Resident at Child's Current Address: years months Parent/Guardian: Laboratory Findings: Date: Blood Lead: Date: Date: Blood Lead: Blood Lead: Dietary Update: Yes No Does the family store food in open cans? Does the family prepare, store, or serve food in homemade or imported ceramic dishes? Does the family use traditional medicines such as greta, azarcon or pay-loo-ah? Does the child receive calcium or phosphorus supplements? Is the child on an iron supplement? Is the child enrolled in the WIC program? Comments: Possible Non-food Sources of Child's Lead Exposure: Yes No Explain Does child play in dirt? Does child put fingers in their mouth? Have you ever seen child eat a paint chip, plaster or chew on painted surfaces? Does child eat or chew on other non-food items? Does family recycle or store old car batteries? Does family use the following for fuel: painted boards? battery casings? Are there plastic or vinyl miniblinds at the child's home? EHS 3651 (Revised 04/12) Environmental Health Section (Review 04/13)

Possible Non-food Sources of Child's Lead Exposure: (Continued) Yes No Explain Is there peeling paint or plaster inside or out at the child's primary residence? Is the primary residence being remodeled or has it been remodeled during the past six months? Does family member work in battery salvage, car repair or painting, smelting or house renovating or have a hobby such as fishing, furniture repair, making stained glass or pottery? Approximate Age of Dwelling: Owner of Dwelling: Number of children in household less than 6 years old: Tested for lead poisoning during past six months? Name/age / Yes No / Yes No / Yes No / Yes No INTERVIEWER: Have I completed the following: Yes No Comments Discussed effects of lead poisoning and need for patient follow-up. Provided education on house cleaning measures to prevent lead poisoning. Provided nutritional information to reduce lead absorption. Made arrangements for subsequent laboratory testing. Has referral been made to physician if needed? If yes, give date and time: Explained reason for environmental investigation. Referred to local health department for environmental investigation. Date: INTERVIEWER: Purpose: To be used by the health care provider to determine potential sources of lead exposure for a child with an elevated blood lead level and to educate the family about lead poisoning. Preparation: Fill in the blanks and check the appropriate answers. Fax a copy to (919) 841-4015. Distribution: Disposition: Retain original at county health department with child's record. Send a copy to the lead investigator upon a referral for an environmental investigation. This form may be destroyed in accordance with Standard 5 of the Records Disposition Schedule published by the North Carolina Division of Archives and History. Additional forms may be ordered from: Environmental Health Section Division of Public Health Environmental Health Services Section 1632 Mail Service Center Raleigh, NC 27699-1632 Phone: (888) 774-0071 EHS 3651 (Revised 04/12) Environmental Health Section (Review 04/13)

NC NC Department of Environment of Health and and Human Natural Services Resources Division Division of Environmental of Public Health Health LEAD RISK ASSESSMENT QUESTIONNAIRE Patient's Name: Medical Record Number: Purpose: For clinical use to identify children who need to be tested for lead exposure. Instructions: At 12 and again at 24 months of age (or at the time of the clinic visit closest to these ages) determine the zip code for all children. Note: If the mailing and residential addresses are not the same, use the zip code of the physical address where the child lives. Also determine the zip code for children between 24 and 72 months of age who have never been tested or for whom testing status is unknown. Conduct a blood lead test for all children who live in one of the high risk zip codes listed on the back of this page. For children who do not live in a high risk zip code ask the assessment questions below. Conduct a blood lead test if the answer to any question is yes or I don't know. Reordering Information: Additional copies of this form may be ordered from: Environmental Health Services Section Section Division of Environmental Public Health Health 1632 Mail Service Center Raleigh, NC 27699-1632 Telephone: 919-715-5381 888-774-0071 Date: Age: Residential Zip Code: 1. Receive Women, Infants, and Children (WIC) Program Services or is your child enrolled in Medicaid (Health Check) or Health Choice? 2. Live in or regularly visit a house that was built before 1950, including home child care centers or homes of relatives? 3. Live in or regularly visit a house that was built before 1978, with recent or ongoing renovations or remodeling (within the last 6 months)? 4. Live in or regularly visit a house that contains vinyl miniblinds? 5. Have a brother, sister, other relative, housemate or playmate who has or has had a high blood lead level? 6. Is your child a refugee, immigrant or adopted from another country? Date: Age: Residential Zip Code: 1. Receive Women, Infants, and Children (WIC) Program Services or is your child enrolled in Medicaid (Health Check) or Health Choice? 2. Live in or regularly visit a house that was built before 1950, including home child care centers or homes of relatives? 3. Live in or regularly visit a house that was built before 1978, with recent or ongoing renovations or remodeling (within the last 6 months)? 4. Live in or regularly visit a house that contains vinyl miniblinds? 5. Have a brother, sister, other relative, housemate or playmate who has or has had a high blood lead level? 6. Is your child a refugee, immigrant or adopted from another country? DENR EHS 3958 3958 (Revised 04/12) 10/11) Environmental Health Services Section (Review 04/13) 10/12)

North Carolina Zip Codes for Children at High Risk for Lead Exposure Conduct a blood lead test on all children who live in one of these zip codes. 27011 27405 27810 27871 27954 28137 28365 28463 28581 28752 27013 27406 27812 27872 27956 28139 28367 28464 28585 28753 27014 27813 27873 27957 28144 28368 28466 28586 28755 27016 27504 27814 27874 27960 28150 28369 28469 28756 27024 27508 27816 27875 27962 28159 28371 28470 28604 28757 27028 27510 27818 27876 27964 28160 28372 28471 28611 28761 27030 27521 27819 27877 27965 28169 28373 28472 28615 28762 27042 27530 27820 27878 27967 28170 28376 28478 28616 28771 27046 27534 27821 27882 27970 28377 28479 28621 28772 27047 27536 27822 27883 27973 28208 28379 28622 28777 27052 27542 27823 27884 27974 28382 28501 28623 28779 27053 27544 27824 27885 27979 28301 28383 28504 28624 28781 27546 27826 27886 27980 28303 28384 28510 28627 28782 27101 27549 27827 27888 27982 28305 28385 28511 28635 28789 27105 27551 27828 27889 27983 28306 28386 28513 28637 28792 27107 27553 27829 27890 27985 28315 28390 28515 28640 27555 27830 27891 27986 28318 28393 28516 28642 28801 27202 27557 27831 27892 28323 28394 28518 28644 27212 27559 27832 27893 28001 28325 28395 28519 28657 28909 27217 27563 27839 27897 28007 28326 28396 28521 28659 27239 27565 27840 28009 28328 28398 28523 28662 27242 27568 27841 27909 28018 28330 28399 28525 28663 27252 27569 27843 27910 28019 28332 28526 28666 27260 27570 27844 27915 28020 28333 28401 28528 28669 27262 27573 27845 27919 28032 28334 28422 28529 28670 27263 27576 27846 27922 28034 28338 28430 28530 28675 27288 27577 27847 27923 28040 28339 28431 28531 28679 27291 27582 27849 27924 28043 28340 28432 28537 28681 27584 27850 27925 28072 28342 28434 28538 28685 27305 27589 27851 27926 28073 28343 28435 28551 27306 27852 27928 28076 28345 28438 28552 28702 27311 27601 27853 27932 28077 28349 28439 28553 28705 27314 27855 27935 28083 28350 28441 28554 28708 27341 27701 27856 27937 28089 28351 28444 28555 28710 27342 27857 27938 28352 28447 28556 28714 27343 27801 27860 27941 28101 28356 28448 28557 28725 27360 27803 27862 27942 28102 28357 28450 28560 28726 27371 27804 27863 27944 28114 28358 28452 28570 28733 27379 27805 27864 27946 28119 28360 28456 28572 28734 27806 27866 27947 28127 28362 28457 28573 28735 27401 27807 27869 27950 28128 28363 28458 28577 28743 27403 27809 27870 27953 28135 28364 28462 28580 28746 EHS DENR 3958 3958 (Revised 04/12) 10/11) Environmental Health Section Services (Review 04/13) 10/12)

1. Last Name First Name MI 2. Patient Number (Soc. Security No.) H 3. Address DO NOT WRITE IN THIS SPACE LABORATORY NUMBER North Carolina Department of Health and Human Services State Laboratory of Public Health Leslie Wolf, PhD, Director 306 N. Wilmington St, P.O. Box 28047 Raleigh, North Carolina 27611-8047 4. Date of Birth Month Day Year 5. Race 1. White 2. Black 3. American Indian 4. Asian 5. Native Hawaiian/Other Pacific Islander 6. Unknown 6. Hispanic or Latino Origin? 1. Yes 2. No 6. Unknown 7. Sex 1. Male 2. Female 8. Co. of Residence 9. Medicaid Client Yes If yes, enter # No 10. WIC Patient? If yes, please check box: ESSENTIAL SPECIMEN DATA DATE COLLECTED M D Y BLOOD LEAD ANALYSIS SEND REPORT TO: EMPLOYER IDENTIFICATION NUMBER: ADDRESS: Initial blood lead test Follow-up blood lead test Microtainer EDTA blood specimen (full, unopened tube) DHHS 3707 (Revised 1/07) LABORATORY (Review 7/09) 1. Last Name First Name MI 2. Patient Number (Soc. Security No.) H 3. Address DO NOT WRITE IN THIS SPACE LABORATORY NUMBER North Carolina Department of Health and Human Services State Laboratory of Public Health Leslie Wolf, PhD, Director 306 N. Wilmington St, P.O. Box 28047 Raleigh, North Carolina 27611-8047 4. Date of Birth Month Day Year 5. Race 1. White 2. Black 3. American Indian 4. Asian 5. Native Hawaiian/Other Pacific Islander 6. Unknown 6. Hispanic or Latino Origin? 1. Yes 2. No 6. Unknown 7. Sex 1. Male 2. Female 8. Co. of Residence 9. Medicaid Client Yes If yes, enter # No 10. WIC Patient? If yes, please check box: ESSENTIAL SPECIMEN DATA DATE COLLECTED M D Y BLOOD LEAD ANALYSIS SEND REPORT TO: EMPLOYER IDENTIFICATION NUMBER: ADDRESS: Initial blood lead test Follow-up blood lead test Microtainer EDTA blood specimen (full, unopened tube) DHHS 3707 (Revised 1/07) LABORATORY (Review 7/09)

COLLECTION INSTRUCTIONS FOR BLOOD LEAD ANALYSIS Preparation of Child 1. Wash hands with soap and water, using hand brush. Rinse well. Dry. 2. Grasp child's hand so that blood drawer's thumb is across top of child's fingers. 3. Hold child's hand so that palm faces him. 4. Use child's middle or ring finger for sample. 5. Use alcohol sponge to scrub briskly an area on child's fingertip for 20 seconds. 6. Wipe scrubbed area once, using dry gauze. 7. Use lancet to stick finger slightly left of center. 8. Use dry gauze to wipe off first drop of blood. Collection of Blood Sample 1. Continuing to grasp the finger, touch the tip of the capillary to the beaded drop of blood. 2. Capillary must be held continuously in a horizontal position during collection to prevent air bubbles forming in the capillary tube. 3. After 3-4 drops of blood fall off the full capillary into the microtainer, you have enough blood. (150-250 ul) 4. Turn capillary/tube unit immediately in a vertical position to allow the blood to flow into the tube. 5. Remove capillary with holder at the same time. Close microtainer with attached cap. 6. Agitate the specimen to mix the anticoagulant through the blood. 7. Properly label with patient's name. Place in appropriate storage until shipping. 8. Specimens must be received in the Laboratory within 2 weeks, however, immediate shipping is recommended to ensure specimen integrity and suitability for analysis. FOR ADDITIONAL INFORMATION SEE "SCOPE" OR CALL (919) 733-3937 DHHS 3707 (Revised 1/07) LABORATORY (Review 7/09) COLLECTION INSTRUCTIONS FOR BLOOD LEAD ANALYSIS Preparation of Child 1. Wash hands with soap and water, using hand brush. Rinse well. Dry. 2. Grasp child's hand so that blood drawer's thumb is across top of child's fingers. 3. Hold child's hand so that palm faces him. 4. Use child's middle or ring finger for sample. 5. Use alcohol sponge to scrub briskly an area on child's fingertip for 20 seconds. 6. Wipe scrubbed area once, using dry gauze. 7. Use lancet to stick finger slightly left of center. 8. Use dry gauze to wipe off first drop of blood. Collection of Blood Sample 1. Continuing to grasp the finger, touch the tip of the capillary to the beaded drop of blood. 2. Capillary must be held continuously in a horizontal position during collection to prevent air bubbles forming in the capillary tube. 3. After 3-4 drops of blood fall off the full capillary into the microtainer, you have enough blood. (150-250 ul) 4. Turn capillary/tube unit immediately in a vertical position to allow the blood to flow into the tube. 5. Remove capillary with holder at the same time. Close microtainer with attached cap. 6. Agitate the specimen to mix the anticoagulant through the blood. 7. Properly label with patient's name. Place in appropriate storage until shipping. 8. Specimens must be received in the Laboratory within 2 weeks, however, immediate shipping is recommended to ensure specimen integrity and suitability for analysis. FOR ADDITIONAL INFORMATION SEE "SCOPE" OR CALL (919) 733-3937 DHHS 3707 (Revised 1/07) LABORATORY (Review 7/09)

FACTS: Childhood Lead Poisoning Lead poisoning is a major public health problem affecting nearly half a million children under the age of six. Lead poisoning is caused when lead, a metal, gets into the body and builds up to dangerous levels. What can you do? Get your child tested. Lead Poisoning Effects Learning and behavior problems Brain damage Hearing loss Anemia Seizures, coma and death Lead poisoned children often do not look sick, so the best way to know is to have a blood lead test. Lead Sources Lead paint (found in homes built before 1978) Plastic/vinyl mini-blinds Water that comes through lead -soldered pipes Soil contaminated with lead Toys recalled for lead Workplaces that use lead How can I prevent lead poisoning? Make sure your children wash their hands often. Feed your children a healthy diet. Nutritious foods high in iron, calcium Vitamin C and zinc can prevent problems. Don t use ceramic dishes or pottery for food unless you know they are lead free. Less developed countries still commonly use lead products. It is especially important for children born in such countries to be tested. Keep your house clean. Wash window sills and floors regularly with soapy water to clean lead dust, and wash anything your children put in their mouth if it falls to the floor. For more information contact: NC Lead Hotline: 1-888-774-0071 or Your Local Health Department cehs.sph.unc.edu Amy MacDonald, Coordinator NC Childhood Lead Poisoning Prevention Program (919) 966-2463 amyjmac@email.unc.edu

HECHOS: El Envenenamiento de los Niños causado por el Plomo El envenenamiento por plomo es uno de los principales problemas de salud pública que afecta casi medio millón de niños menores de seis años de edad. El envenenamiento por plomo se ocurre cuando el plomo, un metal, entra al cuerpo y se aumenta a niveles peligrosos. Qué puede hacer usted? Pídale al doctor que haga una prueba del plomo en la sangre de sus niños. Los niños envenenados por plomo no aparecen enfermos así que la mejor manera para asegurarse de la salud de su niño es hacer una prueba del plomo en la sangre. Los Efectos del Envenenamiento por Plomo Problemas de aprendizaje y comportamiento Daño cerebral Pérdida del oído Anemia Ataques, coma, y muerte Fuentes del Plomo La pintura a base de plomo (se encuentra en cases construidas antes de 1978) Las persianas de plástico El agua que llegue por tubería con soldadura de plomo La tierra contaminada por plomo Los juguetes retirados por plomo Los lugares de trabajo que utilizan el plomo Cómo puedo prevenir el envenenamiento por plomo? Asegúrese que sus niños laven sus manos frecuentemente. Déles a sus niños de comer una dieta sana. Alimentos ricos en hierro, calcio, vitamina C, y zinc pueden prevenir problemas. No se utilice las cerámicas para comer a menos de que esté seguro que no contienen el plomo. Algunos países extranjeros utilizan productos que contienen el plomo. Es muy importante que los niños nacidos en estos países tienen pruebas del plomo en la sangre. Mantenga una casa limpia. Lave los antepechos de las ventanas y los pisos a menudo con agua jabonoso para limpiar el polvo de plomo. Lave cualquier cosa que pongan los niños en sus bocas si haya caído en el piso. Para más información se encuentra: La línea telefónica gratuita del Plomo en Carolina del Norte: 1-888-774-0071 El Departamento de Salud en su localidad o cehs.sph.unc.edu Amy MacDonald, Coordinadora El Programa de Prevención del Envenenamiento por Plomo en Carolina del Norte (919) 966-2463 amyjmac@email.unc.edu

