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DHMH : Request For Comment

 
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Request for Comment on Management of Childhood Lead Exposure
 
In May, 2012, the U.S. Centers for Disease Control and Prevention (CDC) responded to recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) to revise the guidelines for childhood lead poisoning.  The CDC adopted the ACCLPP’s recommendation that eliminated the term “level of concern” (since there is no known safe blood lead level, or BLL) and the recommendation for a new BLL reference level of 5 mg/dL, based on the current lead levels in the population.  The CDC also agreed in principle with ACCLPP recommendations that “no children in the U.S.[should] live or spend significant time in homes, buildings or other environments with lead-exposure hazards.”  However, CDC did not describe a specific plan to achieve this goal.  The CDC also agreed in principle with the ACCLPP’s recommendations that clinicians should:
 
  • [B]e a reliable source of information on lead hazards and take the primary role in educating families about preventing lead exposures. This includes recommending environmental assessments PRIOR to blood lead screening of children at risk for lead exposure. 
  • [M]onitor the health status of all children with a confirmed BLL ≥5 μg/dL for subsequent increase or decrease in BLL until all recommended environmental investigations and mitigation strategies are complete, and should notify the family of all affected children of BLL test results in a timely and appropriate manner. 
  • [E]nsure that BLL values at or above the reference value are reported to local and state health and/or housing departments if no mandatory reporting exists and collaborate with these agencies in providing the appropriate services and resources to children and their families.
 
CDC also accepted in principle other ACCLPP recommendations regarding the need to emphasize the importance of environmental assessments to identify and mitigate lead hazards before children demonstrate BLLs at or higher than the reference value, and adopt prevention strategies to reduce environmental lead exposures in soil, dust, paint, and water before children are exposed.  However, no specific plans were proposed by CDC for these recommendations. 
 
On June 7, 2012, the Department released a letter to health care providers with information about the CDC response and the Department’s position.  Key points of the letter were:
 
  1. There is no change in the recommendations for the age of testing for children in Maryland.  The requirement remains that children living in zip codes identified as “at-risk”) in the Maryland State Targeting Plan (view at-risk zip codes: http://fha.dhmh.maryland.gov/mch/Documents/Lead-revisedatriskareas2004a.pdf), and all children enrolled in Maryland Healthy Kids (EPSDT), should receive a lead test at ages 12 and 24 months.
  2. DHMH, consistent with the new CDC guidance, recommends that children with a lead level greater than the new reference level of 5 mg/dL should be retested within 3 months.  In addition, families whose children have a confirmed level greater than 5 mg/dL should receive lead and nutritional education, and be assessed for possible sources of lead exposure.
  3. There has been no change in the Maryland law related to housing and lead levels.  Maryland law still recognizes a level of 10 mg/dL as the level that triggers regulatory action related to rental housing. 
As noted in the June 7, 2012 letter, children with a venous lead level greater than the new reference level of 5 mg/dL should be retested within 3 months.  A child with a capillary test of 5 – 9 mg/dL should always have a confirmatory venous sample drawn as soon as possible.  In addition, families whose children have a confirmed level greater than 5 mg/dL should receive lead and nutritional education, and be assessed for possible sources of lead exposure.

Referral and Case Management
 
Currently, when the Maryland Childhood Lead Registry (CLR) receives a test of 10 mg/dL or greater, that result is reported to the local health department (LHD) in the jurisdiction where the child resides.
 
At that point, there is typically telephone or in-person contact by a case manager at the LHD with the family, to evaluate possible sources of exposure, discuss clinical follow up if necessary, and otherwise manage the case.  This takes place for approximately 500 new cases each year, under the former CDC guidelines. 
 
An outstanding question is how the new CDC guidelines should influence current protocols for referral and case management. 
 
The Department is considering two alternatives for case management under the new guidelines.  These are:
 
  1. Continue current case management strategies with lower levels – Under this option, there would be no difference between the LHD response to a child regardless of the lead level – as long as the level is 5 mg/dL or higher, the LHD would do the same thing (contact the family, arrange for follow up if necessary).  Health Departments would be instructed to prioritize children with higher lead levels. Without substantial additional funding, this would likely contribute to a significant increase in workload, and could result in delays in processing cases. 
  2. Create an alternative case management strategy for children with lower blood lead levels – This option involves creation of a modified case management strategy, involving greater reliance on follow up by the primary care provider.  Under this strategy, case managers at the LHD would notify the primary care provider, who would be expected to perform follow-up testing, screen family for risk factors, and refer for case management if indicated. 
 
The Department is seeking public comment on the pros and cons of these two strategies and whether other approaches are optimal.  Please comment on whether the current approach to children with lead levels over 10 is optimal for children with leads of 5-9 mg/dL, given potential other sources of lead exposure besides the household for these children.

Look-Back for Children
 
The Department is also requesting comments and public input on the most appropriate management of children who have previously had blood lead levels between 5 – 9 mg/dL.  Prior to the new CDC recommendations, general clinical recommendations were to follow up on children with any detectable lead, since there is no “natural” level of lead in the human body.  However, in practice there may have been children with blood lead levels less than 10 who did not have either a follow up lead test or evaluation to determine whether there was a source of possible lead exposure that could be eliminated.
 
The Department is considering working with MDE to notify parents of children who tested between 5 and 9 mg/dL in recent years of the new levels and recommending retesting as an initial step, to be followed up as appropriate.  Possible reasons for retesting might include confirmation of a single capillary test, tests reported to clinicians only as “less than 10,” or other indications. 
The Department seeks comment on the appropriate length of time for this “look-back,” given the fact that lead exposure peaks by the age of 3 years (36 months) and then starts to decline, particularly after 6 years (72 months) of age.  

The Department requests comments by Friday, September 28, 2012, on these issues and any other recommendations related to the new CDC guidelines.  The Department has also asked the Lead Poisoning Prevention Commission to review public comments and to make recommendations on whether the Department should take any additional action.  The Lead Poisoning Prevention Commission was created by statute in 1994 (Chapter 114, Acts of 1994).  The Commission studies and collects information on the effectiveness of the Lead Poisoning Prevention Program and current risk reduction treatments in reducing exposure to lead as well as risk and liability issues including availability of insurance (Environment Article, Secs. 6-801, 6-848).  In addition to reviewing written comments, the Council will hold a hearing to solicit public input on the questions above on October 11, 2012.  The Commission will then vote on recommendations to forward to the Secretary of Health and Mental Hygiene regarding the consent form and the consent and age verification procedures.  
 
Written comments should be submitted by Friday, September 28, 2012, at 5:00 PM.
 
Comments may be submitted by mail to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 W. Preston St., Room 512, Baltimore, MD 21201 or call 410-767-6499, TTY: 800-735-2258, or by email to dhmh.regs@maryland.gov, or by fax to 410-767-6483.