PHYSICIAN DUTY TO SCREEN FOR CHILDHOOD LEAD POISONING: STRICTER STANDARDS ADOPTED

[Editor’s Note: If you are currently screening for childhood lead poisoning, please note that some standards, forms, and the lead risk questionnaire, have changed recently. Please note the information below.]

As trusted health care providers, chiropractic physicians (and other health care providers) are mandated by law to perform lead poisoning screening on all patients who are 6 years of age or younger (up to the day before the 7^th birthday).  Screening is accomplished by using a Department of Public Health (IDPH) Childhood Lead Risk Questionnaire.  If the results of the questionnaire indicate a high risk of elevated lead levels, further testing or referral is required, as detailed below.  

IDPH has lowered the threshold blood lead level from 10 micrograms per deciliter (µg/dL) to 5 µg/dL as the trigger for public health interventions for these children.  This change conforms to the Centers for Disease Control and Prevention (CDC) childhood lead standards.   Although most experts believe that no level is acceptable, the new 5mg/dL level means that more children will be identified as having lead exposure, allowing earlier corrective action for children.  Screening is especially critical in Illinois, because our state remains one of the highest in the nation for child lead exposure, according to the IDPH. 

ILLINOIS LAW ON LEAD POISONING PREVENTION

The Illinois Lead Poisoning Prevention Act (410 ILCS 45) requires every physician licensed to practice medicine in all of its branches and “health care providers” to perform lead screening on all children through 6 years who reside in an area defined as high risk by the Department of Public Health (DPH).  Even though the term “physicians licensed to practice medicine in all of its branches” refers only to medical and osteopathic doctors, the Department defines “health care provider” as any provider who is authorized to request blood testing under Illinois law.  Because chiropractic physicians are so authorized, they must comply with the lead poisoning prevention law.

WHAT IS REQUIRED? A BRIEF OVERVIEW

Illinois law requires that every health care provider must “screen” ALL children in the targeted age group by using the Department of Public Health Childhood Lead Risk Questionnaire. Screening should be performed at 12 months, 24 months, 3, 4, 5, and 6 years of age.

If any of the answers to the questions on the questionnaire is “yes” or “don’t know” for a particular child, he or she must then undergo blood lead tests. The health care provider may, but is not required to, perform the test in the office.  If the provider performs the test in the office, he or she is required to report the test to the Department of Public Health, as detailed below.

THE LEAD RISK ASSESSMENT PROCESS AND AGE GUIDELINES

Because there are a number of overlapping federal and state regulations for lead testing, including some that apply to children enrolled in federal and state health plans (including All Kids), it can be confusing to decipher when and how often to administer the screenings.  The simplest approach for the provider is found in the “Childhood Lead Risk Assessment Questionnaire” published by the Illinois Department of Public Health.  This form contains the questionnaire, as well as helpful guidelines for the health care provider.  Note that the IDPH updated the questionnaire in 2019, so doctors who have previously used the form must make certain they are now using the most recent version.  All IDPH Lead Program forms can be found here. 

The provider should start by assessing all children through 6 years old with the questionnaire.  The answers will direct the provider to the proper follow-up, because when any question is answered with a “Yes” or “Don’t Know,” a blood lead test should be performed.

Under the questionnaire, certain categories of children are deemed to be at risk and all of the children in those categories will have a “yes” answer.  For example, the Department of Public Health has identified ZIP code areas in which children have an increased risk for exposure to lead due to higher percentages of older homes and low-income families.  All of the children residing in these ZIP codes will have a “yes” response to the questionnaire and will require blood lead testing (for example, the entire City of Chicago).  These ZIP codes are listed by county on the Lead Risk Assessment Questionnaire, as well as on the Department of Public Health website.

CHILDREN WHO ARE REQUIRED TO HAVE BLOOD LEAD TESTS

Under the Lead Risk Assessment Questionnaire, children for whom any of the following answers are “Yes” or “Don’t Know” must undergo blood lead tests):             

1. Does this child reside or regularly visit a home/residential building, child-care setting, school, or other facility built before 1978 or in a high-risk ZIP code area?
   (High-risk ZIP code areas are listed on the reverse side of the questionnaire.)  
2. Is this child eligible for or enrolled in Medicaid, All Kids, Head Start, WIC, or any HFS medical program?

***All Medicaid-eligible children and children enrolled in HFS medical programs shall have a blood lead test at 12 and at 24 months of age. If a Medicaid-eligible child or HFS medical program enrolled child between 36 months and 72 months of age has not been previously tested, a blood lead test shall be performed.