Lead Poisoning and Your Child s Eating Habits Lead is a metal that can harm your child. Even a little lead can cause affect your child s growth and learning. Large amounts of lead can damage the brain, nervous system and kidneys. Some of these health effects may be permanent. Lead also makes it hard for your child s body to use good minerals and vitamins like iron, calcium and Vitamin C. 1. Get Your Child Tested for Lead. The only way to know if your child has a lead problem is to get a blood lead test from a doctor or nurse. A healthy diet is one way to prevent lead poisoning. 2. Feed Your Child Good Foods. Feed your child at least 3 meals and 2 snacks each day. Include foods high in: Iron chicken, turkey, greens, iron-fortified cereals and breads Calcium low-fat milk, cheese, yogurt, and greens Vitamin C oranges, red and green peppers, strawberries and potatoes Zinc brown rice, oatmeal, lentils, fish and eggs 3. Keep Your Child Safe from Lead. Wash hands before eating. Make sure your child doesn t eat peeling paint, dust, dirt or things that aren t food. Let water run for 15-30 seconds before you use it. Never use hot water from the faucet to prepare food. Don t store food in open cans. Use a plastic or glass pitcher to store juice, not pottery or ceramic pitchers. Rinse all fresh fruit and vegetables in cool running water before eating or cooking. A full stomach helps the body take in less lead. Wash hands regularly to prevent lead dust from entering your child s body. cehs.sph.unc.edu Amy MacDonald, Coordinator NC Childhood Lead Poisoning Prevention Program (919) 966-2463 amy.macdonald@unc.edu NC Lead Hotline 1-888-774-0071

El Envenenamiento por Plomo y Los Hábitos de Alimentación de Su Niño El plomo es un metal tóxico que puede hacer daño a su niño. Aún un poquito de plomo puede afectar el crecimiento y el aprendizaje de su niño. Una gran cantidad de plomo puede hacer daño al cerebro, el sistema nervioso, y los riñones. Algunos de estos efectos pueden ser permanentes. El plomo también hace difícil que el cuerpo de su niño utilize los minerales saludables y vitaminas como el hierro, el calcio, y la vitamina C. 1. Pídale al doctor que haga una prueba del plomo en la sangre de su niño. La única manera para saber si su niño ha sido afectado por el plomo es obtener una prueba de plomo en la sangre de un doctor o un enfermero. Una dieta saludable es una manera para prevenir el envenenamiento por plomo. 2. Déle a su niño de comer alimentos saludables. Déle a su niño de comer por lo menos 3 comidas y 2 meriendas cada día. Incluya comidas ricas en: Hierro pollo, pavo, verduras de hoja verde, cereales y panes fortificados con hierro Calcio leche baja en grasa, queso, yogur y verduras de hoja verde Vitamina C naranjas, pimientos rojos y verdes, fresas y papas Un estomago lleno ayuda al cuerpo para reducir la absorción de plomo. 3. Mantenga a su niño salvo del plomo. Lave las manos antes de comer. Asegúrese de que su niño no coma pintura que está despellendose, polvo, tierra o cosas que no son alimentos. Deje correr el agua del grifo durante 15 o 30 segundos antes de utilizarlo. Nunca utilice agua caliente del grifo para preparar la comida. No guarde la comida en latas abiertas. Utilice una jarra de plástico o vidrio para guardar el jugo. No lo guarde en jarras de cerámica o barro. Enjuagar todas las verduras y frutas en agua fresca antes de comer o cocinar. Lave las manos de sus niños frecuentemente para prevenir que el polvo del plomo entre al cuerpo de su hijo. cehs.sph.unc.edu Amy MacDonald, Coordinadora El Programa de Prevención del Envenenamiento por Plomo en Carolina del Norte (919) 966-2463 amy.macdonald@unc.edu Número Telefónico: 1-888-774-0071

Lead-Safe Toys for North Carolina Children Prepared by the N.C. Childhood Lead Poisoning Prevention Program Lead can cause permanent damage, especially to children under the age of 6. Children exposed to lead can have: Stunted growth. Mental problems like low IQ and/or learning problems. Severe lead poisoning, which can cause seizures, coma and even death. Lead can be in: Paint on toys. Plastic parts of toys. Lead-based paint that is still in older homes. Paint can chip or form a harmful dust. Dust from toys that have lead in them or lead-based paint on them. Lead dust cannot be seen and has no smell. Soil, vinyl mini-blinds, imported candy, lead-glazed pottery, fishing tackle and some home remedies, such as azarcan and greta. Drinking water pipes with lead-based solder. What can I do? Find out if your child s toys have lead. Call the Consumer Product Safety Commission or check out its Web site at www.cpsc.gov. This agency can tell you about recalls of toys with lead and where to send a toy to be tested (Note: testing damages the toy so it may not be returned). Ask your doctor to do a simple blood test. It s the only sure way to know. There is no safe level of lead in a child. Give your child a full, healthy diet with lots of calcium and iron such as milk, cheese, broccoli, collards, canned salmon and meats. Do not drink, cook or make baby formula with water from the hot-water tap. Run the cold water for 15 30 seconds before you use it to flush lead from pipes. Wash your child s hands often, especially before they eat and after playing outside to help prevent lead poisoning. Children can be exposed to lead by putting toys in their mouths or by playing with contaminated toys. Wash children s hands often to remove lead.

What about home testing kits? Do not trust home testing kits. They don t always show that lead is present when it actually is. What should I do with contaminated toys? If a toy is recalled, return it to the manufacturer. Throw the toy out do not donate it to a charity. Be sure to clean any other toys that were near the toy to remove lead dust. What are some tips for buying lead-safe toys? Check for recalled toys with CPSC before you shop. Check CPSC to see which toy manufacturers are doing voluntary lead testing. Look at where the toy was made (some toys made in China have had lead in them). Throw away toys with chipped paint or cracked plastic. Do not buy metal toy jewelry, such as toys in vending machines. It can be hard to tell if your child has lead poisoning. Symptoms are not always present. Some common symptoms are: headache stomachache vomiting diarrhea muscle weakness irritability tiredness aggressiveness hyperactivity loss of appetite Keep your child safe from lead! Learn more from N.C. Childhood Lead Poisoning Prevention Program: Call the Lead Hotline with questions. 1-888-774-0071 (toll free) N.C. Children s Environmental Health Branch: www.deh.enr.state.nc.us/ehs/children_health/lead/lead.html Check for recalled toys by the Consumer Product Safety Commission: www.cpsc.gov Center for Environmental Health and Susceptibility: cehs.sph.unc.edu Don t buy low-cost metal toy jewelry. It can be hard to detect lead poisoning. There is no safe level of lead in a child.

Juguetes Libres de Plomo Para los Niños de Carolina del Norte Preparado por el Programa de Prevención del Envenenamiento con Plomo en Carolina del Norte El plomo puede causar daño permanente, especialmente a los niños menores de 6 años. Los niños expuestos al plomo pueden tener: Crecimiento impedido. Problemas mentales como CI bajo y problemas de aprendizaje. Envenenamiento grave con plomo, lo que puede provocar ataques de apoplejía, coma, o muerte. El plomo se encuentra en: La pintura en los juguetes. Las partes plásticas de los juguetes. Pintura basado con plomo que permanence en las casas viejas. Pintura rasgada o cascada puede crear polvo venenoso. Polvo de juguetes que contienen plomo o que están pintados con pintura basado con plomo. El polvo del plomo no se ve y no tiene olor. El suelo, las persianas de vinilo, dulces importados, cerámicas de barro con vidriado de plomo, aparejos de pesca y algunos remedios caseros, como azarcón y greta. Tuberías de agua con soldadura de plomo. Qué puedo hacer? Entérese si los juguetes de su niño contienen plomo. Llame a la CPSC (Comisión de Seguridad de los Productos para los Consumidores) o visite a la pagina del Internet www.cpsc.gov. Esta agencia puede informarle sobre los juguetes retirados del mercado y donde puede mandar un juguete para ser revisado. (La prueba para el plomo puede dañar el juguete, y es posible que no le devolverán el juguete). Pregúntele a su doctor que le administre a su niño una prueba sencilla para detectar el plomo en la sangre. Es la única manera de estar seguro. No hay un nivel sano de plomo en un niño. Déle a su niño una dieta sana y completa con comidas que contienen calcio y hierro como leche, queso, broccoli, verduras con hojas verdes, salmón enlatado, y carne. No tome, cocine, o haga fórmula infantil con agua caliente de la llave de agua.. Deje correr el agua fría por 15 30 segundos antes de usarla para eliminar el plomo de las tuberías. Lave las manos de sus niños con frecuencia, sobre todo antes de que coman y después de jugar afuera. Niños pueden ser expuestos al plomo cuando ponen los juguetes en la boca o cuando juegan con juguetes contaminados. Lave las manos de sus niños con frecuencia para quitarse el plomo.

Y qué de las Home Testing Kits (pruebas que se pueden comprar para hacer en casa)? No confíe en los Home Testing Kits. No siempre muestran que el plomo esta presente. Qué debo hacer con los juguetes contaminados? Si un juguete está retirado del mercado, devuélvalo al fabricante. Tire el juguete a la basura no lo done a una organización benéfica. Asegúrese de limpiar bien cualquier otro juguete que estuvo cerca del juguete contaminado para quitar cualquier polvo de plomo. Cuáles son las recomendaciones para comprar juguetes libres del plomo? Antes de comprar juguetes, consulte el CPSC para ver los juguetes retirados. Consulte el CPSC para ver cuáles fabricantes están chequeando sus propios juguetes. Note dónde se hizo el juguete (algunos juguetes hecho en China han contenido plomo.) Bote los juguetes con pintura rasgada o plástico cascado. No compre joyería barata hecha de metal, como juguetes que se compran en máquinas. Puede ser difícil saber si su niño ha sido afectado por el plomo. Los síntomas no siempre están presentes. Algunos síntomas comunes son: No compre joyería barata hecha de metal. Puede ser difícil detectar el envenenamiento con plomo. *dolor de cabeza *dolor del estómago *vomitós *diarrea *debilidad muscular *inquietud *cansancio *comportamiento agresivo *hiperactividad *pérdida del apetito Mantenga a su hijo libre del plomo! Aprenda más del Programa de Prevención del Envenenamiento con Plomo en Carolina del Norte Llama al Línea del Plomo con preguntas: 1 888 774 0071 (llamada gratis) No hay un nivel seguro de plomo en un nino. Para mas información, visite el sitio Internet de la CPSC a la http://www.cpsc.gov o las páginas en español a http://www.cpsc.gov/cpscpub/spanish/spanish.html N.C. Children s Environmental Health Branch: www.deh.enr.state.nc.us/ehs/children_health/lead/lead.html Center for Environmental Health and Susceptibility: cehs.sph.unc.edu

For more information: Call your child s doctor or your local health department. Are You Pregnant? Protect your baby from lead poisoning. Division of Environmental Health Children s Environmental Health Branch (888) 774-0071 State of North Carolina Beverly Eaves Perdue, Governor Department of Environment and Natural Resources Dee Freeman, Secretary 41500 copies of this public document were printed at a cost of $2,666.89 or $0.06426 per copy. Protect your baby from lead poisoning. Lead poisoning is caused by breathing or swallowing lead. Lead can pass from a mother to her unborn baby. Ask your medical provider if you are at risk for lead poisoning. You may need a blood test to find out if you have lead in your body that could affect your pregnancy.

Why is lead harmful? Lead can put you at risk for miscarriage. Lead can cause your baby to be born too early or too small. Lead can hurt your baby s brain, kidneys and central nervous system. Lead can cause your child to have learning or behavior problems. Questions? Call (888) 774-0071 Where is lead found? Paint and dust in older homes, especially dust from renovation or repairs. Candy, make-up, glazed pots and folk medicine made in other countries. Worksites involving battery manufacturing, construction, furniture refinishing, automotive repair and plumbing. Soil and tap water. Vinyl mini-blinds. What can I do to protect myself and my baby? Eat foods high in calcium, iron and vitamin C. Calcium: milk, yogurt, cheese and green, leafy vegetables such as spinach. Iron: red meat,beans, iron-fortified cereals, raisins and spinach. What should I do to avoid lead? Avoid lead dust. Avoid certain hobbies. Furniture refinishing, stained-glass and jewelrymaking may expose you to lead. Avoid using imported ceramic pottery. Do not use dishes that are chipped or cracked. Use caution when eating candies, spices and other foods that have been brought into the country. Use a damp cloth to dust, and mop to keep lead dust cleaned up. If you are pregnant, do not stay in the house during painting or remodeling of a room with lead paint. Talk to your provider about medicines and vitamins. Some home remedies and dietary supplements may have lead in them. Tell your provider about any cravings you are having, such as eating dirt or clay, because they may have lead in them. Vitamin C: oranges, green and red peppers, broccoli, tomatoes and vitamin C-fortified fruit juices. Wash your hands, especially before you eat. This will keep lead dust you may have touched from getting into your body.

Los riesgos en el hogar pueden (onducir a problemas de salud serios para los nifios. Plomo EI plgrno se encuentra en la pintura de casas pintadas antes del 1978, en canerias, en persianas de vinil, en tierra y juguetes. ~y enenamiedtq par P1om.a puede causar problemas de porvida, de aprendizaje, crecimiento ycomportamiento en los nirios. Moho Techos que goterean, canerfas, a ires acondicionados loca lizados en ventanas y satanos pueden generar el crecimiento dem,gho.. EI Moho causa alergias y asma. Pesticidas Si se usan sin precauci6n, algunos,pesticjdas pueden causarenyeneoamieoto, defectos de nacimiento, darios a los nervios y hasta cancer... Calidad del A ire Interior Aaentes ' potamjnantes generados del humo del tabaco, ve las perfumadas, muebles nuevos, tapetes/alfombras y algunos productos para la limpieza pueden hacer que el respirar el aire sea eeliqroso. Seguridad en el Hogar Ninos pequenos y adultos de edad avanzada son los mas propensos a lastjmarse en la casa debido a cafdas, fuegos, envenenamiento, asfixia, ahogarse, estrangu lamiento, 0 por armas de HEArTH~ OMES

pasos TENER UN hagar saludable del Plomo. i vive en una casa construida antes de 1978, haga que su hijo/a y hagar sean evaluados contra el contenido de plomo. L:lvele las manos a su hijo/a frecuentemente. No trate de quitar el plomo par usted mismo, cant rate a un contratista que 10 haga sin peligro. Nunca barra, aspire 0 lim pie el paiva con un trapo seed en un cuarto donde haya pintura con plomo-use metodos humedos. N.C. Lead: www.deh.enr.state.nc.us/ehs/childrenhealth /i ndex.html ~ EUmine Fuentes de humedad y remueva el moho este visible. Repare goteras paredes, puertas yventanas. Mantenga las superficies limpias y secas. No deje agua acumulada en vasijas, s6tanos y aires acondicionados. Use un ventilador 0 una ventana abierta en el banc cuando se bane. Ventile la secadora de ropa hacia afuera de la casa. Incremente el paso de aire donde no 10 halla. N.C. Salud Publica: www.eplstate.nc.us/epiloii/ mo ld/ ~ Maneje las Plagas con mucho Cuidado. Selle las grietas y huecos en su casa. Limpie la cocina y lave los platos sucios inmediatamente. La tapa de la basura debe estar bien sellada. De ser necesario, use trampas para plagas y evitan usar insecticidas de en forma de aereosor. Mantenga los insecticidas fuera del alcance de los nin~s, lea y siga las instrucciones en las etiquetas. Proteja su piel, ojos y pulmones y lavese las manos despues de usarlos. N.C. Salud Ambiental Manejo de Plagas: www.d eh.enr.state.nc. us/php m/index.ht m el Aire Interior. ventanas 0 use ventiladores para dejar entrar aire fresco despues de usar cualquier quimico. Airee tapetes y muebles nuevos antes de entrarlos a su hogar. Use velas y aerosoles que emiten perfumes muy de vez en cuando. Controle las plagas y el polvo. Hogares limpios son hogares sanos. U.S. Agenda para la Protecdon Ambiental: www.epa.gov/iaq/ ~ Use un Plan de Seguridad su HtJtJtJ'. Desarrolle un plan de seguridad de casa en caso de evacuaci6n. Prevenga tropezones y caidas, limpiando rapidamente 10 que se encuentre en el suelo y usando alfombras que no se deslicen. Guarde materiales que puedan causar envenenamiento bajo liave. U.S. Departamento de Vivienda y Desarrollo Urbano: www.hud.gov/offices/lead/ hea lthyho mes/ho mesafety.cfm Informacion obrenida de: Cirujano General de los Es tados Unidos, Pedido para la Promocion de Hogares Sail os Departamento de Vivienda y Desarrollo Urbano de los Es tados Unidos Age/Kia para la Proteccioll Ambielltal de los Estados Unidos Aprenda mas visitando: www.nchealthyhomes.com AVA NCDENR

