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Testing recommendations from the Centers for Disease Control and Prevention

There is no safe level of blood lead concentration. According to the CDC, children should be tested by venous blood draw for lead exposure above the BLRV at:

• 12 months
• 24 months
• Or at least once before age 6 if not previously tested

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Contents

• Guidelines for Testing by Coverage Type
• Council of State and Territorial Epidemiologists Definitions
• Additional Screening Recommendations

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Guidelines for Testing by Coverage Type

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Age	Children Covered by Medicaid and NV Checkup	Children Covered by Private Insurance
1 year (9-17 months)	Blood lead test mandatory	Blood lead test unless annual risk assessment questionnaire is negative
2 years (18-36 months)	Blood lead test mandatory	Blood lead test unless annual risk assessment questionnaire is negative
3-5 years (36-72 months)	If not previously tested: conduct blood lead test If previously tested: Blood lead test yearly unless annual risk assessment questionnaire is negative.	Yearly blood lead test unless annual risk assessment questionnaire

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Council of State and Territorial Epidemiologists Definition of Lead Poisoning

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Laboratory Criteria for Diagnosis Blood lead concentration, as determined by a Clinical Laboratory Improvement Amendments (CLIA)-certified facility, of ≥3.5 µg/dL (0.169 µmol/L) in a child (person <16 years of age). Criteria to Distinguish a New Case from an Existing Case Counted once per year, regardless of the number of blood lead levels above the CDC's BLRV in the same year. Case Classification

• Confirmed One venous blood specimen with a lead concentration above the BLRV, or two capillary blood specimens, drawn within 12 weeks of each other, both with lead concentration above the BLRV.
• Unconfirmed A single capillary or unknown blood specimen with a lead concentration above the BLRV or two capillary blood specimens, drawn greater than 12 weeks apart, both with lead concentration above the BLRV.
• Case Classification Comments Lead exposure above the CDC's BLRV, as defined above, should be used as standard criteria for case classification for the purposes of surveillance but may not correspond to action levels determined by individual public health programs or by providers with respect to patient care.

The classification of lead exposure above the CDC's BLRV does not use any case classification categories other than “confirmed” and “unconfirmed”. The “unconfirmed” category identifies tested children with a potential lead exposure above the BLRV but where testing was inadequate to make that determination.   .

Additional Screening Recommendations

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Currently, screening rates in Nevada for blood lead levels in children are lower than 3%, making it difficult to know the totality of pediatric lead poisoning in Nevada. Therefore, the NvCLPPP and CDC recommend universal screening as a method to adequately assess individual patient needs and population-level epidemiological data. However, at a minimum the NvCLPPP recommends: Providers should screen all children in accordance with the CDC guidelines for blood lead to ensure the best health outcomes. Providers should also screen children who are symptomatic or potential exposure to lead has been identified, regardless of the child's age. Providers for children not eligible for Medicaid or NV Checkup should - at a minimum - conduct a lead risk evaluation using the Childhood Lead Risk Questionnaire (CLRQ) to determine the risk of potential exposure during a healthcare visit if screening is not a viable option. The CLRQ was adapted from the Illinois Department of Public Health. Children of all ages who are recent immigrants, refugees, or adoptees are more likely to have lead exposure above the CDC's BLRV and should be screened at the earliest opportunity.  Additionally, children who live in lower socioeconomic areas may be at higher risk. Consider a blood test, regardless of age, if children have any of the following conditions:

• Unusual oral behavior, pica, developmental delays, behavior problems, ADHD
• Unexplained illness such as severe anemia, lethargy, abdominal pain
• Ingestion of paint chips or object that might contain lead

Recommended Testing Schedule for Recently Arrived Children Who Are Refugees

• Perform a blood lead test for children aged 6 months to 16 years within 30 days of entry to the US
• Within 3-6 months of an initial test, conduct a follow-up test for children aged 6 months to 6 years, regardless of the initial test result
• Consult the US CDC screening guidelines for children who are immigrants and refugees.

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Contents

• Screening Via Capillary Test Or Venous Draw
• Capillary Test Confirmation Schedule

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Screening Via Capillary Test Or Traditional Venous Draw

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Providers have the option of screening via capillary test or traditional venous draw. Capillary blood analysis may be completed using a CLIA waved in-office testing device, such as the Magellan LeadCare II device, and directly reporting the results to the local health authority. All capillary screening results must be reported to the local health authority, as required by NRS 441A. For help obtaining an in-office capillary blood lead testing device, contact the NvCLPPP at 702-895-1040. Higher capillary test results necessitate the urgent need for venous test confirmation. Venous test results are required to access health authority services. .

