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Childhood Lead Levels

Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning

Report Number: 2019-105



Lead is a naturally occurring toxic metal with many uses. It is highly damaging when absorbed into the human body, particularly for children. The amount of lead in the environment rose dramatically during the 20th century, reflecting the increased worldwide use of leaded gasoline. Lead was also widely used in house paint and plumbing pipes and fixtures, and it continues to be used in batteries and electronics. Although the federal government has now banned some uses of lead, its nonbiodegradable nature and continuous use means that it has accumulated in the environment, causing lead poisoning in both children and adults. Today lead can be found in the air and soil. It is also present in the drinking water of housing and other structures that contain lead pipes, such as some schools.

Children younger than six years of age are especially vulnerable to lead poisoning and its harmful effects. Because of their increasing mobility and normal developmental behavior, the blood lead concentrations of children in lead‑contaminated environments typically increase rapidly when those children are between the ages of six months and 12 months, and they peak when the children are between 18 months and 36 months of age. Young children also absorb lead more efficiently than adults and are less likely to eliminate it through their waste once it has entered their bodies. Further, children are more sensitive than adults to the negative health effects of lead exposure, some of which may be irreversible.

The primary way to determine whether a child has been exposed to lead is to perform a blood test. Lead exposure is generally measured by the level of lead in a person’s blood, expressed in micrograms per deciliter (micrograms). For the purpose of this report, we define childhood lead poisoning as a child’s blood lead levels reaching or exceeding a concentration of 10 micrograms of lead per deciliter of blood, which is the point at which health care providers in California are required to take action to reduce the child’s lead level. Because California rounds lead test results to the nearest whole number, this definition includes lead levels of 9.5 micrograms and greater.  Although extreme lead poisoning can lead to seizures and death, studies have indicated that even lead levels below 10 micrograms per deciliter can affect normal growth patterns. Studies have also shown that low levels of lead exposure at an early age can lead to reduced IQ, as Figure 1 shows. This exposure can affect children's ability to pay attention and to succeed in school, and it can cause decreased productivity when those children become adults. According to research cited by the American Academy of Pediatrics, one in five cases of attention‑deficit/hyperactivity disorder among U.S. children has been attributed to lead exposure.

Figure 1
Increased Lead Levels Result in Increasingly Harmful Effects and Require More Extensive Treatment and Services

Lead Level
in Micrograms*
Potential Health
Effects Associated With
Elevated Lead Levels

include but are not limited to . . .
California Department of Public Health's (CDPH)
Medical treatment and case management services guidance
> 69.5 Seizure
Retest immediately, then every 2‑4 weeks.
Chemically treat blood to remove lead.
Test kidney function.
44.5‑69.4 Vitamin D deficiency
Impaired tooth and bone development
Obtain abdominal X‑ray.
Retest in 24 or 48 hours, depending on blood lead level, then every 2‑4 weeks.
Consider chemically treating blood to remove lead.
Consider hospitalization.
Test kidney function.
19.5-44.4 Anemia Retest in 1‑4 weeks, then every 2–4 weeks.
State or local prevention program provides full case management services and possible referral to a program for children with serious chronic medical conditions.
14.5‑19.4 May affect the cardiovascular and immune systems Retest in 1‑4 weeks.
State or local prevention program provides full case management services.
9.5‑14.4 Behavioral disorders Retest in 1‑3 months.
If two tests 30 days apart show these levels, state or local prevention program provides full case management services, which include home visits by a public health nurse and an environmental professional.
4.5‑9.4 Damaged hearing Retest in 1‑3 months.
Test for iron insufficiency.
State or local prevention program provides outreach and education.
< 4.5 Decreased IQ level Health care provider assesses nutrition, considers lead exposure risks, and provides counsel on identified risk factors.

Source: CDPH’s California Management Guidelines on Childhood Lead Poisoning for Health Care Providers; California Childhood Lead Poisoning Prevention Branch Information for Health Care Providers; Mayo Clinic; Agency for Toxic Substances and Disease Registry; CDPH budget change proposal.

Note: The sources we cite attribute symptoms to different and imprecise levels of exposure because different individuals may experience symptoms at various levels of exposure. Thus, our presentation of symptoms at certain lead levels is estimated and we do not use this information as the basis for any of the conclusions in our audit.

* CDPH rounds lead levels to the nearest whole number for the purpose of determining treatment and services. This figure presents ranges of lead levels by decimal values and the associated medical treatment and case management services.

Each lead level range on this figure includes the potential health effects and medical treatment listed for that range, among other things, as well as those shown for the levels that fall below the minimum of the range. 