GREEN CLEANING You can clean your entire house and save money with these basic ingredients: White vinegar: An antifungal that also kills germs and bacteria. Baking soda: Eliminates odors and works as a gentle scouring powder. Borax: Eliminates odors, removes dirt, and acts as an antifungal and possible disinfectant. Use with care around children and pets, as it can be toxic if swallowed. Hydrogen peroxide (3% concentration): A nontoxic bleach and stain remover. Club soda (fresh): A stain remover and polisher. Lemon juice: A nontoxic bleaching agent, grease-cutter, and stain remover. Liquid castile soap: An all-purpose cleaner, grease-cutter, and disinfectant. Corn meal: Used to pick up carpet spills. Olive oil: A furniture polish. Why Clean Green? US EPA reports that levels of air pollution can be 2-5 times higher inside the home than outside. Using green cleaners is one way to make your air safer to breathe. Find more information on indoor air quality at: www.epa.gov/iaq/ For more information on healthy homes, visit www.nchealthyhomes.com

Recipes for a Healthy Home Multi-Purpose Cleaner 2 Tbsp. white vinegar 1 tsp. borax Hot water 1/4 cup of liquid castile soap 16 oz. spray bottle essential oil (optional) Combine white vinegar and borax in a 16 oz. spray bottle. Fill the rest with hot water and shake until the borax is dissolved. Next, add liquid castile soap. Shelf Life: indefinite Bathroom Surfaces For tough jobs: baking soda or borax (scouring powder, wear gloves when scrubbing then rinse well) Shelf Life: indefinite For a softer scrub: ½ cup baking soda castile soap (add enough to achieve a frosting-like consistency) Shelf Life: Use and discard. For plumbing fixtures: club soda Shelf Life: indefinite Carpet club soda cornmeal (for big spills) Club soda will remove many acidic stains, like coffee, wine, or juice. For larger carpet spills, pour cornmeal on the spill, wait 15 minutes, then vacuum with a wet/dry vacuum. Shelf Life: indefinite (if not stone ground cornmeal) Hard Floors 1/4 cup liquid castile soap up to 1/2 cup white vinegar or lemon juice 2 gallons of warm water Combine 1/4 liquid castile soap, up to 1/2 cup white vinegar or lemon juice, and 2 gallons of warm water in a large plastic bucket. Use with a mop or sponge. Always follow manufacturer s instructions on special flooring. Shelf Life: Use and discard. Glass club soda 1 tsp. lemon juice (optional) spray bottle Pour club soda in a spray bottle. Add 1 tsp. of lemon juice to increase your window cleaner s degreasing power. Shelf Life: indefinite (if lemon juice is added, refrigerate or discard after use) Wood Furniture Polish olive oil Dab olive oil onto a soft cloth and rub on wood surface. Shelf Life: indefinite baking soda water Oven Cover the oven floor with baking soda, spray with water until very damp, and let set overnight. Spray with water every few hours before you go to bed to keep damp. In the morning, clean out the baking soda, and the stuck-on gunk will be loosened and ready to scrub off. Shelf Life: Use and discard. Toilet baking soda or borax or white vinegar Sprinkle baking soda or borax and let sit overnight. Or, pour white vinegar into the toilet, and let sit for a few minutes. Scrub with a toilet brush. Shelf Life: indefinite There are many green cleaning recipes to try. These recipes were collected from: -Green Clean by Linda Mason Hunter & Mikki Haplin -Green Up Your Clean Up Jill Potvin Schoff -Clean House, Clean Planet by Karen Logan -www.care2.com/greenliving/make-your-ownnon-toxic-cleaning-kit.html Always follow any manufacturer instructions for cleaning special surfaces in your home. If in doubt, test a small area first.

HOGARES SALUDABLES DE CAROLINA DEL NORTE LIMPIEZA VERDE Usted puede limpiar toda su casa y ahorrar dinero con éstos ingredientes básicos: Vinagre blanco: Un antifúngico que también mata a los gérmenes y bacterias. Bicarbonato de soda: Elimina olores y trabaja suavemente como un detergente en polvo. Bórax: Elimina olores, remueve la fuciedad y actúa como un antifúngico y posible desinfectante. Úselo con cuidado alrededor de los niños y las mascotas, pues puede ser tóxico si se ingiere. Peróxido de hidrógeno (3% de concentración): Un blanqueador no tóxico y removedor de manchas. Soda club (fresca): Un removedor de manchas y pulidor. Jugo de limón: Un agente blanqueador no tóxico, corta grasa y remueve manchas. Jabón de castilla líquido: Un limpiador para todo uso, corta grasa y desinfecta. Harina de maíz: Se usa para recoger los derrames en las alfombras. Aceite de oliva: Un lustrador de muebles. Por qué limpieza verde? US EPA reporta que los niveles de contaminación en el aire pueden ser de 2 a 5 veces más alto dentro del hogar que afuera. Usando limpiadores verdes es una forma de hacer el aire de su hogar más sano de respirar. Encuentre más información acerca de la calidad del aire adentro en: www.epa.gov/iaq/ Para más información sobre hogares saludables, visite www.nchealthyhomes.com

Recetas para un hogar saludable Limpiador Múltiple 2 cdas. de vinagre blanco 1 cta. de borax Agua caliente 1/4 tza. de jabón de castilla líquido botella de spray de 16 oz. Aceite esencial (opcional) Combine el vinegre blanco con el bórax en la botella de spray de 16 oz. Llena el resto con agua caliente y ágite hasta que el bórax se disvuelva. Después añada el jabón de castilla líquido. Expiración: indefinido Superficies del baño Para trabajos dificiles: bicarbonato de soda o bórax (utilice guantes para fregar y enjuague bien) Expiración: indefinida Para trabajos suaves: ½ tza. de bicarbonato de soda jabón de castilla (sodauficiente para obtener una consistencia de frosting) Expiración: use y bote Para las llaves de plomería: Soda club Expiración: indefinida Pisos De Madera 1/4 tza. de jabón de castilla líquido hasta 1/2 tza. de vinagre blanco ó jugo de limón 2 galones de agua tibia Combine 1/4 de jabón de castilla líquido, no más de 1/2 tza. de vinagre blanco ó jugo de limón y 2 galones de agua tibia en un cubo plástico grande. Use un trapeador o esponja. Siempre siga las instrucciones del manufactor en pisos especiales. Expiración: use y bote Vidrio Soda club 1 cta. de jugo de limón (opcional) botella de spray Vierta la soda de club en la botella de spray. Añada 1cta. de jugo de limón para aumentar el poder cortagrasa de su limpiador de ventanas. Expiración: indefinida (si jugo de limón es añadido, refrigere o bote después de usar) Oven bicarbonato de soda agua Cubra el fondo del horno con bicarbonato de soda, salpique con agua hasta que esté bien húmedo y déjelo durante la noche. Spray con agua ocasionalmente antes de ir a dormir para mantenerlo húmedo. En la mañana limpie el bicarbonato de soda y la suciedad pegada estará lísto para salir. Expiración: use y bote Inodoro bicarbonato de soda ó vinagre blanco Espolvoree bicarbonato de soda o bórax y déjelo reposar durante la noche. Ó vierta vinagre blanco en el inodoro y déjelo reposar unos minutos. Restriegue con un cepillo para inodoro. Expiración: indefinida Alfombra soda club harina de maíz (para derrames grandes) Soda club removerá muchas manchas acídicas como café, vino o jugo. Para derrames más grandes, vierta harina de maíz y espere 15 minutos con una mojada/seca aspiradora. Expiración: indefinida (si no es harina moilda en piedra) Lustrador para Muebles Aceite de oliva de Madera Unte aceite de oliva en un limpión y úntelo sobre las superficies de madera Expiración: indefinida Hay muchas recetas de limpiadores verde para tratar. Éstas recetas fueron extraídas de: -Green Clean por Linda Mason Hunter and Mikki Haplin -Green Up Your Clean Up - Jill Potvin Schoff -Clean House, Clean Planet por Karen Logan -www.care2.com/greenliving/make-your-own-nontoxic-cleaning-kit.html Siempre siga las instrucciones del manfactor para limpieza de superficies especiales en su hogar. Si tiene dudas, trate en un área pequeña primero.

ETHAN S HOUSE GETS HEALTHIER With a Visit from the Lead Poisoning Prevention Team

Prevent Lead Poisoning Get your child tested Get your home tested Get the facts http://www.cdc.gov/nceh/lead http://www.cdc.gov/healthyhomes/programs.html U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Environmental Health

Ethan s House Gets Healthier With a Visit from the Lead Poisoning Prevention Team Written by Joyce K.Witt, MPH, RN Illustrated by Robert Hobbs September 2012 Tips page adapted from health educational material from Philadelphia Lead Poisoning Prevention Program California Lead Poisoning Prevention Program CDC at http://www.cdc.gov/nceh/lead/tips.htm Reference: Lead Poisoning: Words to Know from A to Z HHS CDC 2011 Acknowledgements: Taran Jefferies and Nikki Walker

Dr. Hoot N. Owl told Irene that her son, Ethan, had lead in his blood. He asked if their home was built before 1978. 1

Many homes built before 1978 have lead paint on the inside and outside. When the lead paint gets old, it starts peeling or coming off in pieces. That is called chipping. Can you find the chipping paint? 2

Irene called her landlord to tell him about the chipping paint on their porch and windows. The landlord hired the Lead Poisoning Prevention Team to test the chipping paint for lead. The paint had lead in it! Leadbert, LaDonna and Leadfrey will fix the lead paint problem in the house. 3

Ethan is excited to go stay with his grandparents while the Lead Poisoning Prevention Team repairs the peeling and chipping paint in the house. It is dangerous for the family to be in the house while the workers fix the lead paint problem. Do you like to visit family? 4

Leadbert is a licensed contractor. He uses a spray bottle to wet painted areas with water before he scrapes so he doesn t create dangerous dust. 5

Leadbert wears coveralls and a special face mask so he won t breathe in lead dust while he works. This protects him from getting lead in his body. 6

Leadfrey cleans the house after Leadbert removes the chipping paint. Leadfrey wears a mask so he doesn t breathe in lead dust while he is vacuuming. He wears gloves so that he won t get lead dust on his skin while he works. 7

Leadfrey likes to clean lead dust from old homes. Leadfrey knows that it is important to wet wipe floors, window sills and play areas with a wet sponge or paper towel. 8

Paint companies cannot put lead in paint anymore. After Leadbert removes the old chipping paint and Leadfrey cleans up, LaDonna paints a fresh layer of paint, so the walls and windows are smooth. What colors would you paint this house? 9

Leadbert, Leadfry and LaDonna have finished their work. Now, the house does not have any chipping paint. The house has been tested and it has no lead dust. Now the family can move back into their house, because the work is finished. 10

The lead that got into Ethan s blood came from lead dust from old peeling paint. Now the house has new paint and the lead dust is gone. Ethan will be healthier. Ethan and his parents are very happy. 11

If the house or the building where your child spends a large amount of time, such as grandparents house or daycare, was built before 1978 and hasn t been tested, assume the building has lead paint. Tips to Prevent Exposure to Lead and Its Harmful Effects Talk to your state or local health department about testing paint and dust in your home for lead. Separate children from areas with lead dust and make sure your child cannot reach peeling paint. Block peeling paint or holes in walls by covering them with contact paper or duct tape. Close and lock doors to keep children away from chipping paint on walls. Keep your child s bed or crib away from chipping paint. Clean up loose paint chips with a wet mop. Do not dry sweep lead dust. Wet-mop floors and wet-wipe windows, sills and baseboards once a week. Keep children from playing in bare soil. Move play areas away from bare soil and away from the sides of the house that have chipping paint or lead dust. Plant grass on bare soil or cover the soil with mulch or wood chips. Keep indoor and outdoor toys separate. Wash toys, bottles and pacifiers regularly to remove lead dust and soil. Regularly wash children s faces and hands, especially before meals. Use only cold water from the tap for drinking, for cooking, and for making baby formula. Run water for at least one full minute when the water has been sitting in the pipes, such as first time in the morning. Some jobs leave lead on clothes. If your job exposes you to lead, shower and change clothes before you leave work. Do not wear work clothes in the family vehicle after work. Wash work clothes separately from family laundry. What to do during Renovation of Buildings and during Soil Remediation Stay out of houses built before 1978 when they are being renovated or during lead paint removal. This is especially important for children and pregnant women. Do not help with activities that disturb old paint or help clean up dust and paint chips after the work is finished.

Give a hoot! Prevent lead poisoning! Dr. Hoot N. Owl For more information, please contact your state or local lead poisoning prevention program:

Prelude to Nutritional Focus Article The following Nutrition Focus article Childhood Lead Poisoning and the Role of Nutrition was written in 2002 and therefore does not reflect the 2012 CDC recommendation to begin diagnostic (venous) testing for all children who have an initial blood lead test result 5 µg/dl. However, the article s information about the health effects of lead, sources and pathways of lead exposure in children, the role of nutrition, nutrition assessment methodology and lead poisoning prevention, education and intervention is still accurate and relevant for childhood lead poisoning prevention. NC CLPPP November 2012

Nutrition for children with special health care needs FOCUS Volume 17, No. 3 May/June 2002 Childhood Lead Poisoning and the Role of Nutrition Kathy Lamb, MS, RD, Nutrition Consultant Women s and Children s Health Section, Division of Public Health North Carolina Department of Health and Human Services Claudia S. Rumfelt-Wright, MSW, Public Health Educator Environmental Health Services Section, Division of Environmental Health North Carolina Department of Environment and Natural Resources BACKGROUND Childhood lead poisoning is a major, preventable, environmental health problem. The persistence of lead poisoning in light of present knowledge about the sources, pathways and prevention of lead exposure, continues to challenge clinicians and public health authorities. Lead has no known physiological value and children are particularly susceptible to its toxic effects. Most poisoned children have no apparent symptoms, and consequently, many cases go undiagnosed and untreated. Recent studies suggest that even blood lead levels (BLLs) below 10 micrograms per deciliter (µg/dl) can adversely affect children s ability to learn, and their behavior. No socioeconomic group, geographic area, racial or ethnic population is spared. The percentage of children ages 1-5 in the United States with elevated blood lead levels has decreased from 88.2% (1976 80) to 4.4% (1991 1994) according to data from the Second and Third National Health and Nutrition Examination Surveys (NHANES). However, the Centers for Disease Control and Prevention (CDC) estimate that approximately 890,000 children in the United States have blood lead levels >10 µg/dl. 1 Moreover, among U.S. children ages 1-5 who had BLLs >20 µg/dl, 83% were Medicaid enrollees, as were 60% of those with BLLs >10 µg/dl. 2 For some states, the Medicaid burden is even greater. For example, from 1998 to 2000 in North Carolina, more than 75% of children with BLLs >10 µg/dl were Medicaid enrollees. Unfortunately, while Medicaid children have a prevalence of elevated BLLs three times that of children in the same age group who are not Medicaid enrollees, 65% of them are not screened according to recent estimates by the Government Accounting Office (GAO). 3 As a result, the CDC recommended targeted screening for all high-risk children at ages one and two in 1998. An example of targeted screening is the establishment of different screening strategies for low and high-risk zip codes, based on the age of housing stock and the number of children with elevated BLLs. Editor s Note This edition is an update of an earlier Nutrition Focus, Lebeuf, JS and Norman, EH. Nutritional Implications of Lead Poisoning in Children. Nutrition Focus. Volume 8, #5, September/ October 1993. Lead poisoning is still a health problem for children and this issue provides current information about this continuing public health issue. Sources of lead exposure are listed in Table 1 and include lead-based paint, soil, house dust and drinking water. While leadbased paint is still the major source of exposure, the concern has shifted from children eating paint chips to ingestion of lead-contaminated dust. There have even been, through hand-to-mouth activities, documented cases of childhood lead poisoning resulting from a pet whose fur was contaminated with lead dust. Imported vinyl miniblinds made with a lead formula have poisoned children. The growing immigrant population in the United States is a challenge for public health professionals to be aware of the cultural differences and traditional products that may put these children at high risk. For example, many household items from Mexico have been found to contain lead including ceramic bean pots and tamarind candy. Some imported traditional medicines, aphrodisiacs and other herbal preparations have also been found to contain high levels of lead. HEALTH EFFECTS Severe lead exposure (>70 µg/dl) can cause lethargy, convulsions, coma and even death in young children. Lower levels can cause adverse effects on the kidneys, and the hematopoietic and central nervous systems. According to the CDC, even blood lead levels below 10 µg/dl, which do not cause specific symptoms, are associated CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON

with decreased intelligence and impaired neurobehavioral development. Other adverse effects begin at low levels of exposure, including decreased growth and growth velocity, decreased hearing acuity, decreased ability to maintain a steady posture and impaired synthesis of vitamin D. Lead also competes with iron for incorporation into the heme molecule and can contribute to iron-deficiency anemia. Epidemiologic studies provide ample evidence on the association between low-level lead exposure and the effects on child development. A recent study analyzed data on 4,835 children, ages 6-16 years, from the NHANES III. 4 The relationship between blood lead concentration and performance on tests of arithmetic, reading, nonverbal reasoning and short-term memory was assessed. The researchers found an inverse relationship between blood lead concentrations and deficits in cognitive functioning and academic achievement in children at levels below 5.0 µg/dl. Reading abilities were especially affected. Behaviorally, the study suggests that attention, judgment and decision-making abilities, visual-motor reasoning skills, and social behavior are particularly affected. These results argue for a reduction in blood lead levels that are considered acceptable. No detectable threshold for the adverse effects of exposure was found by these researchers. In a number of prospective studies, prenatal exposures have been associated with delayed sensory-motor and early cognitive development. However, these effects appear to diminish as children grow older, given low postnatal exposure and favorable socioeconomic conditions. 5 Table 1 Sources and Pathways of Lead Exposure in Children Lead-based paint: The most common source of lead exposure for young children is lead-based paint. The use of lead-based paint for homes, furniture and toys is now prohibited; however, it is still found in homes built before 1978, and homes built before 1950 can contain paint with high concentrations of lead exceeding 50% by weight. Soil and house dust: Contaminated by deteriorated paint, leaded gasoline and industry emissions, soil containing lead is found near the foundation of homes, in industrial areas and near major roads. The phase-out of lead in gasoline mandated by the EPA was completed in 1987. Remodeling and renovation, which is done without using lead-safe work practices, can generate lead dust. Dust in deteriorated window areas is often contaminated with lead. Ceramic ware: Imported and decorated dishes or handmade pottery can be frequent sources of lead for immigrants and others. Foods stored or served in leaded crystal or food cooked and/or stored in improperly fired ceramic dishes can contain lead. Drinking water: Water can be contaminated by plumbing in homes with lead pipes or copper pipes soldered with lead. Food and supplements: Some imported canned products, natural dietary supplements such as bone meal, and some calcium supplements such as dolomitic limestone and oyster shells, while not widely recommended for young children, can be a source of lead. Levels vary considerably from trace amounts to higher levels. Air: Emissions from active lead smelters and other lead-related industry can be inhaled. Occupations and hobbies: Workers may take home lead dust on their clothing or bring scrap material home from work with radiators, car batteries, dirt near freeways, paint removal, smelters and factories. Hobbies such as making stained glass, pottery, fishing weights, or jewelry; reloading or casting ammunition; and refinishing furniture are sources of lead. Traditional medicines: Folk remedies from Latin America used to treat empacho (upset stomach) such as greta and azarcon (also known as Rueda, Coral, Maria Luisa, Alarcon or Liga) have been found to contain more than 90% lead by weight. Pay-loo-ah is a reddish powder used by the Hmong to treat fever and rash. Some Chinese herbal remedies and teas have also been found to contain high levels of lead. Lead has also been found in aphrodisiacs imported from India and Africa. Cosmetics: Cosmetics used by some Indian, African and Middle Eastern immigrants such as surma and kohl contain lead. Vinyl Products: As they age and deteriorate, imported, lead containing vinyl mini-blinds may have lead dust on their surfaces. In 1996, the Arizona and North Carolina Departments of Health first alerted the U.S. Consumer Product Safety Commission (CPSC) to the problem of lead in the imported vinyl mini-blinds. Lead was added to stabilize the plastic in imported blinds. Using electron microscopy, it was confirmed that as the blinds deteriorated from sunlight and heat, lead-containing dust formed on the surface of the blind slats, posing a potential risk to young children. Young children can ingest lead by touching the mini-blinds and then putting their hands in their mouths, mouthing the window, or mouthing the blinds themselves. In some tested blinds, the levels of lead in the dust was so high that a child ingesting dust from less than one square inch of blind a day for 15 30 days could result in blood levels at or above 10 µg/dl. Children s vinyl toys may be another source of lead for young children. Studies done at the University of North Carolina in Asheville have demonstrated that as some soft vinyl toys are exposed to light and to chewing they can release lead as well as cadmium, another toxic heavy metal. This was particularly true among soft vinyl toys from Asia. Highest levels of cadmium were found in toys, soft lunchboxes and rainwear that were bright yellow. 6 2 Nutrition Focus Vol. 17 #3 May/June 2002

RECOMMENDATIONS FROM THE CENTERS FOR DISEASE CONTROL The CDC s level of concern remains at 10 µg/dl. Targeted screening, based on geographic areas or demographic populations of highest risk, is recommended. Some states screen by evaluating blood from a finger stick. If the level is equal to or greater than 10 µg/dl then a venous blood draw is the next step. All children receiving Medicaid are required to be tested at 12 and again at 24 months of age, or upon their first entry into the health care system at a later age. A multi-tier approach to follow-up is recommended (Table 2) 1. Children with blood leads <10 µg/dl at 12 months of age are not considered to have an elevated exposure, however, those at risk should be rescreened at 2 years of age. Table 3 lists questions to ask parents or caregivers to determine if a child is at risk for lead exposure. Additional questions may be added to tailor the questionnaire for likely sources of exposure in different communities (e.g., questions related to industry or traditional medicines). If the answers to all questions are negative, the child is considered to be at low risk for lead exposure. If the answer to any question is positive or I don t know, the child is considered high risk for lead exposure. Community-wide education (primary prevention activities) is recommended when many children in an area are found to have blood lead levels > 10 µg/dl. In most states, children with blood lead levels >10 µg/dl are medically eligible for participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC Program). Individual case management, including nutrition and education interventions (described below and in Table 5) and frequent retesting, is recommended for children with blood leads > 15 µg/dl. In many areas, families of children with BLLs >10 µg/dl are offered environmental investigations. More involved medical and environmental interventions are indicated for children with blood lead levels > 20 µg/dl. The medical evaluation consists of a careful history and a physical examination as well as evaluation of iron status and other special diagnostic tests. A medical evaluation should be conducted whether or not symptoms are present. Environmental interventions are aimed at identifying the source of exposure Table 2 Interpretation of Screening Test Results and Recommended Follow-up Blood Lead Level (µg/dl) Comments <10 A child with this Blood Lead Level (BLL) is not considered to have an elevated level of exposure. Reassess or rescreen in one year. No additional action is necessary unless exposure sources change. 10-14 The CDC considers 10 µg/dl to be a level of concern. Perform diagnostic test on venous blood within three months. If the diagnostic test is confirmatory, the child should have follow-up tests at three month intervals until the BLL is <10 µg/dl. Provide family lead education. Refer for nutrition counseling. 15-19 A child in this category should also receive a diagnostic test on venous blood within three months. If the diagnostic test is confirmatory, the child should have additional follow-up tests at three month intervals. Children with this level of exposure should receive clinical management. Parental education and nutritional counseling should be conducted. A detailed environmental history should be taken to identify any obvious sources of lead exposure. 20-44 A child with a BLL in this range should receive a confirmatory venous test within one week to one month. The higher the screening test, the more urgent the need for a diagnostic test. If the diagnostic test is confirmatory, coordination of care and clinical management should be provided. An abdominal x-ray is completed if particulate lead ingestion is suspected. Nutrition and education interventions, a medical evaluation, and frequent retesting (every 3 months) should be conducted. Environmental investigation and lead hazard control is needed for these children. 45-69 A child in this category should receive a confirmatory venous test within 48 hours. If the screening blood lead level is between 60-69 µg/dl, the child should have a venous blood lead level within 24 hours. If confirmatory, case management and clinical management should begin within 48 hours. Environmental investigation and lead hazard control should begin as soon as possible. A child in this exposure category will require chelation therapy and an abdominal x-ray is completed if particulate lead ingestion is suspected. >70 A child with a BLL >70 requires immediate hospitalization as lead poisoning at this level is a medical emergency. Confirmatory venous testing should be done as soon as possible. An abdominal x-ray is completed if particulate lead ingestion is suspected and chelation therapy should begin immediately. Case and clinical management including nutrition, education, medical and environmental interventions, must take place as soon as possible. Information from Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Offices. November 1997. Atlanta, Georgia. United States Department of Health and Human Services, Public Health Services, CDC, 1997 and Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Children: Recommendations from the Advisory Committee on ChildhoodLead Poisoning Prevention. March 2002 (home investigation) and reducing lead hazards (abatement or remediation). For BLLs > 20 µg/dl an abdominal x-ray is recommended if particulate lead ingestion is suspected. If positive, bowel decontamination is indicated. Chelation therapy (the administration of a drug(s) that bind with lead to remove it from the body) is recommended for children with BLLs >45µg/dL. 7 An oral chelating agent, succimer, that can be used on an outpatient basis, was approved for use in 3 Nutrition Focus Vol. 17 #3 May/June 2002

children with blood leads > 45 µg/dl. Chelation therapy may be considered if the BLLs are >25 µg/dl however recent studies concluded that this treatment offers limited benefits to children with BLLs < 45 µg/dl. A randomized, placebo-controlled, double blind trial of chelation therapy in 780 children with BLLs less than 45 µg/dl was undertaken by NIEHS at the Triangle Research Institute. In an article published in the New England Journal of Medicine, the researchers reported that treatment with succimer did not lead to better scores on cognitive, neuropsychological or behavioral tests than placebo. 8 Care must be taken to keep recently chelated children away from environmental lead hazards during outpatient chelation therapy, as this type of therapy increases internal lead mobilization and can increase the absorption of lead. THE ROLE OF NUTRITION Young children, particularly one- and twoyear-old children, are at greatest risk for lead poisoning due to their increased mobility and hand-to-mouth activity. With greater access to lead hazards and normal mouthing of hands and other items, there is greater ingestion of lead. Nutrition, in its broadest application, plays an integral role in young children s susceptibility to lead. Young children s dietary intake and nutritional status can influence the absorption, retention and effects of lead toxicity through total food intake and lead-nutrient interactions involving iron, calcium, Vitamin C, and zinc. In turn, lead can influence nutritional status through its effect on growth in stature, iron status and vitamin D metabolism. Table 3 Questions for Families to Assess the Risk of Exposure to Lead Does your child:! Receive the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Program Services or is your child enrolled in Medicaid?!Live in or regularly visit a house built before 1978, including home childcare centers or homes of relatives with peeling or chipped paint with recent, ongoing, or planned renovation or remodeling?!have a brother or sister, housemate, or playmate being followed or treated for lead poisoning (blood lead >15 µg/ dl)?!live in or regularly visit a house that contains vinyl mini-blinds? which is possibly due to the higher density of intestinal transport proteins during periods of growth. In turn, the effects of lead in children generally occur at lower blood lead levels than in adults. For example, the developing nervous system in children can be affected adversely at levels even below 10 µg/dl compared to adults. Consumption-Related Exposure to Lead Efforts to limit exposure to lead-containing paints, gasoline, and food and beverage containers have made a tremendous impact. The U.S. Food and Drug Administration s 1994-1996 Total Diet Studies showed that, since 1982-1984, daily intakes of lead from food dropped 96 percent in 2- to 5-year-olds (from 30 to 1.3 micrograms). 10 However, the most common source of lead exposure for young children continues to be deteriorating lead-based paint chips and dust inside and outside homes, particularly those built before 1950 when paint containing as much as 50% or more lead by weight was still widely used. Children can ingest loose paint as a result of pica (compulsive eating of nonfood items). line; consequently lead can be deposited on and retained by crops, particularly leafy vegetables. Lead in soil can also be taken up by plants as they grow. Lead glazes are used in making pottery and ceramicware which may be used for cooking or storage of food. Traditional pottery imported from Mexico or other countries often use glazes which may contain large amounts of lead. Foods stored in cans made with lead solder have been found to contain lead. For the last decade, lead solder in canning has been banned from use in the United States but other countries continue to use lead solder. This is particularly a problem with imported canned meats and acidic foods like tomatoes. If lead crystal is used for storing acidic beverages such as orange or tomato juice, the acid can facilitate leaching of lead into the beverage. It is estimated that drinking water contributes 10-20% of total lead exposure in young children. Typically, lead gets into the water supply after it leaves the treatment plant or well. The source of lead in homes is most likely leaded pipe or lead-soldered plumbing despite the Environmental Protection Agency s ban in 1988 on using lead solder and other lead-containing materials in connecting household plumbing to public water. Many older structures still have lead pipe or lead-soldered plumbing which may substantially increase the lead content of water at the tap. Also, lead solder is still widely available and may be misused. Calcium supplements from natural sources, such as dolomitic limestone and oyster shells, while not widely recommended for young children, can be a source of lead. Levels vary considerably from trace amounts to higher levels. Ingestion and Absorption of Lead in Young Children As previously defined in Table 1, some Lead poisoning begins with ingestion and traditional medicines which may contain lead inhalation of lead. Studies show that children may be used by immigrant families. Children absorb close to 50 percent of the lead who are given these powders may actually they ingest or inhale in contrast to adults be ingesting lead, and they may develop the who absorb only approximately 10 percent. same symptoms that these medicines are intended It is estimated that young children s absorption to treat. rates of lead from non-food sources exceed 50 percent. Rates are closer to 40 percent Human Milk when the lead source is infant formula, Lead levels in human milk are lower than milk, and other beverages. 9 Reasons for more would be expected based on maternal blood efficient lead absorption by young children lead levels. Lead s inability to attach to the include their lower body weights and the lack fat in human milk prevents it from becoming of effective mechanisms adults develop for When food contains lead, it may be from concentrated. However the Health Resources clearing lead once ingested or inhaled. Young the environment or from containers used for and Services Administration recom- children also have an enhanced capacity to food or beverage storage. Agricultural vehicles mends that women with blood lead levels of absorb lead from the gastrointestinal tract are not required to use unleaded gaso- 40 µg/dl or above not breastfeed their inmends Nutrition Focus Vol. 17 #3 4 fants. May/June 2002

Nutritional Influences on Lead Absorption There is wide individual variation in the gastrointestinal absorption of lead. Factors which impact absorption and susceptibility to lead toxicity include age, frequency of eating, quality of the diet, and nutritional status. The state of satiety affects lead absorption. When adults ingest lead on a full stomach, about 8% of the lead is absorbed compared to about 35% when ingested after a brief fast. 9 As previously stated, lead absorption rates are much higher in children. Absorption is further enhanced, and in many situations, exposure to lead occurs more frequently, in children who have not eaten recently. Children playing in lead-contaminated soil, eating paint chips or inhaling lead dust hours after their last meal are at significant risk. Parents and caretakers of young children should be encouraged to provide frequent meals and snacks to children at risk for lead exposure. Nutrients: Calcium, Iron, Vitamin C, Zinc and Fat Dietary recommendations which are typically made in an effort to help protect children from lead poisoning are still not consistently backed up with scientific evidence. These recommendations are not controversial from a nutrition point of view, and in fact, can be easily endorsed for all children regardless of their risk of lead exposure. But, care must be taken not to make assumptions about specific nutrients and their efficacy in helping prevent lead poisoning. Animal absorption studies have demonstrated that dietary calcium can decrease gastrointestinal lead absorption. Human studies in adult and children indicate there may be a direct interaction between lead and calcium which are consumed simultaneously, suggesting possible competition for absorptive sites in the gut. Furthermore, it has been postulated that when lead interferes with normal calcium absorption, normal growth and development may be affected. But the evidence is not strong enough to demonstrate that dietary calcium can actually reduce lead toxicity. It has been known for a long time that iron deficiency and lead toxicity frequently coexist. In the mid-1980 s, the American Academy of Pediatrics, in their Statement on Childhood Lead Poisoning, stated that Iron deficiency, even in the absence of anemia, appears to be the single most important predisposing factor for increased absorption of lead. 11 One theory for the association between iron and lead levels in the blood comes from the fact that the two are biochemically similar and symptoms of severe iron deficiency even mimic those of lead poisoning including lethargy, inattentiveness and delays in cognitive development. This theory has also postulated that the absence of iron creates a nutrient deficit in the body, which responds by grabbing more of the lead that is ingested by the child, or hanging onto the lead more strongly once it is in the body. However, as in the case of calcium, more recent studies indicate there is no strong evidence that increasing dietary iron will definitely decrease lead absorption and lead toxicity. Zinc status influences lead absorption at the gastrointestinal level. Animal research has demonstrated an increase in tissue lead levels and lead toxicity as dietary zinc content decreases. There is some clinical data associating zinc status and elevated lead levels in children. For proper brain development in children, the body relies on the trace mineral zinc to help regulate genes that coordinate brain cell growth. In findings that shed new light on understanding how lead affects the developing brains of children, researchers believe that when lead is introduced into the body in sufficient quantities, it displaces zinc and ultimately disrupts brain cell growth. Although several animal studies suggest a protective relationship between blood lead concentrations and ascorbic acid, there are no conclusive results regarding the beneficial effect of vitamin C on lead concentrations in human studies. Serum ascorbic acid concentrations were inversely associated with the prevalence of elevated blood lead concentrations, but there was no significant relationship between dietary vitamin C intake and blood lead Table 4 NUTRITION ASSESSMENT FOR CHILDREN WITH ELEVATED BLOOD LEAD LEVELS Anthropometric Assess growth parameters including: - weight-for-age - appropriate rate of weight gain if indicated - length/height-for-age - weight-for-length for infants and children < 2 years, or BMI children > 2 years of age - calculate mid-parental height if height-for-age is below the 5 th percentile Biochemical - Assess test results for blood lead level - Review tests for iron deficiency Clinical - determine nutritional implications of medical management of lead toxicity Dietary Assess dietary intake for: - adequate food supply - number of meals and snacks eaten on a typical day - water supply and usage patterns for infant formula, beverages and foods - adequacy of calcium iron, and zinc, and vitamin C intake - food storage techniques - use of imported canned foods/candy - use of traditional medicines that might contain lead Ecosocial - Review findings from environmental assessment if available - Ask questions regarding pica or excessive mouthing behaviors - Assess home sanitation: - meal preparation area - hand washing practices - washing pacifiers/bottle nipples/toys 5 Nutrition Focus Vol. 17 #3 May/June 2002