3. Does this child have a sibling with a confirmed blood lead level of 5 μg/dL or higher?
4. In the past year, has this child been exposed to repairs, repainting, or renovation of a building/home built before 1978?
5. Is this child a refugee, adoptee, or recent visitor of any foreign country?
6. Is this child frequently exposed to imported items (such as, ayurvedic medicine, folk medicines, cosmetics, toys, glazed pottery, spices or other food items, sindoor, or kumkum)?
7. Does this child live with someone who has a job or a hobby that may involve lead (for example; jewelry making, building renovation, bridge construction, plumbing, furniture refinishing, work with automobile batteries or radiators, lead solder, leaded glass, bullets, lead fishing sinkers, or recycling facility work)?
8. If the child is younger than 12 months of age, did the child’s mother have a past confirmed blood lead level of 5 μg/dL or higher?
9. Has the water in your home/residential building, child-care setting, school, or other regularly visited facility been tested and had a confirmed level of lead (5 ppb or higher)?
10. Does your child live near an active lead smelter, battery recycling plant, or another industry likely to release lead, or does your child live near a heavily-traveled road where soil and dust may be contaminated with lead?

The guidelines attached to the questionnaire form contain additional step-by-step details regarding follow-up evaluation and testing. 

WHEN THE QUESTIONNAIRE ANSWER IS “YES” OR “DON’T KNOW” — OPTIONS FOR HEALTH CARE PROVIDERS

Due to the number of categories deemed to indicate high lead level risk, many children will require blood testing.  If a “yes” or “don’t know” response is obtained, the health care provider has the following options:

1. The provider may counsel the patient’s parents and refer the patient to a DPH approved provider for blood lead testing.  The provider should carefully document the above, and, if properly documented, those steps will fulfill the provider’s responsibility under DPH regulations.
2. The provider may do the blood draw in office and send the sample to a DPH laboratory.  Again, if carefully documented, these steps will fulfill DPH regulations.
3. The provider may do the blood draw in office and may send to a private laboratory.  However, in this instance, the provider has the added responsibility to report the test to the Department of Public Health.
4. The provider may obtain testing equipment and do the blood draw and testing in the office.  However, in this instance, the provider has the added responsibility to report the test to the Department of Public Health.

It is important to note that all blood lead testing results, whether elevated or normal, must be reported to the Department of Public Health.  Providers who opt to refer the testing out of the office or send a sample to a DPH lab (options 1 and 2 above) do not have to report, because the lab where the testing is done completes the report.  However, under options 3 and 4 above, the provider is required to report all test results.

Regardless of which option the provider chooses, he or she should educate the patient’s parent to the benefits of testing vs. the risks of not testing, and should so document the chart.  From a patient care standpoint, it may be a better option to draw the blood in the office and send it to a DPH lab.  This alternative ensures that the patient is tested, but removes the reporting responsibility from the doctor.

What if the questionnaire results dictate blood testing, but the parent tells the provider that the child has already been tested?  Prudent practice would suggest that the provider document that the parent has indicated the child was already tested; counsel the parent on the benefits of testing and risks of not testing; request the parent to provide documentation that the child has been tested; and if documentation cannot be obtained, refer the parent and patient to a DPH provider for blood testing, noting all of the above in the chart.

REPORTING OF BLOOD LEAD RESULTS

Where providers are required to report results (if they choose options 3 or 4 above), reports should be made to the Illinois Lead Program Reporting system.  Reports may be made by phone to 866-547-3572 or by fax to 217-557-1188.  A blood lead fax reporting form is available here.

Section 7 of the Act requires that ALL blood lead results be reported to the Illinois Lead Program. All blood lead results ≥ 5 μg/dL must be submitted to the Illinois Lead Program within 48 hours. Any person violating this provision can be fined; the IDPH asks that providers who are obligated to report ensure that they report ALL blood lead results (not just elevated levels) to the Illinois Lead Program.

In accordance with the newly adopted amendments to the Code, per Section 845.55(a), case management and environmental investigation will now be initiated for any child with a venous blood lead test of ≥5 μg/dL. Capillary tests are common for initial testing; however, a venous confirmatory test must be obtained if the capillary results are ≥5 μg/dL.  In a case where blood lead results are determined to be elevated, Public Health will assign a case manager and will work with the treating physician to formulate appropriate treatment and follow-up care.

RESOURCES

The Department of Public Health has a number of helpful resources to assist physicians in implementing the lead prevention program.  They have a number of publications on their website, including a lead screening reference guide for physicians and health care providers.  The general website is located here.  In addition, Public Health offers many other forms of assistance to providers, including on-site visits to doctors’ offices where requested. 

The ICS has worked with the Department of Public Health regarding the implementation of lead screening procedures and is available to assist members with questions.  Although these procedures may be unfamiliar, they are designed to identify a potentially devastating health hazard in children.  The law has designated you as a trusted health care provider to be an important part of the process of eradicating this threat. 

LEAD POISONING LINKS 

Childhood Lead Risk Questionnaire (includes list of high-risk Zip codes)

All DPH Lead Program Forms (click on Lead Testing and Case Management for list of forms)

CDC’s Guide to Interpreting and Managing Blood Lead Levels

Illinois Lead Program Surveillance Reports

Find information about Illinois’ Lead Poisoning Prevention Program here.