Many California Children Face the Health Risks of Lead Exposure

Thousands of California children have experienced elevated lead levels. For the purpose of this report, we define an elevated lead level as the point at which a lead test indicates a child’s blood has reached or exceeded a concentration of 4.5 micrograms.  The California Department of Public Health (CDPH)—which receives lead test results from laboratories and health care providers—provided reports showing that the percentage of children with elevated lead levels has dropped considerably since 2010, and the number of children tested also decreased significantly. Nevertheless, as Table 1 shows, nearly 10,000 children in California in 2017 had elevated lead levels that met or exceeded CDPH’s criteria to provide, at a minimum, education and outreach related to lead poisoning. Of these children, 86 percent were younger than six years old. Further, the number of children with lead at these elevated levels increased by more than 1,000 from 2015 to 2017, even as the number of children tested declined by nearly 15,000.

Table 1
Thousands of Children Statewide Had Elevated Lead Levels
in Calendar Years 2015, 2016, and 2017
year Number of Children With
Elevated Lead Levels
Ages 0–20
Total Number of
Children Tested
Ages 0–20

Source: Summary lead test data provided by CDPH.

Residential sources of lead exposure pose a health hazard to children in California. Lead‑based paint and lead‑contaminated dust in older buildings, along with lead‑contaminated soil, are the most common sources of exposure for children with elevated lead levels. Lead‑contaminated dust in homes is frequently a byproduct of deteriorating lead‑based paint on surfaces, especially those that rub together, such as sliding windows. Similarly, urban soil has often been contaminated by the past use of lead‑based paint and leaded gasoline, among other sources. In some communities, airborne emissions from the ongoing operation of battery recyclers, incinerators, and piston engine aircraft also may contaminate soil. Other sources of lead poisoning include certain imported foods and spices, traditional remedies, cosmetics, ceramic dishware, jewelry, toys, bullets, and fishing weights, as Figure 2 shows. Finally, take‑home lead exposure—when children are exposed to lead that adults bring home from their jobs—is another common source of childhood lead poisoning. A CDPH analysis of the sources of lead exposure for a sample of 188 children in 31 counties during fiscal year 2015–16 indicated that the children were exposed to lead from a variety of sources, including 30 from take‑home sources and 37 from items such as cosmetics or remedies.

Figure 2
Sources of Lead Exposure

A series of eight pictographs representing sources of lead exposure.

Source: U.S. Centers for Disease Control and Prevention and CDPH health education materials.

The State and the federal government have been working for decades to prevent childhood lead poisoning. Congress approved the creation of the U.S. Environmental Protection Agency (EPA) in 1970 to address a variety of environmental concerns. In 1971 Congress passed the Lead‑Based Paint Poisoning Prevention Act to determine the nature and extent of the problem of lead‑based paint poisoning and how lead paint hazards could most effectively be removed from housing where children might be exposed. In 1973 the EPA implemented regulations that began reducing the lead content in leaded gasoline in 1975. The federal government banned the manufacture of lead paint for use in residential properties in 1978 and banned lead pipes in 1986, and in 1990 it prohibited the sale of leaded automobile gasoline after 1995. Additionally, Figure 3 shows that the U.S. Centers for Disease Control and Prevention (CDC) has gradually lowered the definition of an elevated blood lead level from 60 micrograms in 1960 to 5 micrograms in 2012, when it concluded that no level of lead exposure is safe.

Figure 3
California and the Federal Government Have Taken a Variety of Steps to Address Lead Poisoning

A timeline from 1960 to 2020 showing how the lead level the CDC considers to be elevated has decreased, along with steps California and the federal government have taken to address lead poisoning.

Source: State and federal law; CDC; U.S. Environmental Protection Agency; U.S. Consumer Product Safety Commission; The Journal of Clinical Investigation.

Although federal law no longer allows lead to be used in residential paint, gasoline, or plumbing, lead contamination from these and a variety of other sources continue to contribute to childhood lead exposure. Because of lead’s durability, lead paint and plumbing lines frequently remain for many decades after installation. Also, according to the federal Agency for Toxic Substances and Disease Registry, lead that falls onto soil sticks to soil particles and lingers in the upper layer, which is why past uses of lead in gasoline and paint continue to contribute to the lead found in soil today. Finally, lead is still used for other purposes, as Figure 2 shows, and is still used in some products in other countries. Children in California can be exposed to these products through foreign travel or through the importation of the products.