Capillary Test Confirmation Schedule

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Capillary Blood Lead Level µg/dL	Time to Confirmation Testing
≥3.5-9	Within 3 months
10-19	Within 1 month
20-44	Within 2 weeks
≥45	Within 48 hours

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Notification of the local health authority

Contents

• Lead Exposure Is A Reportable Condition By Law
• Clark County
• Washoe County
• Carson City
• Rural Counties

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Lead Exposure Is A Reportable Condition By Law

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In the state of Nevada, lead exposure is a reportable condition by law. Per NRS 441A, reports of specified diseases, outbreaks, and extraordinary occurrences of illness MUST be made to the local health authority. This law requires physicians, registered nurses, and directors of medical facilities to report lead exposure and blood lead levels above the CDC's BLRV as events of concern. Failure to report is a misdemeanor and subject to an administrative fine of $1,000 for each violation. Provider Disease Reporting may be accomplished by contacting your local health authority through the following methods: .

Clark County

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• Electronically (Preferred) SNHD Reporting Forms https://www.southernnevadahealthdistrict.org/diseasereports/forms/disease-reporting
• Telephone Southern Nevada Health District 702-759-1300
• Fax the Nevada Confidential Morbidity Report Form to 702-759-1454

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Washoe County

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• Telephone Washoe County Health District 775-328-2447 or Email epicenter@washoecounty.us
• Fax the Nevada Confidential Morbidity Report Form to 775-328-3764

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Carson City

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• Telephone Carson City Health and Human Services 775-887-2190
• Fax the Nevada Confidential Morbidity Report Form to 775-887-2138

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Rural Counties

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• Telephone Nevada Division of Public and Behavioral Health 775-684-5289
• Fax the Nevada Confidential Morbidity Report Form to 775-850-1144

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BLL Test Results (μg/dL)	Venous Confrmation Retest Within	Recommended Actions based on BLL	Venous Retest After Recommended Actions
< 3.5	None	Education on the sources and prevention of lead exposure Routine assessment focusing on iron and calcium intake Follow-up blood lead monitoring at recommended intervals	Retest according to Blood Lead Screening Plan
≥3.5 - 9	3 mo	Above Actions, plus: Environmental exposure history to identify potential lead sources Refer to health department for environmental investigation of home Lab work: iron status, hemoglobin, hematocrit Discuss child's diet and nutrition with focus on calcium and iron and refer to supportive services if needed (WIC) Developmental monitoring and referral to support services if needed	3 months for frst 2-4 tests 6-9 months after BLL are declining
10 – 19	1 mo		1-3 months for frst 2-4 tests 3-6 months after BLL are declining
20 – 44	Within 2 Weeks	Above Actions, plus: Complete history and physical exam Environmental investigation of home and refer for lead hazard reduction program Consider abdominal x-ray (if lead ingestion is suspected) Contact Pediatric Environmental Health Specialty Unit (PEHSU) or Nevada Poison Center (1-800-222-2222) for guidance	2 weeks-1 months for frst 2-4 tests 1-3 months after BLL are declining
≥45	ASAP Within 48 hours	Above Actions, plus: Complete history and physical exam with detailed neurological exam Perform abdominal X-ray and, if needed, bowel decontamination Consider hospitalization if lead-safe environment cannot be assured, or source of lead has not been identifed and further exposure possible Commence gastrointestinal decontamination or chelation therapy with consultation from medical toxicologist or pediatrician experienced in treating lead poisoning	Every 24 hours or as medically indicated

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Resources for education and lead-safe homes

Services are available for families of children with lead exposure above the CDC's BLRV to evaluate and place them into programs appropriate for their level of ability. The Southern Nevada Health District provides a full lead investigation of a child’s home environment when a venous blood lead test result is 10 μg/dL or greater.

Contents

• Nevada Early Intervention Services (NEIS)
• Child Find Department

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Nevada Early Intervention Services (NEIS)

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Nevada Early Intervention Services (NEIS) provides an evaluation of children’s development and services at no cost to children 3 years old and younger at no cost. dhhs.nv.gov/programs/idea/early_intervention_programs

Child Find Department

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Child Find Department offers services for children age 4 and older through the family’s local school district at no cost. dhhs.nv.gov/programs/idea/projectassist/local-resources

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Below is a small selection of leading and novel research in the field of environmental lead exposure that discusses the health, cognitive, social and physiological effects of lead exposure in our communities. Continued research is essential to assisting healthcare providers and public health practitioners in advocating for best practices that lead to the best health outcomes for the populations that we serve.