concentrations. There is however enough evidence to support the beneficial effect vitamin C has on iron absorption thereby improving iron status and helping prevent lead absorption. 12 Fat Intake There is limited scientific evidence showing that increased intakes of dietary fat increase absorption and retention of lead. Dietary fat intake was found to enhance the absorption of lead in animal studies but these results have not been replicated in children. PREVENTION, EDUCATION AND INTERVENTION Primary Prevention Public health departments and health care practitioners should, at a minimum, support, oversee, and monitor the activities necessary to prevent childhood lead poisoning. Primary prevention activities include public education and providing anticipatory guidance to families about the causes of lead poisoning. Participation of young children in targeted public health programs, such as the WIC Program, has helped lead poisoning prevention and detection efforts. Nutrition education, referrals and supplemental foods are the cornerstones of helping families; and foods provided by WIC are nutritious and include nutrients previously mentioned. A study published in 1998 used data from the 1989-1991 Continuing Survey of Food Intakes by Individuals (CSFII) conducted by the U.S. Department of Agriculture. The study found that the WIC Program had major effects in improving nutrient intakes among low-income preschoolers. 13 WIC had significantly positive effects on preschoolers intakes of ten nutrients including three of the four nutrients most frequently deficient in the diet of preschoolers iron, zinc, and vitamin E. The researchers noted that iron deficiency is the single most prevalent nutritional deficiency in the United States and that anemia rates are still high among young low-income children. They also noted that previous studies indicate zinc deficiencies may be related to growth retardation. Table 5 Preventing Lead Poisoning in Young Children - Guidelines for Education, Nutrition and Hygiene Recommendation Offer young children breakfast and other meals and snacks at regular, well spaced intervals, such as every 2-3 hours. Ensure that young children s daily intake of calcium, iron,vitamin C, and zinc meet recommendations. Use fully-flushed cold water for drinking and food preparation. Store food and beverages in glass, plastic or other lead-free containers Avoid use of traditional medicines which have been found to contain lead, such as: azarcon, greta, payloo-ah Be aware of and limit opportunities for pica. Also keep children from chewing on or licking anything painted like windowsills. Wash the child s hands and face before every meal and snack. Wash toys, pacifiers and cups after each time they fall on the floor or ground. Discourage cruising while eating meals or snacks. Food needs to be eaten at a clean table or kitchen counter under the supervision of an adult. Rationale Lead is more readily absorbed when the body is in a fasting state, such as when the body has been without food for an extended period (e.g. after a night s sleep). Children exposed to lead absorb less when they have recently consumed food. Children with diets adequate in these nutrients may absorb and retain less lead than children with inadequate intakes. Lead or lead-soldered pipes leach lead into the water supply. Hot tap water leaches more lead from pipes and pipe solder than cold water. Water that has been sitting in the pipes for several hours or overnight has higher lead levels than water from flushed pipes. If the cold water hasn t been used for more than two hours, run it for 30-60 seconds before drinking it or using it for cooking. Lead soldered cans (used sometimes for imported foods), improperly glazed ceramic pottery, and lead crystal can contribute to a child s overall lead level. Food stored in or regularly consumed from leaded containers may contain significant amounts of lead. Traditional medicines may contain significant amounts of lead and cause the same symptoms for which they are taken in addition to contributing to elevated lead exposure Pica, or the consumption of non-food items such as paint chips or lead-contaminated soil, is the leading cause of lead poisoning in young children. Children may ingest lead from places which have been painted with lead-based paint. Hand and face washing before eating cuts down on the possibility of lead-laden dust being transferred to the food and into the child s mouth. Washing items which go into the child s mouth will also decrease the amount of dust and dirt ingested. Food eaten on the run gets dropped on the floor, dragged over furniture, or placed on a window sill and then retrieved and eaten along with the potentially lead-laden dust it has collected. 6 Nutrition Focus Vol. 17 #3 May/June 2002

Secondary Prevention Secondary prevention activities include conducting blood lead level screenings, providing medical management when problems are identified and providing education to manage lead poisoning and prevent further lead exposure. In most of the target communities in North Carolina, for example, families of children with elevated BLLs receive a home visit, a cleaning kit and instructions on how to do specialized cleaning to remove lead dust. Clinical management of individuals with elevated BLLs includes a nutrition assessment, obtaining the ABCDE parameters: anthropometric, biochemical, clinical, dietary, eco-social. See Table 4. Within these parameters are areas which warrant special consideration when assessing the nutritional status of children exposed to lead or at high-risk for lead poisoning. Secondary preventive measures include nutrition education and counseling aimed at: ensuring an intake of calcium, iron, Vitamin C, and zinc sufficient to meet daily requirements ensuring the young child s total dietary intake over three meals and at least two snacks preparing infant formula, beverages and foods with cold tap water from fully flushed pipes storing foods in lead-free containers washing hands before eating, and cleaning bottle and pacifier nipples, and toys each time they fall on the ground limiting opportunities to eat non-food items such as lead-contaminated soil or lead-based paint chips. Table 5 provides additional guidelines for the prevention of lead poisoning in young children. SUMMARY Lead is the number one environmental pollutant affecting the health of children in the United States. The CDC guidelines were developed in response to evidence that blood lead levels even below 10 µg/dl in young children are associated with decreased intelligence, impaired neurobehavioral development, decreased growth in stature, decreased hearing acuity, and other adverse effects. There is a growing body of evidence that levels as low as 2.5 µg/dl are associated with decreased reading skills and antisocial behavior. No lower limit or threshold has been established below which no health effects occur. It is imperative that pre-school children be tested for lead poisoning, especially at ages 1 and 2 years. Healthcare and education professionals as well as parents and caretakers of young children should be informed about the sources of lead exposure and trained in both primary and secondary lead poisoning prevention activities, especially the importance of nutrition. REFERENCES 1. Centers for Disease Control and Prevention. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Offices. November 1997. Atlanta, Georgia. United States Department of Health and Human Services, Public Health Services, CDC, 1997. 2. Centers for Disease Control and Prevention. Recommendations for Blood Lead Screening of Young Children Enrolled in Medicaid: Targeting a Group at High Risk. MMWR. December 8, 2000; 49/RR-14. 3. United States General Accounting Office. Medicaid : Elevated Blood Lead Levels in Children. Washington, DC, United States General Accounting Office, 1998. GAO Publications No. GAO/HEHS-98-78. 4. Lanphear. BP, et. al. Cognitive Deficits Associated with Blood Lead Concentrations <10 mg/dl in U.S. Children and Adolescents. Public Health Reports 2000; 115: 521-529. 5. Dietric, KN, et. al. Early Exposure to Lead and Juvenile Delinquency. Neurotoxicology Tetrology 2001; 23(6): 511-18. 6. Miranda, M.L., Yarger, L., Dolinoy, D. Coghlan J., and Engel, D. Childhood Lead Exposure: Effect and Policy Options.1998. Durham, N.C.: Nichols School of Environment, Duke University. 7. Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Children: Recommendations from the Advisory Committee on ChildhoodLead Poisoning Prevention. March 2002 8. Rogan, Walter J., et. al. The Effect of Chelation Therapy with Succimer on Neuropsychological Development in Children Exposed to Lead. New England Journal of Medicine 2001; Vol. 344 (19): 1421-6. 9. Zeigler, E.E. et al. Absorption and Retention of Lead by Infants. Pediatr Res. 1978; 12: 29-34. U.S. Food and Drug Administration, FDA Consumer, January-February 1998 10. Bruening, K., Kemp, F., Simone, N. et al. Dietary Calcium Intakes of Urban Children at Risk of Lead Poisoning. Environmental Health Perspectives. 1999; 107: 431-435. 11. American Academy of Pediatrics. Statement on Childhood Lead Poisoning. Pediatrics. 1987; 79:457-465. 12. Houston, D.K., Johnson, M.A. Does Vitamin C Protect Against Lead Toxicity?. Nutr Rev. 2000; 58:73-75. 13. Rose, D., Habitch, J., Devaney, B. Household Participation in the Food Stamp and WIC Programs Increases the Nutrient Intakes of Preschool Children. J Nutr. 1998; 128: 548-555. ADDITIONAL REFERENCES Childhood Lead Poisoning Prevention: Strategies and Resources. April 1997. Building Communities. Washington, DC: U.S.Public Health Service Ballew, C., Bowman, B. Recommending Calcium to Reduce Lead Toxicity in Children: A Critical Review. Nutr Rev. 2001; 59: 71-78. Lawrence, R.A. A Review of the Medical Benefits and Contraindications to Breastfeed in the U.S. MCH Technical Information Bulletin. Arlington, VA: National Center for Education in Maternal and Child Health, Health Resources and Services Administration, 1997. Mahaffey, K.R. Nutritional Factors in Lead Poisoning, Nutrition Review 1981; 39:353-362. Strupp BJ. Childhood Lead Exposure: Effects and Potential Treatments. Cornell Cooperative Extension via the Internet. www.cce.cornell.edu/ food/expfiles/topics/strup/struppoverview.html U.S. Food and Drug Administration, FDA Consumer, Jan. Feb. 1998. 7 Nutrition Focus Vol. 17 #3 May/June 2002

10-9306 Nutrition Focus Vol# 17, No. 3 CHDD, University of Washington Box 357920 Seattle, WA 98195-7920 Nonprofit Organization U.S. POSTAGE PAID Seattle, WA Permit No. 62 RESOURCES 1. The National Lead Information Center, 1-800-424-LEAD www.epa.gov/lead/nlicdocs.htm This Center provides information about lead prevention, lead poisoning, testing for lead in your home, and home repairs when lead paint is present. Information is available in English and Spanish. Written information includes: a. Lead Poisoning and Your Children, developed by the Environmental Protection Agency, is a colorful, attractive brochure which reviews possible sources of lead exposure and suggests how to reduce the risk of exposure. The brochure unfolds into an 11" x 17" poster which can be displayed in a clinic, office, or school setting. The poster lists seven methods to protect children from lead poisoning. The seven methods are explained in more detail on the reverse of the poster. Single copies of the poster are available by calling the National Lead Information Center. b. Fight Lead Poisoning with a Healthy Diet: Lead Poisoning Prevention Tips for Families is a colorful, attractive brochure which provides parents and caretakers information on preventing lead exposure in young children. The brochure focuses on nutrition and healthy foods NUTRITION FOCUS is published six times per year by the Nutrition Section at the Center on Human Development and Disability, University of Washington Annual subscription rate is $33.00 ($36.00 US funds for international subscriptions) and must be prepaid to the University of Washington. Mail your payment, complete address and phone number to the editor. Some back issues are available. For a list of these or to share resources and comments please contact the Editor: Sharon Feucht, M.A., R.D., Nutrition Focus, CHDD-University of Washington, Box 357920, Seattle, WA 98195-7920. Phone: 206-685-1297 FAX: 206-543-5771 email: sfeucht@u.washington.edu Current subscription or renewal questions should be addressed to the Nutrition Focus Subscription Manager, Alisha Peltz. Contact her at CHDD-University of Washington, Box 357920, Seattle, WA 98195-7920. Phone: 206-616-3831 FAX: 206-543-5771 e-mail: alishap@u.washington.edu For those with access to the internet we have a web page at http://depts.washington.edu/chdd/ucedd/co/co_nutrifocus.html and includes simple recipes. It was developed by the Environmental Protection Agency s Office of Pollution Prevention. For a copy of the brochure contact the National Lead Information Center. c. Lead in Your Home: A Parent s Reference Guide is a 70-page paperback book that discusses environmental lead, sources of lead in the home, how to reduce the risk of lead in your home, protecting your children, repair, remodeling, interim controls, abatement, cleaning up lead waste and resources for further information. The book is published by the Environmental Protection Agency and can be ordered by calling the National Lead Information Center. 2. The Environmental Protection Agency s Safe Drinking Water Hotline provides information on lead hazards in your drinking water. Call the hotline at 1-800-426-4791. 3. Resources on the World Wide Web www.epa.gov/lead for the Environmental Protection Agency Lead Program www.cdc.gov/nceh/lead for Center for Disease Control and Prevention s lead program www.hud.gov/offices/lead for Housing and Urban Development s lead program and activities Future issues of NUTRITION FOCUS July/August - Vol 17 #4 Nutrition and Attention Deficit Hyperactivity Disorder 8 Nutrition Focus Vol. 17 #3 May/June 2002

CLPPP Nutrition Assessment Potential Red Flags Notes/Referrals Anthropometric Assess growth parameters including: - weight-for-age and length/height-for-age - weight-for-length for infants and young children < 24 months of age OR BMI-for-age > 2 years of age - appropriate rate of weight gain if indicated Biochemical Assess test results for blood lead level Asses hemoglobin or hematocrit for iron Clinical Determine nutritional implications of medical management of lead toxicity Dietary Screen dietary intake for: - number of meals and snacks eaten on a typical day - adequacy of diet including sources of iron, vitamin C, calcium and zinc - water supply source and usage patterns - food storage techniques and receptacles - use of imported canned foods - use of traditional home remedies that might contain lead Ecosocial Review findings from environmental assessment if available Question regarding pica or excessive mouthing behaviors Assess home sanitation: - meal preparation area - hand-washing practices - washing pacifiers/bottle nipples/toys Child s weight-for-age is tracking above or below the highest or lowest growth channels or changing from the child s normal. Child s length/height-for-age is changing from the child s normal. Child is failing to track their normal growth channel for weight-for-length or BMI-for-age percentile. Child (one year or older) is gaining excessively (> 1lb in 6 months) or inadequately (< 1 lb in 6 months). Child s BLL > 5 ug/dl. Child s hgb/hct < 11.0 or 33%. Child is eating < 3 meals and 2 snacks daily. Child is not consuming a varied diet; refer to a nutritionist if there is a concern with getting adequate variety or sources of iron-, vitamin C-, calcium- and zinc-rich foods. Tap water is not flushed before using or warm water from tap is used for food preparation or drinking. Food may be exposed or stored in containers that have lead, i.e. high-acid foods such as orange juice or tomatoes are stored in lead-glazed containers. Child is eating imported, canned foods. Child is given traditional remedies with high lead content. Child is eating non-food items. Child has normal (developmental stage) mouthing behaviors that may increase exposure to lead. Child s food is prepared in an area that may be exposed to lead dust. Child s hands are not routinely washed before eating. Child s toys, pacifiers and bottle nipples are not washed regularly. Coordinate care with child s health care provider. Referrals: WIC Other: NC CLPPP November 2012

Refugee Children and Lead Screening Recommendations Refugees are a special group of immigrants who are admitted into the United States because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. These individuals enter the United States legally as a refugee pursuant to Section 207 of the Immigration and Naturalization Act. For the most part, refugees cannot return home because of the danger they would face upon returning. There are a few additional immigration statuses that fall under the refugee umbrella: (1) asylees, (2) Cuban/Haitian entrants and humanitarian parolees, (3) Amerasians, (4) certified international victims of a severe form of human trafficking,and (5) Iraqi and Afghan Special Immigrant Visa holders. Since refugee children (1) often enter into the country after the universal blood lead testing ages of 12 and 24 months, (2) are likely to never have received prior testing, and (3) are at above-average risk for lead poisoning, CDC has special post-arrival recommendations for them. The following section includes some resources for those health care providers serving refugee children. The below links can also be accessed for more information. Lead Screening Guidelines for Refugee Children http://www.cdc.gov/immigrantrefugeehealth/guidelines/lead-guidelines.html CDC s Lead Poisoning Prevention in Newly Arrived Refugee Children: Toolkit http://www.cdc.gov/nceh/lead/publications/refugeetoolkit/refugee_tool_kit.htm Q&A: CDC s Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children http://www.cdc.gov/nceh/lead/publications/refugeetoolkit/pdfs/q-and-a.pdf CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children http://www.cdc.gov/nceh/lead/publications/refugeetoolkit/pdfs/cdcrecommendations.pdf