The California State Legislature declared that childhood lead exposure was the most significant childhood environmental health problem in the State when it established the State’s Childhood Lead Poisoning Prevention Program (lead prevention program) in 1986 to, among other things, reduce the incidence of excessive childhood lead exposures. In 1991 the Legislature expanded the lead prevention program to include case management for children with lead poisoning and lead testing for at‑risk children. At the same time, it created a fee that manufacturers of certain products that contribute or have contributed to environmental lead contamination must pay to help support the lead prevention program.

With Limited Exceptions, State and Federal Requirements Mandate That Children Enrolled in Medi‑Cal Receive Lead Tests

In accordance with state law, California employs a targeted approach for testing children the State believes to be at the greatest risk of lead poisoning. This includes testing children enrolled in the California Medical Assistance Program (Medi‑Cal) or other publicly funded programs for low‑income children. With limited exceptions, state and federal requirements mandate that all children enrolled in Medi‑Cal receive lead screening tests at 12 months of age and again at 24 months of age. DHCS, which oversees the Medi‑Cal program, adopted a schedule of care for children in Medi‑Cal that includes these required tests. However, according to federal Medicaid data for 2017, California ranked 31st among states in the nation for providing lead tests to children at these ages.

State regulations also generally require that children in Medi‑Cal from two to six years of age who were not tested at age two be tested whenever their providers become aware of the missed test. Further, state regulations require that health care providers inform parents or guardians of all children—whether or not they are in Medi‑Cal—about lead poisoning at each periodic health assessment from the time they begin to crawl until six years of age. DHCS’ recommended schedule of care for children in Medi‑Cal also includes periodic lead risk assessments from age six months to six years. Moreover, beginning January 1, 2018, state law has required CDPH to develop regulations identifying which environmental risk factors health providers must consider when determining whether children are at risk of lead poisoning. Although state law permits parents or guardians to refuse lead tests for their children, CDPH and DHCS both stated that they do not track these refusals.

CDPH Contracts With County and City Agencies to Reduce and Prevent Lead Poisoning in Children

Although DHCS oversees the provision of lead tests to children in Medi‑Cal, CDPH is the state agency responsible for overseeing the statewide lead prevention program and implementing it in a way that will reduce the incidence of excessive childhood lead exposures. In addition, when lead tests identify that a child has lead poisoning, state law requires CDPH to ensure the delivery of appropriate case management services for that child. These case management services include nutritional assessments and home visits by public health nurses, as Table 2 describes.

Table 2
Children With Lead Poisoning Are Provided Access to a Variety of Services
Examples of Services Description
Nutritional Assessment An assessment of the child’s nutritional status by a public health nurse or the child's health care provider. This assessment includes evaluating eating habits, dietary intake, and possible food sources of lead poisoning. Nutritional guidance can be instrumental in decreasing the child’s susceptibility to lead absorption and retention.
Home Visit A visit by a public health nurse to the child's home to perform a nutritional assessment, assess the needs and capabilities of the family, explain the case management services the State or local prevention program will provide, educate the family about lead poisoning, discuss the importance of follow-up tests, and help the family understand practical approaches to reducing lead exposure in the home. The public health nurse also searches for possible sources of lead poisoning, such as imported food and spices and lead-soldered cans. CDPH recommends that the home visit and environmental investigation be conducted together, if possible.
Environmental Investigation An environmental professional holding one of several qualifications, such as certification as a CDPH inspector/assessor, performs an assessment at the address at which the child resides. The assessment consists of a number of elements, including testing potential sources of lead poisoning, such as paint, dust, soil, and water. If lead hazards are identified, the environmental professional notifies the property owner of the requirement to abate the hazards and must follow up with the property owner until the lead hazards are abated. After the lead hazard control work is performed, the environmental professional performs a clearance inspection to ensure that the work was performed and no lead contaminated dust remains. As resources permit, environmental inspections may also be performed at an additional property where the child spends a significant amount of time. CDPH recommends that the home visit and environmental investigation be conducted together if possible.

Source: CDPH Childhood Lead Poisoning Prevention Branch Public Health Nurse Case Management Guidance Manual; the Childhood Lead Poisoning Prevention Branch Guidance Manual for Environmental Professionals; CDPH’s fiscal year 2016–17 Childhood Lead Poisoning Prevention Branch budget change proposal.