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Title	Author(s)
Update of the Blood Lead Reference Value — United States, 2021	Ruckart, P. Z., Jones, R. L., Courtney, J. G., LeBlanc, T. T., Jackson, W., Karwowski, M. P., Cheng, P. Y., Allwood, P., Svendsen, E. R., & Breysse, P. N. (2021). Update of the blood lead reference value – United States, 2021. Morbidity and Mortality Weekly Report, 70(43), 1509–1512. https://doi.org/10.15585/mmwr.mm7043a4
Biological Factors That Impact Variability of Lead Absorption and Blood Lead Level Estimation in Children: Implications for Child Blood Lead Level Testing Practices	Del Rio, M., Sobin, C., & Hettiarachchi, G. (2022). Biological factors that impact variability of lead absorption and blood lead level estimation in children: Implications for child blood lead level testing practices. Journal of Environmental Health, 85(5).
Both physiology and epidemiology support zero tolerable blood lead levels	Shefa, S. T., & Héroux, P. (2017). Both physiology and epidemiology support zero tolerable blood lead levels. Toxicology Letters, 280, 232–237. https://doi.org/10.1016/j.toxlet.2017.08.015
Relationship Between Primary Language Spoken at Home and Blood Lead Levels in Children from Northeast Ohio, United States: A Retrospective Cohort Study	Shakya, S., Ojha, S., White, P.C., Bhatta, M.P. (2022). Relationship between primary language spoken at home and blood lead levels in children from Northeast Ohio, United States: A retrospective cohort study. Journal of Immigrant and Minority Health. https://doi.org/10.1007/s10903-022-01432-7
An interdisciplinary team-based approach for significantly reducing lower-level lead poisoning in U.S. children	Del Rio, M., Obeng, A., Galkaduwa, B., Rodriguez, C., Costa, C., Chavarria, C.A., Navarro, E.A., Avila, J., Wekumbura, C., Hargrove, W.L., Hettiarachchi, G., Sobin, C. (2023). An interdisciplinary team-based approach for significantly reducing lower-level lead poisoning in U.S. children. Toxicology Reports, 10, 76-86. https://doi.org/10.1016/j.toxrep.2022.12.004
Health Remedies as a Source of Lead, Mercury, and Arsenic Exposure, New York City, 2010–2019	Hore, P., Alex-Oni, K., Sedlar, S., Patel, K., Saper, R.B. (2022). Health remedies as as a source of lead, mercury, and arsenic exposure, New York City, 2010-2019. American Journal of Public Health, 112, S730-S740. https://doi.org/10.2105/AJPH.2022.306906
Bioaccumulation of lead (Pb) and its effects on human: A review	Collin, S.M., Venkatraman, S.K., Vijayakumar, N., Kanimozhi, V., Arbaaz, S.M., Stacey, R.G.S., Anusha, J., Choudhary, R., Lvov, V., Tovar, G.I., Senatov, F., Koppala, S., Swamiappan, S. (2022). Bioaccumulation of lead (Pb) and its effects on human: A review. Journal of Hazardous Materials Advances, 7, Article 100094. 10.1016/j.hazadv.2022.100094.
Lead Poisoning in Children	Warniment, C., Tsang, K., & Galazka, S. S. (2010). Lead poisoning in children. American Family Physician, 81(6), 751-757.
Low-level lead exposure and mortality in US adults: a population-based cohort study	Lanphear, B.P., Rauch, S., Auinger, P., Allen, R.W., Hornung, R.W. (2018). Low-level lead exposure and mortality in US adults: A population-based cohort study. The Lancet Public Health, 3(4), e177-e184. https://doi.org/10.1016/S2468-2667(18)30025-2
Childhood Lead Poisoning	World Health Organization. (2010, September 1). Childhood lead poisoning. https://www.who.int/publications/i/item/childhood-lead-poisoning
Lead and Arsenic in Shed Deciduous Teeth of Children Living Near a Lead-Acid Battery Smelter	Johnston, J. E., Franklin, M., Roh, H., Austin, C., Arora, M. (2019). Lead and arsenic in shed deciduous teeth of children living near a lead-acid battery smelter. Environmental Science & Technology, 53(10), 6000-6006. https://doi.org/10.1021/acs.est.9b00429
Pb Neurotoxicity: Neuropsychological Effects of Lead Toxicity	Mason, L. H., Harp, J. P., & Han, D. Y. (2014). Pb neurotoxicity: Neuropsychological effects of lead toxicity. BioMed Research International, 2014, Article 840547. https://doi.org/10.1155/2014/840547