LEAD SCREENING DURING THE DOMESTIC MEDICAL EXAMINATION FOR NEWLY ARRIVED REFUGEES U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine April 16, 2012

Background Epidemiology and Geographic Distribution Following the phase-out of leaded gasoline and the ban on lead-based paint, the prevalence of lead poisoning, as defined by a blood lead level (BLL) 10 µg/dl, among children in the United States has dramatically declined since the 1970s, decreasing from 78% during 1976-1980 to 1.6% during 1996-2002. 1 In contrast, refugee children arriving in recent years have much higher rates of elevated BLL on average when they enter the United States, because of exposures prior to relocation. In addition, refugee children are at above-average risk for lead poisoning from exposures in the United States, because they typically settle into high-risk areas and substandard housing. In areas of the world where many refugees originate, potential lead exposures include leadcontaining gasoline combustion, industrial emissions, ammunition manufacturing and use, burning of fossil fuels and waste, and lead-containing traditional remedies, foods, ceramics, and utensils. 2,3 Among 299 refugee children under the age of 6 years from 25 different countries arriving to Minnesota during 2000-2002, 22% had a BLL of 10 µg/dl. 2 This finding indicates that the prevalence of lead poisoning in newly arrived refugee children may be 14 times higher than that of the general U.S. population of comparable age. Among the children with elevated BLLs, 29 (45%) had levels 10-14.9 µg/dl, 15 (23%) had levels from 15-19.9 µg/dl, and 21 (32%) had levels 20-44.9 µg/dl. Of the children with BLLs from 20 to 44.9, 19 were from sub-saharan Africa and two were from Bosnia and Herzegovina. Although children from all regions of the world are at risk for having elevated BLL upon entering the United States, this risk appears to vary to some degree. In an analysis of screening data from Massachusetts, the prevalences of elevated BLL among newly arrived refugee children under 7 years old were 7%, 25%, 27%, 37%, and 40% among those from Northern Eurasian countries, the Near East (predominately Iraq), Africa, Asia (predominately Vietnam), and Central America/Caribbean countries, respectively. None of 33 Bosnian children born in Germany had elevated BLL. This finding suggests that birthplace and other areas of residence are more important than ethnicity as predictors of elevated lead levels. 3 Ongoing lead exposure among refugee children in the United States has been well documented. Reports from Massachusetts and New Hampshire indicate that 6%-29% of children who have normal BLL at new arrival screening may have elevated BLLs when retested several weeks to months later. 3,4 Malnutrition is a known risk factor for increased BLL. In New Hampshire, malnutrition was commonly identified in refugee children with elevated BLL (22 % had a low weight-for-height ratio and 35% had a low height-for-age ratio at the time of repeat testing). The median age of those with elevated BLL on repeat testing was 4.9 years (range, 14 months to 13 years), which is considerably older than the ages of recommended screening for most children in the United States. The most common lead exposures identified among children with elevated BLL at repeat testing were lead-based paints and lead-contaminated soil where the children had played. Of the refugee children in New Hampshire with BLLs >15 µg/dl, 89% lived in rental homes built before 1978, when lead-based paints were still used. Furthermore, two-thirds of the parents reported witnessing behaviors by their children that may increase lead exposure, such as frequently putting nonfood items into their mouths (pica); picking at loose paint, plaster, or

putty; or chewing on painted surfaces. Investigators also noted limited parental awareness of the dangers associated with lead exposure. 4 In addition to exposure to lead-based paints and contaminated soil, refugee children are vulnerable to other unique sources of lead exposure. A variety of foods, candies, and traditional therapies have been found to be the source of exposure for many immigrant children (Table 1). Table 1. Examples of culture-specific exposures associated with elevated lead levels in children. Exposure Area of Origin Reported Uses Description Pay-loo-ah Southeast Asia Treatment of fever and rash Greta Mexico Treatment of digestive problems Azarcon Mexico Treatment of digestive problems Litargirio Dominican Republic Deodorant/antiperspirant and treatment of burns and fungal infections of the feet. Surma India Improve eyesight Unidentified ayuvedic Lozeena Tamarind candies (multiple brand names) Lead-glazed ceramics Make-up and beauty products Tibet Iraq Mexico Often made in Latin America Multiple cultures Treatment for slow development Added to rice and meat dishes for flavor Lollipops, fruit rolls, candied jams Bean pots, water jugs Decoration Orange-red powder. Administered by itself or mixed in tea. Yellow-orange powder. Administered with oil, milk, sugar, or tea. Sometimes added to baby bottles or tortilla dough. Bright orange powder. Administered similarly to greta. Yellow or peach-colored powder. Black powder administered to inner lower eyelid. Small gray-brown balls administered several times a day. Bright orange spice 'Bolirindo' lollipops are soft and dark brown. Candied jams are typically packaged in ceramic jars. Many types

This table is modified from the one published in the Textbook of Immigrant Medicine, 1st Edition. Patricia Walker and Elizabeth Barrett (Eds). Rajal Moday, Preventive Healthcare in Children, page 517. Copyright Elsevier (2007). Refugee Populations at Risk Refugee children originating in all regions of the world, especially those from resourcepoor countries, are at risk of having lead poisoning upon arrival to the United States. Malnourished children may be at increased risk for lead poisoning, likely through increased intestinal lead absorption mediated by micronutrient deficiencies. The beststudied micronutrient deficiency related to lead levels is iron deficiency. Iron-deficient children are at increased risk for developing lead poisoning. 5 Deficiencies in calcium and zinc may also increase a child's risk. 6 Clinical Presentation Since 1991, the value indicating elevated BLL has been 10 µg/dl. Above this value lead is known to impair intelligence and neurodevelopment. 6 However, more recent studies call into question whether levels below 10 µg/dl are safe. The results of one study suggest that the magnitude of the decrease in intelligent quotient (IQ) for each incremental increase in BLL is greatest among those children with levels below 10 µg/dl. 7 At levels higher than 10 µg/dl, more acute symptoms may appear. Above a level of 60 µg/dl, children may experience headaches, abdominal pain, anorexia, constipation, clumsiness, agitation, and lethargy. 8 At BLLs as low as 70 µg/dl, children may develop severe neurologic complications, including seizures, ataxia, mental status changes, coma and death. 6 Although such severe poisonings are rare, in 2000 a 2-year-old Sudanese refugee girl with a BLL of 392 µg/dl died 5 weeks after arrival to the United States. This was the first lead poisoning-related death in the United States in a 10-year period and underscores the unique vulnerability of refugee children to this condition. 9 Medical Screening Screening and Testing Prior to Departure for the United States None Recommendations for Post-Arrival Evaluation Driven by the above data specific to refugees, the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Childhood Lead Poisoning Prevention Branch and Division of Global Migration and Quarantine, in collaboration with the U.S. Department of State, Bureau of Population, Refugees and Migration, developed recommendations specifically to address lead exposure among refugee children. (The full document is available at: www.cdc.gov/lead/factsheets/refugeechildrenfactsheet.htm.) 10 Identification of Refugee Children with Elevated Blood Lead Levels (pertinent to the new refugee medical screening examination) 1. Check BLL of all refugee children 6 months to 16 years of age at the time of arrival to the United States.

2. Children younger than 6 years should undergo nutritional assessments as well as testing for hemoglobin or hematocrit level with one or more of the following: mean corpuscular volume with the red cell distribution width, ferritin, transferrin saturation, or reticulocyte hemoglobin content. 3. Provide daily pediatric multivitamins with iron for refugee children 6-59 months of age. 4. Follow-up blood lead testing should be done 3-6 months after placement in a permanent residence. The refugee status of most children entitles them to Medicaid, Women, Infants and Children's Program (WIC), and other social services for at least 8 months after their resettlement, regardless of the family financial status. Evaluation and Treatment of Refugees with Elevated Blood Levels An in-depth discussion of management of lead is beyond the scope of this document. If a child has a BLL 10 µg/dl, clinicians should refer to the reference "Managing Elevated Blood Lead Levels Among Children" prepared by CDC, which can be obtained at www.cdc.gov/lead/scientificandeducation.htm. 11 Further information on appropriate history taking, medical management, environmental assessments and follow-up testing are also available from the CDC (www.cdc.gov/nceh/lead). Many of the questions typically asked of children in the United States are not pertinent in refugees, since they have recently relocated (moved) from the most likely source of exposure. However, children's lead levels may increase in a relatively short amount of time (within weeks), and so typical exposures should be solicited. These questions might include such exposures as peeling paint in their current residence and whether the child spends significant amounts of time in play areas where there is bare soil. In addition, folk remedies, traditional therapies, pottery or metal vessels, and imported foods may be of particular concern in this population, and these risks should be assessed in a culturally sensitive manner (Table 1). In case reports, parents have denied giving "folk remedies" to their children with high BLL, even when the ultimately identified source is a culture-specific remedy. This confusion may be explained by differences in what is considered "folk remedies" between clinicians and parents. If no lead sources can be identified in children with lead poisoning, clinicians should consider checking BLLs in other family members. If other family members of various ages have elevated levels, a shared source 12, 13, 14 exposure, such as ceramic ware, spices, foods, and remedies, may be present. Appropriate management of children with confirmed elevated BLL is based on the extent of the elevation (www.cdc.gov/nceh/lead/casemanagement/casemanage_chap3.htm). Follow-up testing is mandatory for all children with documented elevated venous BLL in addition to the special refugee groups mentioned above, who should be re-evaluated regardless of their initial level. Trends are especially important in this population since, although they may have left the environment of exposure when they migrated, they are generally moving into high-risk housing in the United States. 4 It is not unusual for a child's lead level to continue to rise after migration to the United States. which would demand formal environmental evaluation. Information on recommended follow-up testing can be found at www.cdc.gov/nceh/lead/casemanagement/casemanage_main.htm. Children with elevated levels should be reported to State Childhood Lead Poisoning Prevention Programs (CLPPP) or appropriate state contact. State and local program contacts may be found at: http://www.cdc.gov/healthyhomes/programs.html.

Sources of Additional Information CDC Lead Poisoning Prevention in Newly Arrived Refugee Children: Tool Kit (This educational kit has modules intended for both refugee resettlement workers and medical providers. It can be downloaded from www.cdc.gov/nceh/lead/publications/refugeetoolkit/refugee_tool_kit.htm CD-ROM copies can be obtained by calling 1-800-CDC-INFO.) CDC. Elevated blood lead levels in refugee children--new Hampshire, 2003-2004. MMWR Morb Mortal Wkly Rep. 2005;54:42-6. Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995 to 1999. Pediatrics. 2001;108:158-62. References 1. CDC. Blood lead levels--united States, 1999-2002. MMWR Morb Mortal Wkly Rep. 2005;54:513-6. 2. Minnesota Department of Health. Lead Poisoning in Minnesota Refugee Children, 2000-2002. Available at: www.health.state.mn.us/divs/idepc/newsletters/dcn/2004/mar04/lead.html. Accessed 6/6/2007. 3. Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995 to 1999. Pediatrics. 2001;108:158-62. 4. CDC. Elevated blood lead levels in refugee children--new Hampshire, 2003-2004. MMWR Morb Mortal Wkly Rep. 2005;54:42-6. 5. Wright RO, Tsaih SW, Schwartz J, Wright RJ, Hu H. Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic. J Pediatr. 2003;142:9-14. 6. Laraque D, Trasande L. Lead poisoning: Successes and 21st century challenges. Pediatr Rev. 2005;26:435-43. 7. Canfield RL, Henderson CR Jr, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 10 micrograms per deciliter. N Engl J Med. 2003;348:1517-26. 8. American Academy of Pediatrics. Lead. In: Etzel R, ed. Pediatric Environmental Health. Vol 1. 2nd ed. United States of America: American Academy of Pediatrics. 2003:249. 9. CDC. Fatal pediatric lead poisoning--new Hampshire, 2000. MMWR Morb Mortal Wkly Rep. 2001;50:457-9. 10. CDC. Lead exposure among refugee children: Fact sheet. www.cdc.gov/lead/factsheets/refugeechildrenfactsheet.htm. Last accessed 12/29/07. 11. CDC. Managing Elevated Blood Lead Levels Among Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Available at: www.cdc.gov/nceh/lead/casemanagement/casemanage_main.htm. Accessed 6/6/2007. 12. CDC. Lead poisoning associated with use of litargirio--rhode Island, 2003. MMWR Morb Mortal Wkly Rep. 2005;54:227-9. 13. CDC. Screening Young Children for Lead Poisoning: Guidance for State and Local Health Officials. Available at: www.cdc.gov/nceh/lead/guide/guide97.htm. Accessed 6/6/2007.

14. CDC. Lead poisoning associated with imported candy and powdered food coloring-- California and Michigan. MMWR Morb Mortal Wkly Rep. 1998;47:1041-3.

CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children Lead poisoning remains one of the most common and preventable pediatric environmental conditions even though the United States (US) has made great strides in reducing the number of children with elevated blood lead levels. One objective of Healthy People 2010 is to eliminate blood lead levels (BLLs) >10 µg/ dl among the nation s children. US children living in poorly maintained housing built before 1978 are at greatest risk for elevated BLLs because of their frequent exposure to lead-based paint and lead-contaminated house dust and soil. The prevalence of elevated blood lead levels (i.e., BLLs >10 µg/dl) among newly resettled refugee children is substantially higher than the 2.2% prevalence for US children. For this reason, the US Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), Childhood Lead Poisoning Prevention Branch and Division of Global Migration and Quarantine, in collaboration with the Office of Global Health Affairs and Office of Refugee Resettlement, and the US Department of State, Bureau of Population, Refugees and Migration, developed the following recommendations specifically to address lead exposure among refugee children. Background: New Hampshire requires blood lead screening of newly arrived refugee children aged 6 months to 16 years. Beginning in May 2004, 242 refugee children, predominately from Africa, were resettled to New Hampshire. Of these, 96 children were tested twice for BLLs. The first blood lead samples were collected within 90 days of the children s arrival, and the second samples were collected 3 to 6 months after their resettlement. Most of the children had initial capillary BLLs <10µg/dL. Venous follow-up tests found that 38 (40%) children had BLLs >10 µg/dl; as did 5 other children who were siblings of cases (range: 11 to 73 µg/dl). Eleven of the recently resettled families had at least one child with a BLL >20 µg/dl. Environmental investigations revealed moderate lead hazards within the residences of the children as well as lead-contaminated soil in play areas frequented by the children. The children with elevated BLLs also showed evidence of extreme chronic malnutrition. Health examinations before arriving in the US indicated that 16 (37.2%) of the children had severe growth retardation (Height per Age Z-score <2; or approximately the second percentile on the standard pediatric growth curve) and, of the 40 children for whom weight was measured, 10 (25%) had evidence of failure to gain weight or of loss of weight (Weight per Height Z-score <2; or approximately the second percentile on the standard pediatric growth curve). Recommendations: Primary Prevention of Elevated Blood Lead Levels Ideally all children would live in lead-safe housing, especially those whose nutritional status and lack of knowledge about the dangers of lead place them at great risk for lead poisoning. However, we recommend the following to reduce the risk of lead exposure in refugee children: CDC Lead Poisoning Prevention in Newly Arrived Refugee Children

Identification of Children with Elevated Blood Lead Levels 1. BLL testing of all refugee children 6 months to 16 years old at entry to the US Federal standards stipulate that a refugee medical screening take place within 90 days after a refugee s arrival in the US. The content of the screenings vary from state to state. Childhood lead poisoning prevention programs report that most states do not have a BLL screening protocol for refugee children and that lead program surveillance data cannot identify which children are refugees. Studies indicate that age is not a significant risk factor for elevated BLLs among refugee children. Although the risk for lead exposure among children older than 6 years may be the result of exposure in their country of origin, many of the prevailing health, social, and economic burdens accompany the children to the US thus suggesting the value of screening ALL refugee children at time of arrival. 2. Repeat BLL testing of all refugee children 6 months to 6 years 3 to 6 months after refugee children are placed in permanent residences and older children, if warranted, regardless of initial test results. Children who mouth or eat non-food items, especially soil, which is common among certain refugee populations, are at risk for lead poisoning, regardless of the age of their housing. The New Hampshire case study demonstrates that although some children had elevated BLLs when they arrived in the US, the majority of the children did not. The follow-up screening which was conducted on average 60 to 90 days after the placement of the children in the state and in their permanent residences, revealed elevated BLLs that ranged from 11 to 72 µg/dl. The refugee status for most of the children entitles them to Medicaid, WIC, and other social services for at least 8 months after their resettlement, regardless of family financial status. Early Post-arrival Evaluation and Therapy 1. Upon US arrival, all refugee children should have nutritional evaluations performed, and should be provided with appropriate nutritional and vitamin supplements as indicated. Pre-existing health burdens such as chronic malnutrition, along with cultural, language, and economic barriers compound refugee children s risk for lead poisoning. For example, iron deficiency, prevalent among refugee children, increases lead absorption through the gastrointestinal (GI) tract. At a minimum, the nutritional evaluation should include an evaluation of the children s iron status including a hemoglobin/hematocrit and one or more of the following an evaluation of the mean corpuscular volume (MCV) combined with red cell distribution width (RDW); ferritin; transferrin saturation; or reticulocyte hemoglobin content. 2. Evaluate the value of iron supplementation among refugee children. Study of iron supplementation in refugee children will provide needed data on its efficacy to reduce nutritional deficiencies and, thus, reduce lead absorption through the GI tract. Health Education/Outreach 1. CDC and its state and local partners should develop healtheducationandoutreachactivitiesthatareculturally appropriate and sensitive to the target population. 2. CDC and its state and local partners should develop training and education modules for health care providers, refugee and resettlement case workers, and partner agencies (e.g., WIC) on the following: Effects of lead poisoning among children. Lead sources in children s environments and ways to reduce the risk of exposure. Nutritional and developmental interventions that can mitigate the effects of lead exposure. Ways to provide comprehensive services to children with elevated BLLs. CDC Lead Poisoning Prevention in Newly Arrived Refugee Children