As Figure 4 illustrates, CDPH currently contracts with 50 local prevention programs. These programs are located in 46 counties, three cities, and the city and county of San Francisco. The programs—which local public health departments operate—are intended to accomplish a number of goals, such as increasing the testing of at‑risk children, providing case management for children with lead poisoning, and eliminating certain sources of lead exposure. In some contracted counties, CDPH performs the environmental investigations, during which an inspector examines a child’s home for sources of lead exposure. In areas where the local public health departments choose not to contract with CDPH, CDPH provides the required case management services directly. However, two noncontracted counties currently perform their own environmental investigations, while CDPH provides the public health nursing services in those counties. Figure 5 shows the relationships between CDPH, DHCS, and local prevention programs.

Figure 4
Local Prevention Programs Provide Case Management Services for Most Children With Elevated Lead Levels

A color-coded map of California showing that 97 percent of children up to age 21 with elevated lead levels live in areas of the State where local prevention programs provide case management services.

Source: Source: Interviews with CDPH staff, auditor analysis of CDPH’s 2017 blood lead data, and CDPH’s list of local public health agencies it allocated funds to for participation in the lead prevention program for fiscal years 2017–18 through 2019–20.

Note: California has 61 local public health officers, one in each of the 58 counties, including the city and county of San Francisco, and in the cities of Berkeley, Long Beach, and Pasadena. Local prevention programs in Long Beach and Pasadena provide case management services and environmental investigation services. Berkeley provides case management services, but CDPH provides environmental investigation services in that city.

Figure 5
DHCS and CDPH Both Have Responsibilities Related to Lead Poisoning

A diagram showing DHCS oversees Medi-Cal while CDPH oversees the Childhood Lead Poisoning Prevention Program, and both have responsibilities related to lead poisoning.

Source: State law; local prevention program contracts; CDPH and DHCS publications; U.S. Census Bureau; interviews with CDPH and DHCS staff.

* As Figure 4 shows, 97 percent of children up to age 21 in the State with elevated lead levels live in areas where local prevention programs provide case management services, and 3 percent live in areas where CDPH provides case management services.

The Lead Prevention Program Relies on a Dedicated Funding Source but Is Currently Operating at a Deficit

The lead prevention program is funded through fees that the State collects from manufacturers or other parties that have contributed or currently contribute to environmental lead contamination. State law has required these manufacturers and other parties to pay this fee annually since 1993. The Legislature originally capped the total amount that the State could collect from this fee at $16 million per year, adjusted for inflation. However, CDPH used its authority through state law to issue regulations effective 2001 to increase this amount to $22 million, after we recommended that it do so in our May 2001 report titled Department of Health Services: Additional Improvements Are Needed to Ensure Children Are Adequately Protected From Lead Poisoning, Report 2000‑013. In that report, we discussed projected funding shortfalls that threatened the level of services CDPH’s lead prevention program was providing.

CDPH retains any unspent funds it collects in the Childhood Lead Poisoning Prevention Fund (lead prevention fund), which the Legislature established. As a result of various legal settlements, the reserve balance in this fund increased from $2 million in fiscal year 2007–08 to $63 million in fiscal year 2011–12. However, after several years when it mostly operated at a surplus, the lead prevention program operated at a deficit in fiscal year 2014–15. Further, when CDPH broadened its definition of lead poisoning to include lower lead levels in fiscal year 2016–17, it increased its program costs and used its reserves to make up for the shortfall. By fiscal year 2018–19, the program’s budgeted operating deficit had increased to more than $13 million per year.

As Figure 6 shows, at its current spending rate and without a fee increase, we project that CDPH will deplete its fund balance during fiscal year 2021–22. This projection takes into account that in 2019 CDPH received approval to spend an additional $9 million from the lead prevention fund for state operations—$8 million of which is for an information technology project. These expenditures will increase the lead prevention program’s deficit to more than $23 million in fiscal year 2019–20, or more than twice as much as it will receive from the lead prevention fee, thereby accelerating the depletion of its reserves. CDPH is considering increasing the total fees by $21.5 million annually, roughly double the amount it currently collects. Because state law requires that the lead prevention program be fully supported by the revenue collected from the lead prevention fee, CDPH stated that unless a fee increase is approved, it will not be able to pay for its expected level of operations. According to CDPH, it has not identified the specific services it would have to reduce.

Figure 6
Without an Increase in the Lead Prevention Fee or a Reduction in Expenditures, the Lead Prevention Fund is Forecast to Deplete its Fund Balance in Fiscal Year 2021–22

A line graph showing CDPH's lead prevention program expenditures exceed its revenues, and its fund balance is projected to be depleted during fiscal year 2021-22.

Source: Auditor-generated from the state budget and CDPH lead prevention program budget documents.

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