Policy Statement - Lead Exposure in Children: Prevention, Detection, and Management	American Academy of Pediatrics Committee on Environmental Health. (2005). Lead exposure in children: Prevention, detection, and management. Pediatrics, 116(4), 1036-1046. https://doi.org/10.1542/peds.2005-1947
NTP Monograph on Health Effects of Low-Level Lead	US Department of Health and Human Services. (2012). NTP monograph on health effects of low-level lead. NTP monograph, 1, xiii, xv-148.
Low-level environmental lead exposure still negatively associated with children’s cognitive abilities	Earl, R., Burns, N., Nettelbeck, T., & Baghurst, P. (2016). Low-level environmental lead exposure still negatively associated with children’s cognitive abilities. Australian Journal of Psychology, 68(2), 98-106. https://doi.org/10.1111/ajpy.12096
Lead in Spices, Herbal Remedies, and Ceremonial Powders Sampled from Home Investigations for Children with Elevated Blood Lead Levels - North Carolina, 2011-2018	Angelon-Gaetz, K. A., Klaus, C., Chaudhry, E. A., & Bean, D. K. (2018). Lead in spices, herbal remedies, and ceremonial powders sampled from home investigations for children with elevated blood lead levels - North Carolina, 2011-2018. Morbidity & Mortality Weekly Report, 67(46), 1290–1294. https://doi.org/10.15585/mmwr.mm6746a2
Intellectual Impairment in Children with Blood Lead Concentrations below 10 μg per Deciliter	Canfield, R. L., Henderson, C. R., Jr., Cory-Slechta, D. A., Cox, C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual impairment in children with blood lead concentrations below 10 μg per deciliter. New England Journal of Medicine, 348(16), 1517-1526. https://doi.org/10.1056/NEJMoa022848
Association Between Maternal Exposure to Lead, Maternal Folate Status, and Intergenerational Risk of Childhood Overweight and Obesity	Wang, G., DiBari, J., Bind, E., Steffens, A.M., Mukherjee, J., Azuine, R.E., Singh, G.K., Hong, X., Ji, Y., Ji, H., Pearson, C., Zuckerman, B.S., Cheng, T.L., & Wang, X. (2019). Association between maternal exposure to lead, maternal folate status, and intergenerational risk of childhood overweight and obesity. JAMA Network Open, 2(10), Article e1912343. doi:10.1001/jamanetworkopen.2019.12343
Very low lead exposure and children's neurodevelopment	Bellinger, D. C. (2008). Very low lead exposures and children's neurodevelopment. Current Opinion in Pediatrics, 20(2), 172–177. https://doi.org/10.1097/MOP.0b013e3282f4f97b
Children's Lead Exposure: A Multimedia Modeling Analysis to Guide Public Health Decision-Making	Zartarian, V., Xue, J., Tornero-Velez, R., & Brown, J. (2017). Children's lead exposure: A multimedia modeling analysis to guide public health decision-making. Environmental Health Perspectives, 125(9), Article 097009. https://doi.org/10.1289/EHP1605
Prevention of Childhood Lead Toxicity	American Academy of Pediatrics Council on Environmental Health. (2016). Prevention of childhood lead toxicity. Pediatrics, 138(1), Article e20161493. https://doi.org/10.1542/peds.2016-1493
Blood Lead Concentrations and Child Intelligence at 6 Years of Age	Jusko, T. A., Henderson, C. R., Lanphear, B. P., Cory-Slechta, D. A., Parsons, P. J., & Canfield, R. L. (2008). Blood lead concentrations < 10 microg/dL and child intelligence at 6 years of age. Environmental Health Perspectives, 116(2), 243–248. https://doi.org/10.1289/ehp.10424
Educational Interventions Children Affected by Lead	U.S. Centers for Disease Control and Prevention Educational Services for Children Affected by Lead Expert Panel, U.S. National Center for Environmental Health Division of Emergency and Environmental Health Services. (2015, April). Educational interventions for children affected by lead. https://stacks.cdc.gov/view/cdc/31182

Lead exposure can cause adverse health effects, even at low levels. A blood test is the best way to know if a child is exposed to lead. However, only 3% of children in Nevada are tested each year.

NvCLPPP can make it easier to do on-site testing by providing:

• A FREE LeadCare II point-of-care system and testing kits
• A $10k mini-grant to establish your clinic’s lead testing policies

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Click here for more information.