Q&A: The Centers for Disease Control and Prevention (CDC) Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children 1) Q: Who was responsible for developing these recommendations, and who else was involved in the process? A: The CDC Childhood Lead Poisoning Prevention Program (CLPPP) developed and published the recommendation. The office is part of CDC s National Center for Environmental Health. CLPPP also worked closely with the CDC Division of Global Migration and Quarantine, the HHS Office of Global Health Affairs (OGHA), and the Office of Refugee Resettlement (ORR) to ensure that the recommendations were appropriate for the refugee and refugee resettlement communities. The recommendations also have the approval of the American Academy of Pediatrics. 2) Q: The recommendations seem to rely entirely on data from New Hampshire. Yet data from Massachusetts and Minnesota were quite different, and did not show evidence of substantial increases in blood lead levels pre- and post- arrival. Did CDC look at other data? A: The recent report in the MMWR (Elevated Blood Lead Levels in Refugee Children New Hampshire, 2003-2004) focused on the experience of refugee children in Manchester New Hampshire. At the time Manchester was one of the few places in the country where refugee children were required to be tested for lead both on arrival and subsequent to permanent placement. This made it possible to identify a pattern that may have been missed in other places where the combination of poorly maintained old housing, poor nutrition and lack of understanding of the dangers of lead put refugee children at exceptional risk for lead exposure. In Massachusetts we also found in a group of 660 refugee children from Europe, Asia, Africa and the Americas, were more likely to have elevated blood lead levels 6 months after resettlement than were U. S. born children (Geltman P, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995 to 1999. Pediatrics 2001;108:158-162.) Given these data it seems prudent to test children 3-6 months after they are resettled. 3) Q: Why has the recommended age of Blood Lead Level (BLL) testing increased to 16 years of age? A: CDC, in consultation with the American Academy of Pediatrics (AAP) decided to increase the age range for BLL testing. Although children 6 years old and younger remain at the highest risk for elevated lead levels and lead poisoning, age does not predict risk for lead exposure in refugee populations who are relocated from areas with high ambient contamination. Therefore all children 16 years and younger should be given at least an initial test for an elevated BLL. Refugee children should be tested for lead on arrival until at least 16 years of age because they may be exposed to lead in the country of origin or to lead in products they brought with them or purchase in import stores. CDC Lead Poisoning Prevention in Newly Arrived Refugee Children

4) Q: Why is it recommended that only refugee children that are age 6 years and younger be repeat tested for elevated BLL, 3-6 months after being placed in residences? A: Most state and local lead poisoning prevention programs recommend screening for children less than 6 years old because; 1) young children are more at risk for exposure because their normal hand to mouth activities puts them in contact with lead dust and soil, 2) they have higher absorption rates than older individuals and 3) they are more sensitive to the adverse health effects of lead. However, in the Geltman article cited above we did not find that age was a predictive of elevated blood lead levels in refugee children. Thus we recommend repeat testing for children less than 6 years old or older children if local conditions indicate. This means that if public health or clinical health providers determine that older children in their care are at risk for lead exposure, these children should be tested as well. 5) Q: Why are younger refugee children at risk of developing elevated BLL, if they have been placed in environmentally safe housing? A: Refugee children suffer a higher incidence of malnutrition and anemia, than can be found in their corresponding U.S.-born age group. Malnutrition and anemia facilitate the quick absorption of trace amounts of lead into the bloodstream, and can therefore lead to harmful BLL in smaller children. Refugee children not only absorb lead through contact with internal surfaces in their housing units, but also through soil and external play spaces as well. In addition, because their parents and caregivers are not knowledgeable about lead exposure and how to prevent it, the children may engage in behaviors, such as eating soil, that place them at increased risk. 6) Q: When should the recommended nutritional evaluation and corresponding blood tests is done? Who should be responsible for administering these tests? A: The blood tests should be performed when refugee children undergo their initial refugee health assessment. The state or local health care provider and corresponding state government official in charge of refugee health assessments are responsible for making sure that these tests are conducted. 7) Q: If a refugee child is identified as anemic or malnourished, who should supplement and monitor their nutritional and iron intake therapies? A: The child s primary health care provider should discuss daily vitamins with the family and if necessary write a prescription for them. The state or local health care providers and state government official should partner with the appropriate resettlement agency or affiliate to ensure that the parents or caretakers of malnourished refugee children receive nutritional education. Iron supplements should be provided by the local health care provider. OGHA and ORR will partner with CDC to provide a nutritional training workshop for resettlement agencies. The nutritional well-being of refugee children is an issue that extends beyond lead. Most if not all of these children qualify for the Supplemental Nutrition Program for Women, Infants and Children (WIC). 8) Q: Who should pay for these lead and nutritional tests, therapies and treatment regimens? A: CDC has consulted with the Centers for Medicare and Medicaid Services (CMS), and all these tests and treatments should be covered under either standard Medicaid, State Child Health Insurance Programs (SCHIP) or Early and Periodic Screening, Diagnostic and Treatment (EPSDT). This is true, regardless of how limited the state s Medicaid plan might be. Refugees who fulfill the Medicaid requirements of a covered group i.e. low income children are mandatory qualified aliens. As such they are eligible for Medicaid and the Early CDC Lead Poisoning Prevention in Newly Arrived Refugee Children

Periodic Screening Diagnosis and Testing program (EPSDT) and state Medicaid agencies MUST provide blood lead screening and other medically necessary tests. If you are told that these services are not covered under Medicaid, please contact a CDC, OGHA or ORR team member and notify them. (Contact information provided below.) 9) Q: CDC does not provide specific recommendations for environmental and housing are they planning to address this in another form? 10) Q: How would a case worker know if a home may contain lead hazards? A: (Answer relevant for Q 9 and 10) CDC is working with several organizations to develop a training toolkit to help resettlement workers and other social service providers who work with refugee families educate them on the hazards of lead exposure. The toolkit will include an easy assessment survey that can help alert the resettlement workers to high lead hazard environments. 11) Q: What are the laws that state what the standards are for housing and lead? Does this vary from state to state? Yes the laws vary from state to state and some states do not have laws that address residential lead paint. State laws and regulations can be found on the CDC Lead Poisoning Prevention branch website at http://www.cdc.gov/nceh/lead/lead.htm 12) Q: Who is responsible if a house poisons a refugee child? Some states have laws or regulations that require that housing with young children, refugee or not, be maintained in a lead-safe manner. These laws may also assign responsibility, usually to the property owner if housing is not lead-safe. State laws and regulations related to childhood lead poisoning prevention can be found at http://www.cdc.gov/nceh/lead/lead.htm 13) Q: Who should I contact if I have more questions? A: Please contact either: Connie Thomas, CLPPP, CDC, (770) 488-3631 cbthomas@cdc.gov Arjun Prasad, OGHA, (301) 443-7243 aprasad@osophs.dhhs.gov Marta Brenden, ORR, (202) 253-3589 mbrenden@acf.hhs.gov

Lead Poisoning Prevention in Newly Arrived Refugee Children: Tool Kit On This Page Introduction to the Tool Kit Background Recommendations Contents of the Tool Kit Refugee Resettlement Worker Module Medical Provider Module Resources Evaluation Click to download complete tool kit [ZIP - 28.2 MB] Introduction to the Tool Kit The Centers for Disease Control and Prevention's (CDC) Lead Poisoning Prevention Program (LPPP) in conjunction with the Office of Refugee Resettlement developed the Lead Poisoning Prevention in Newly Arrived Refugee Children tool kit in response to the increasing number of refugee children entering in the United States and subsequently developing elevated blood lead levels. CD-ROMs of the tool kit are available by calling 1-800-CDC-INFO. Background On April 21, 2000, a two-year-old Sudanese refugee girl became the first child in the United States known to have died from lead poisoning in 10 years. Her exposure occurred in the United States and was caused by lead paint in the home. Beginning in May 2004, after the resettlement of 242 refugee children, predominately from Africa, it was discovered that a significant number of the children age range from 6 months to 15 years developed elevated blood lead levels after their arrival to the United States. Most of the children were resettled to a state that had established a policy to

screen refugee children for lead during their initial health examination. The first blood lead screening was done within 90 days of the children's arrival; the second screening was done 3 to 6 months after their placement in permanent residence. Most of the children had initial capillary BLLs <10 µg/dl which supports the hypothesis that exposure occurred after arrival to the United States. Environmental investigations revealed moderate lead hazards in the residence, and some contamination in soil in play areas frequented by the children. The children showed evidence of extreme chronic malnutrition and other moderate to severe health conditions. Lead poisoning continues to be a reoccurring problem for refugee children resettled in the United States. Although little is know about lead exposure in their country of origin, data collected and research supports that most of the children are poisoned after their resettlement to the United States. Recommendations Primary Prevention of Elevated Blood Lead Levels Ideally all children would live in lead-safe housing, especially those whose nutritional status and lack of knowledge about the dangers of lead place them at great risk for lead poisoning. However, we recommend the following to reduce the risk of lead exposure in refugee children: Identification of Children with Elevated Blood Lead Levels 1. BLL testing of all refugee children 6 months to 16 years old at entry to the US 2. Repeat BLL testing of all refugee children 6 months to 6 years 3 to 6 months after refugee children are placed in permanent residences and older children, if warranted, regardless of initial test results. Early Post-arrival Evaluation and Therapy 1. Upon US arrival, all refugee children should have nutritional evaluations performed, and should be provided with appropriate nutritional and vitamin supplements as indicated. 2. Evaluate the value of iron supplementation among refugee children. Health Education/Outreach 1. CDC and its state and local partners should develop health education and outreach activities that are culturally appropriate and sensitive to the target population. 2. CDC and its state and local partners should develop training and education modules for health care providers, refugee and resettlement case workers, and partner agencies (e.g., WIC) on the following: Effects of lead poisoning among children. Lead sources in children s environments and ways to reduce the risk of exposure. Nutritional and developmental interventions that can mitigate the effects of lead exposure. Ways to provide comprehensive services to children with elevated BLLs. Further details are available at: CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children [PDF - 454 KB]

Contents of the Tool Kit The tool kit is divided into three sections. 1. Refugee Resettlement Worker Module Direct download: PowerPoint Presentation [PPT - 11.6 MB] and Presentation Notes [DOC - 82 KB] Purpose: This self-guided module provides information about the importance of identifying and determining possible lead hazards in the homes of newly arrived refugee children, assuring blood lead medical services to these children, and educating the refugee population on lead poisoning prevention. Intended Audience: This module was developed for refugee coordinators, refugee health coordinators, state and local health departments, and additional organizations involved with the well-being and resettlement of refugees. 2. Medical Provider Module Direct download: PowerPoint Presentation [PPT - 14.1 MB] and Presentation Notes [DOC - 66 KB] Purpose: This self-guided module provides information about CDC's recommendation for identifying children with elevated blood lead levels and early post-arrival medical evaluation and therapy. Intended Audience: This module was developed for those involved with direct medical services to refugees. 3. Resources Purpose: This section includes resources for refugee resettlement workers and medical providers such as frequently asked questions about CDC's recommendations for lead poisoning prevention in newly arrived refugee children, fact sheets, training materials, links to childhood lead poisoning prevention organizations, and more. Intended Audience: These resources were collected to assist anyone interested in learning more about the issue of lead poisoning among newly arrived refugee children. Evaluation We would like to receive feedback from you on the usefulness of this tool kit as it applies to your job. We would also like to know what we can do to enhance this product and that of future tool kits. Pleaselink to our evaluation form [DOC - 160 KB] and email it to leadinfo@cdc.gov. Email page link Print page Contact Us: Centers for Disease Control and Prevention 1600 Clifton Rd Atlanta, GA 30333 800-CDC-INFO (800-232-4636)

North Carolina Childhood Lead Poisoning Prevention Program NCLEAD and Clinical follow-up Recently revised state guidelines call for clinical follow-up of children under the age of six who have a blood lead level (BLL) at or above a reference value based on the 97.5th percentile of the BLL distribution among children 1 5 years old in the United States (currently 5 micrograms per deciliter). These guidelines are based on recent recommendations by the Center for Disease Control and Prevention citing compelling evidence that low BLLs are associated with IQ deficits, attention-related behaviors, and poor academic achievement. North Carolina data indicate there may be as many as ten times the number of children requiring clinical follow-up under the revised recommendations. NCLEAD, a web-based statewide surveillance system is used for tracking case management services for these children. NCLEAD was implemented in July 2010 and provides real-time information to providers of clinical and environmental follow-up services. NC General Statute 130A-131.8 requires electronic submission of all blood lead test results for children under the age of six. Data from the NC State Laboratory of Public Health, LabCorp and Mayo feed directly into the system. Electronic data from all other laboratories are reformatted and standardized by data management staff before upload. NCLEAD is helpful to clinical case managers by providing workflows of children in need of diagnostic testing and other clinical follow-up services. The system provides the ability to capture follow-up documentation notes, assign case-specific tasks, flag cases with concerns, add attachments and share cases between jurisdictions. State and local environmental specialists who provide environmental follow-up services also use the system. Clinical staff can access lead investigation information related to sources of lead exposure. This information can be useful to clinicians in reinforcing educational efforts to limit children s exposure to lead. 12/10/2012

Quick Reference Guide to Clinical Print Documents Updated 6-09-2010 The Print Documents screen is accessed by clicking on the following icon from the Dashboard toolbar A Child Event must be loaded. Topic Document Name NCLEAD Document Description Event How to get fields on document populated correctly Additional info needed to fill in the template Consent Refusal ConsentRefusal.rtf Consent/Refusal EBL Child No fields populate. Select Tenant/ Owner Fill out Property Address Select Consent to/ Refuse All Event Info Event_Print.xsl Generic Event Template Child This prints to a web page that you can print manually. Prints all of information regarding Child Event. All of the BLL Results are listed, and all question pack information. Form 3651 Form3651.rtf Evaluation of Child with Elevated Blood Lead Level Child Demographic Question Package filled out Clinical Question Package: Answer the 3651 questions and they will populate the document. You can use the pre-populated information. Save as a Word document, and enter other information manually. Form 3958 Form3958.rtf Risk Assessment Questionnaire Child Child's name Populates the Patient's Name Field. You can use the pre-populated information. Save as a Word document, and enter other information manually.

NCLEAD: Attaching a File Or Word Document to an Event Often, there may be a document or a file, such as a lab report, letter, or photograph that should be attached to an event. As long as the document is accessible from the user s computer, the file can be attached to an event. Attachment is found on the last line in the Event Summary Box. To attach an event to a file follow these quick steps: 1. Open the Event to which an attachment will be added (Note: It is not possible to attach a file to an event without first having the event loaded in the Dashboard) 2. From within the Event Summary box, on the line specifying Attachments, click on the link that says Add. (Note: Add will be highlighted in blue) 3. After you click Add a new screen will appear with a box that says Add Attachment On the first line of the box click Browse 4. Search for the necessary document you would like to attach. ( e.g., Form 3460 or Form 3651). Once you locate the file either double click or click Open. You should then see the file in the top bar of the attachments box. 5. Enter a brief description of the attachment in the next box (this is a required field in NCLEAD) 6. Enter the status, type of attachment, and security level. 7. Add a note if necessary (Note: this is not a required field, but the more information you can provide, the better) 8. Click Save once you ve entered in all the necessary information. This will bring you to the Manage Attachments screen. 9. Your attachment should be listed. Under Actions, you can view, edit, or delete your attachment. If you would like to add another attachment to your event click Add attachment at the bottom of the screen and repeat steps 4-8. 10.Once you are finished adding attachments click Dashboard at the bottom of the Manage Attachments screen. In the Event Summary section it will show the number of the attachments you have attached to the event.

