Source: Ed Norman, Program Manager Childhood Lead Poisoning Prevention Program, Environmental Health Section
Issue
Included in the recently approved state budget is a special provision, which lowers the blood lead action level triggering an environmental investigation (for children less than 6-years-old) from 10 micrograms per deciliter (µg/dL) to 5 µg/dL to align with the federal guidelines published by the Centers for Disease Control and Prevention in 2012. For children with confirmed blood lead levels of 5 - 9 µg/dL, an investigation must be offered to the family. For children with confirmed blood lead levels of 10 µg/dL or greater, the investigation and remediation of lead hazards are required. The amended state law also includes environmental investigations and remediation for pregnant women with similarly elevated blood lead levels.
Discussion / Rationale
Funding for the expanded program will come from Medicaid receipts, and six new environmental health regional specialist positions have been established to meet the anticipated increase in investigations. We anticipate that the new regional positions will be filled by January 2018 and that most of the new hires will need to receive training to become certified lead risk assessors. Barring additional budgetary or human resource obstacles, we hope to begin implementing the mandatory investigation and remediation components of the amended state law by January 1, 2018; and offering to conduct investigations for children with blood lead levels in the 5 - 9 µg/dL range by July 1, 2018. Unfortunately, the Medicaid reimbursement process does not provide for aid-to-county support, State Laboratory of Public Health (State Lab) funding, or resources for legal assistance. In particular, securing resources for the State Lab is of concern and could limit the extent of environmental sampling conducted during investigations.
To qualify for this expanded environmental service, a child (or pregnant woman) will need to receive two consecutive blood lead test results (within a 12-month period) at or above the new action level(s). Based on consultation with staff at the Office of the Attorney General, this statutory amendment includes the following situations: 1) those whose most recent of two consecutive elevated blood lead tests was drawn on or after July 1, 2017 and 2.) those with two consecutive elevated tests drawn prior to July 1, 2017, but not reported until after July 1, 2017. This caveat should only affect cases identified in the later part of June 2017 for whom laboratories are allowed five calendar days to report test results. In addition, the investigation protocol is still two-tiered. For children with blood lead levels of 5 - 9 µg/dL, only the primary residence is eligible for an investigation. For children with blood lead levels >10 µg/dL, primary and supplemental addresses (e.g., child care centers) must be investigated and remediated. For pregnant women, the focus will be on investigation and remediation of the primary residence, and referrals must come directly from a medical provider.
Response / Interpretation
Since the state program is to be the primary recipient of expanded Medicaid funding, we propose shifting some of the tasks currently conducted by local health departments to the regional specialists in exchange for more limited assistance with an anticipated increased number of investigations. Most notably, the state is offering to write the investigation reports and enter the initial investigation-related data into the NC LEAD surveillance system. Local authorized lead agents will still need to assist with each environmental investigation, issue legal notices (using templates), and enforce remediation requirements as is current policy. Childhood lead will remain a separate authorization track as well.
Counties are encouraged to take on greater responsibility for childhood lead poisoning prevention beyond that stipulated in this updated policy. For instance, four counties (Forsyth, Guilford, Mecklenburg, and Wake) conduct environmental lead investigations independently (without state assistance). These counties share in the small amount of Medicaid reimbursement currently received by the state and will continue to share in the much larger revenue stream anticipated under expanded Medicaid funding (assuming they continue to complete this work independently). In case other counties are interested in revenue sharing, it does require the purchase, licensing, and maintenance of expensive field equipment (i.e., an x-ray fluorescence analyzer) and maintaining a certified lead risk assessor on staff, which involves training beyond authorization.
Finally, the new regional positions will be responsible for all children’s environmental health programs including child care and school sanitation; however, since there will be a total of 10 regional specialists plus a field supervisor and a public health epidemiologist who are certified lead risk assessors, regional territories will be substantially reduced.
Hopefully, even with the increased investigation caseload, the shorter travel within regions will reduce response times for all program areas (including authorizations). I appreciate your continued support for this important public health issue as we continue our work to eliminate childhood lead poisoning. Please call me at 919-707-5951 if you have any questions related to this implementation plan.
References
Appropriations Act of 2017 / Session Law 2017-57 / Senate Bill 257 / Section 11E.6: Implementation of the federal elevated blood lead standard in North Carolina (amends NCGS 130A-131.7 and 130A-131.9)
Centers for Disease Control and Prevention blood lead reference value
** Revisions are bolded.