Print date: 10/15/2010 Quick Reference Guide to Workflows Updated 10-15-2010 The Workflow Queues screen is accessed by clicking on the following icon from the Dashboard toolbar Workflow How Event gets onto the workflow How Event gets off of the workflow Last Update 1. General Childhood Lead Childhood Lead Events with System Generated Concerns Childhood Lead Events with User Generated Concerns NCLEAD has detected a data entry issue for this event (e.g. data missing, data values are implausible, etc.) Once it is corrected, it will no longer appear in this workflow or in the Concerns Tab. It is possible that what you've entered is correct, or the missing information is unattainable. In such situations, the concern will remain active until the event is closed. LHDs do not close events. Events where a user- not the systemhas added a concern. *Only concerns marked as "very high" severity will Resolve the concern and mark it as resolved under the appear on the dashboard in red.* Concerns tab. Visible by Group Refresh Rate in minutes ALL 30 ALL 30 Shared Cases - Cases shared by me Shared Cases - Cases shared with me or my group(s) Events I've shared with another person or group. Events shared with me or my group(s). When the event is no longer shared. ALL 15 "Unshare" event(s) shared with you if you no longer need to access event. ALL 15 Page 1 of 5

Print date: 10/15/2010 3. Clinical Workflow How Event gets onto the workflow How Event gets off of the workflow Last Update Children In Need of Follow-up Testing (EBLL or CLP child) and no two consecutive test results < 10 µg/dl after last confirmation date. Child has two consecutive test results < 10 µg/dl after last confirmation date. Visible by Group Refresh Rate in minutes CLINICAL 15 Diagnostic testing needed (Last test result 10 µg/dl and not a confirmed EBLL and not a CLP) OR (last test result 20 µg/dl & not a CLP). (Child is a CLP) OR (child is a confirmed EBLL and last test result < 20 µg/dl) OR (child is not a confirmed EBLL and not a CLP and last test result < 10 µg/dl). CLINICAL 30 Refugee Children in need of testing (Refugee child and age 6 months and age < 16 years) AND ((no lead test) or (one lead test and 90 days after test date)). Refugee child AND ((one test result and < 90 days after test date) or (2 test results at least 90 days apart)). 5/25/2010 CLINICAL 30 Page 2 of 5

Print date: 10/15/2010 Workflow How Event gets onto the workflow How Event gets off of the workflow Last Update 6. Environmental Health 1. Children with EBLs in need of environmental follow-up All of the following: Child is an EBLL; here is no investigation; no refusal date; no unable to locate patient date; no failure to respond date. Environmental Activity= Investigation (in property event) OR there is a Refusal Date (in child event- Environmental Follow- Up Wizard) OR there is an Unable to Locate Patient Date (in child event- Environmental Follow-Up Wizard) OR there is a Failure to Respond Date (in child event- Environmental Follow-Up Wizard). Visible by Group EHS Refresh Rate in minutes 8hrs updated 10/15/10 2. Children with CLPs in need of environmental follow-up Child is a CLP AND (there is no investigation of primary address or supplemental address question "yes"). Environmental Activity= Investigation (in property event) and Investigation of Supplemental Address question = YES (in child event- Environmental Follow-Up Wizard). EHS 8hrs updated 10/15/10 3. Active Property Investigations (Property has investigation) AND ((Required notices/order sent is not checked) OR (Date sent is empty) OR (Remediation required selection has not been made)). Note: Last three items are in Remediation package. Required notices/order sent is checked (property event- Remediation Qpak) AND Date sent (property event- Remediation Qpak) is entered AND Remediation required selection has been made (property event- Remediation Qpak). 5/24/2010 EHS 30 Page 3 of 5

Print date: 10/15/2010 Workflow How Event gets onto the workflow How Event gets off of the workflow Last Update 4. Remediation Incomplete Questions in property event- Remediation Qpak: (Remediation required selection is "No, but voluntary remediation" OR "Yes, by Division of Child Development" OR "Yes, by local ordinance" OR "Yes, by NC General Statute") AND Questions in property event- Environmental Qpak: ((there is no passed clearance date) OR (there is a failed monitoring after passed clearance date)). Passed Clearance Date (property event- Clearance Activity). Visible by Group Refresh Rate in minutes EHS 30 Properties in need of Annual Monitoring Annual Monitoring is required to be performed on the property. Questions are on the Environmental Activity Qpak below the RED bar. "Do you want to track this property for annual monitoring?" = YES. Below the above question is "Enter the date.". It must have a date in this date field. EHS Daily Abandonment Monitoring This workflow tags the properties that have been Cleared, and the Questions are on the Environmental Activity Qpak below the remediation was abandonment. It RED bar."do you want to be reminded to check for checks to see if the Abandonment was abandonment?" = YES verified 6 months from the clearance Below the above question is "Enter the date.". It must have a date. The abandonment must be date in this date field. verified every 6 months. EHS Daily Remediation Past Due If the remediation has not been completed within the 60 day time period. On the PROPERTY- REMEDIATION Qpak, the question "Remediation complete within 60 days?" is NO. Verify the remediation work has been complete and fill in the Remediation Verification Date (property event- Remediation Qpak). EHS Page 4 of 5

Print date: 10/15/2010 Workflow How Event gets onto the workflow How Event gets off of the workflow Last Update Task Specific Monitors (Add Task) Completed Tasks Created by Me (less than 30 days old) My Groups' Open Tasks My Open Tasks My Overdue Tasks Tasks that you (specifically) created which are now complete. This workflow is FYI only. Tasks assigned to your group(s) which are not yet completed. Anyone in the group can complete the task. Tasks assigned specifically to you. Anyone in your group can complete task. Tasks assigned to you or your group that have not been completed by the assigned due date. Events will automatically drop out of this workflow 30 days after completion date. To clear, open task and mark the "Status" field as "Completed." If task is not completed by due date, it will drop out of this workflow and appear in "My Overdue Tasks" workflow. To clear, open task and mark the "Status" field as "Completed." To clear, open task and mark the "Status" field as "Completed." Anyone in your group can do this. Visible by Group Refresh Rate in minutes ALL 15 ALL 15 ALL 15 ALL 15 Open Tasks Created by Me Overdue Tasks Created by Me Tasks created by you specifically which are not yet completed. It is FYI only. Tasks created by you which have not been completed by due date. This workflow is FYI only. After task is completed, tasks will move to the "Completed Tasks Created by Me" workflow. Or, if task is not completed by due date, it will drop out of this workflow and move to "Overdue Tasks Created by Me." You do not clear this workflow. After assigned individual or group completes task, it will move to the "Completed Tasks Created by Me" workflow. Note that if you change the task due date to a date in the future, the event will drop out of this workflow. ALL 15 ALL 15 Page 5 of 5

North Carolina Childhood Blood Lead Surveillance Data "Target Population" is based on the number of live births in preceding years. "Number Tested" is an unduplicated count of children tested for lead poisoning within the calendar year. "Percent Tested" is the number of children tested divided by the target population. Children are counted as being tested for lead poisoning in successive years until they are confirmed to have a lead level >10 micrograms per deciliter ( g/dl). Confirmation is based on a child receiving two consecutive blood lead test results >10 g/dl within a sixmonth period. "Confirmed" lead levels are based on the confirmation date and are classified according to the highest level confirmed during the calendar year. The categories "Confirmed 10-19" and "Confirmed >20" are mutually exclusive. "Percent Tested Among Medicaid**" is based on a data match of blood lead tests with Medicaid encounter data and includes ages 9-35 months. This larger 9-35 months category reflects Health Check visits and blood lead testing for children around their first and second birthdays and up to age three. The numbers reported for North Carolina Childhood Blood Lead Surveillance Data may vary somewhat from previous reports due to ongoing data corrections. Last updated 09/24/2009

2010 NORTH CAROLINA CHILDHOOD BLOOD LEAD SURVEILLANCE DATA, BY COUNTY Ages 1 and 2 Years Tested for Lead Poisoning Ages 6 Months to 6 Years Target Number Percent Tested Among Lead Percent Number Confirmed County Population* Tested Tested Medicaid** >10 >10 Tested 10-19 >20 ALAMANCE 3,899 1,963 50.3 73.6 10 0.5 2,575 3 2 ALEXANDER 804 438 54.5 77.1 2 0.5 562 ALLEGHANY 208 151 72.6 86.8 1 0.7 174 ANSON 585 347 59.3 88.6 3 0.9 575 1 ASHE 528 319 60.4 80.4 1 0.3 419 AVERY 318 243 76.4 91.6 0.0 263 BEAUFORT 1,146 812 70.9 88.5 6 0.7 930 4 BERTIE 486 346 71.2 85.4 1 0.3 438 1 1 BLADEN 790 546 69.1 84.3 2 0.4 691 BRUNSWICK 2,282 1,230 53.9 74.7 7 0.6 1,590 1 1 BUNCOMBE 5,413 3,258 60.2 82.8 6 0.2 3,679 1 1 BURKE 2,048 1,492 72.9 90.6 7 0.5 1,753 3 CABARRUS 5,261 3,183 60.5 86.5 14 0.4 3,714 3 CALDWELL 1,710 1,277 74.7 89.8 6 0.5 1,457 1 CAMDEN 194 107 55.2 93.1 0.0 137 CARTERET 1,190 875 73.5 92.2 8 0.9 961 1 CASWELL 434 246 56.7 83.3 1 0.4 324 CATAWBA 3,920 2,526 64.4 85.0 6 0.2 2,933 2 CHATHAM 1,433 604 42.1 78.3 0.0 680 CHEROKEE 517 309 59.8 84.6 0.0 457 1 CHOWAN 364 214 58.8 83.4 1 0.5 253 CLAY 182 125 68.7 91.9 1 0.8 174 CLEVELAND 2,440 1,609 65.9 89.8 5 0.3 2,171 COLUMBUS 1,420 1,047 73.7 89.7 3 0.3 1,346 2 CRAVEN 3,410 2,275 66.7 92.4 10 0.4 2,661 2 CUMBERLAND 11,898 3,732 31.4 76.1 18 0.5 4,627 3 CURRITUCK 448 188 42.0 71.6 1 0.5 270 DARE 802 344 42.9 70.9 6 1.7 403 DAVIDSON 3,884 2,641 68.0 87.3 8 0.3 3,060 1 DAVIE 920 564 61.3 84.1 3 0.5 637 1 DUPLIN 1,629 1,093 67.1 86.9 1 0.1 1,295 1 DURHAM 9,047 4,071 45.0 83.0 14 0.3 5,491 5 EDGECOMBE 1,490 1,054 70.7 85.8 11 1.0 1,209 3 1 FORSYTH 9,930 6,146 61.9 88.5 37 0.6 6,687 9 1 FRANKLIN 1,427 732 51.3 82.4 4 0.5 846 1 GASTON 5,450 1,872 34.3 58.6 9 0.5 2,687 1 2 GATES 220 105 47.7 83.9 1 1.0 154 GRAHAM 182 115 63.2 90.6 0.0 150 GRANVILLE 1,257 574 45.7 72.7 2 0.3 639 2 GREENE 484 276 57.0 73.6 3 1.1 392 GUILFORD 12,531 9,009 71.9 91.2 31 0.3 11,215 10 4 HALIFAX 1,321 1,209 91.5 95.5 9 0.7 1,276 2 3 HARNETT 3,372 1,687 50.0 90.6 15 0.9 2,228 6 1 HAYWOOD 1,174 784 66.8 88.4 3 0.4 864 1 HENDERSON 2,420 1,353 55.9 85.5 3 0.2 1,860 2 1 HERTFORD 634 427 67.4 89.8 1 0.2 518 HOKE 1,807 691 38.2 83.2 1 0.1 808 HYDE 95 56 58.9 91.9 1 1.8 71 IREDELL 3,886 1,666 42.9 82.4 5 0.3 1,999 2 JACKSON 830 426 51.3 89.6 1 0.2 534 1 JOHNSTON 4,956 2,249 45.4 77.4 10 0.4 2,954 4 *Target Population is based on the number of live births in 2008 and 2009 Prepared by NC CLPPP **Includes ages 9-11 months Last updated 11/14/2012

2010 NORTH CAROLINA CHILDHOOD BLOOD LEAD SURVEILLANCE DATA, BY COUNTY Ages 1 and 2 Years Tested for Lead Poisoning Ages 6 Months to 6 Years Target Number Percent Tested Among Lead Percent Number Confirmed County Population* Tested Tested Medicaid** >10 >10 Tested 10-19 >20 JONES 181 162 89.5 81.6 0.0 185 LEE 1,834 1,207 65.8 85.6 7 0.6 1,516 2 1 LENOIR 1,497 951 63.5 92.0 8 0.8 1,512 4 1 LINCOLN 1,809 575 31.8 43.4 3 0.5 847 MACON 737 462 62.7 89.6 2 0.4 626 MADISON 380 274 72.1 91.9 0.0 352 MARTIN 615 406 66.0 88.5 0.0 524 MCDOWELL 1,022 580 56.8 76.3 0.0 692 1 MECKLENBURG 29,355 9,618 32.8 67.0 24 0.2 12,176 8 MITCHELL 328 203 61.9 78.8 1 0.5 223 MONTGOMERY 705 564 80.0 95.6 0.0 703 MOORE 1,932 1,195 61.9 84.5 5 0.4 1,394 2 1 NASH 2,537 1,780 70.2 90.5 14 0.8 2,113 2 NEW HANOVER 4,798 3,181 66.3 88.0 6 0.2 3,986 3 NORTHAMPTON 453 326 72.0 92.5 1 0.3 399 ONSLOW 7,723 2,486 32.2 63.8 7 0.3 2,999 ORANGE 2,678 1,128 42.1 72.6 2 0.2 1,321 PAMLICO 223 155 69.5 82.6 0.0 208 PASQUOTANK 1,102 699 63.4 87.5 6 0.9 835 3 PENDER 1,151 782 67.9 78.6 3 0.4 940 PERQUIMANS 266 173 65.0 90.3 0.0 213 PERSON 951 499 52.5 80.5 6 1.2 701 2 PITT 4,648 1,778 38.3 84.2 6 0.3 2,488 3 POLK 316 145 45.9 79.9 0.0 283 RANDOLPH 3,538 2,099 59.3 83.8 9 0.4 2,586 2 RICHMOND 1,296 735 56.7 79.0 4 0.5 848 1 ROBESON 4,352 2,973 68.3 87.6 11 0.4 3,500 3 ROCKINGHAM 2,098 1,179 56.2 76.2 3 0.3 1,503 2 1 ROWAN 3,526 1,692 48.0 79.6 7 0.4 2,057 2 1 RUTHERFORD 1,446 668 46.2 81.7 0.0 1,063 SAMPSON 1,806 1,307 72.4 89.0 9 0.7 1,487 5 SCOTLAND 1,011 735 72.7 82.6 3 0.4 804 1 STANLY 1,429 1,178 82.4 93.1 6 0.5 1,266 4 STOKES 873 566 64.8 85.1 2 0.4 656 SURRY 1,774 1,176 66.3 82.4 6 0.5 1,355 SWAIN 355 307 86.5 81.6 1 0.3 321 TRANSYLVANIA 611 363 59.4 74.0 1 0.3 515 TYRRELL 98 73 74.5 89.9 0.0 79 UNION 5,308 1,662 31.3 72.7 4 0.2 2,481 2 VANCE 1,249 521 41.7 64.4 4 0.8 635 1 1 WAKE 26,552 10,441 39.3 78.9 27 0.3 12,254 6 WARREN 389 218 56.0 83.5 2 0.9 266 1 WASHINGTON 327 268 82.0 92.8 0.0 313 WATAUGA 756 511 67.6 95.9 1 0.2 635 WAYNE 3,434 2,513 73.2 90.7 4 0.2 3,031 1 WILKES 1,487 645 43.4 81.1 5 0.8 746 2 WILSON 2,259 1,478 65.4 92.6 6 0.4 1,735 1 YADKIN 896 541 60.4 88.1 4 0.7 638 1 YANCEY 356 230 64.6 83.1 0.0 259 STATE 257,543 132,014 51.3 81.1 519 0.4 162,060 146 24 *Target Population is based on the number of live births in 2008 and 2009 Prepared by NC CLPPP **Includes ages 9-11 months Last updated 11/14/2012

Lead Poisoning Prevention and Healthy Homes Outreach Materials Lead Poisoning Can Be Prevented: Some do s and Don ts (English/Spanish) Facts About Lead (English/Spanish) Lead and Eating Habits (English/Spanish) Lead Safe Toys for NC Children (English/Spanish) Are You Pregnant? Protect Your Baby from Lead Poisoning (English/Spanish) 5 Steps to a Healthy Home (English/Spanish) Green Cleaning (English/Spanish) CDC Coloring Book: Ethan s House Gets Healthier With a Visit from the Lead Poisoning Prevention Team (English) www.cdc.gov/nceh/lead/coloring_book/coloring_book.pdf