Blood Lead Screening Research Articles

Who tests for lead and why? A 10-year analysis of blood lead screening & follow-up in a US healthcare system

Who tests for lead and why? A 10-year analysis of blood lead screening & follow-up in a US healthcare system

Who tests for lead and why? A 10-year analysis of blood lead screening, follow-up and CNS outcomes in a statewide US healthcare system

ObjectivesThis study aims to determine (1) which providers in US healthcare systems order lead tests, why and at what frequency and (2) whether current patient population lead levels are predictive...

“Only Time Will Tell”: The Underexplored Impacts of Lead Poisoning and COVID-19 on Pre-Existing ACEs in New York

The peak of the coronavirus-19 (COVID-19) in New York City significantly impacted communities that lived in the New York City Housing Authority (NYCHA). However, these same communities have been historically reported to test positive for lead poisoning due to neglect of proper lead abatement and the removal of lead sources within these buildings. The consequences of these failed actions by NYCHA resulted in multiple generations of lead-poisoned children, which can be argued as a form of mass atrocity and genocide. The long-term neurodevelopmental and socio-economic outcomes of children exposed to lead and COVID-19 remain to be elucidated. This short communication attempts to bring attention to this overlooked matter and draws upon the scarce, but emerging, reports in the literature to start a conversation on the synergistic potential of these looming public health issues. Further, suggestions for providing consistent blood lead screening and COVID-19 testing could serve to clarify whether a “two-hit” hypothesis of a neurotoxicant (lead) and a neuroimmune (COVID-19) virus that produces an Adverse Childhood Experience (ACE-19). More work is needed in this area to (dis)confirm the potential for this “two-hit” hypothesis, and only time will tell.

Stability of blood lead levels in children with low-level lead absorption.

Current child blood lead (Pb) screening guidelines assume that blood lead levels (BLLs) are relatively stable over time, and that only youngest children are vulnerable to the damaging effects of lower-range BLLs. This study aimed to test the stability of lower-range (≤ 10 μg/dL) child BLLs over time, and whether lower-range BLLs diminished with age among children aged 6 months to 16 years living in a lower-income neighborhood with a density of pre-1986 housing and legacy contamination. Age, sex, family income, age of residence, and/or residence proximity to point sources of Pb, were tested as potential additional factors. Capillary blood samples from 193 children were analyzed by inductively coupled plasma mass spectrometry (ICPMS). Multiple imputation was used to simulate missing data for 3 blood tests for each child. Integrated Growth Curve models with Test Wave as a random effect were used to test BLL variability over time. Among N = 193 children tested, at Time 1 testing, 8.7% had the BLLs ≥ 5 μg/dL (CDC "elevated" BLL reference value at the time of data collection) and 16.8% had BLLs ≥ 3.5 μg/dL (2021 CDC "elevated" BLL reference value). Modeling with time as a random effect showed that the variability of BLLs were attributable to changes within children. Moreover, time was not a significant predictor of child BLLs over 18 months. A sex by age interaction suggested that BLLs diminished with age only among males. Of the additional environmental factors tested, only proximity to a major source of industrial or vehicle exhaust pollution predicted child BLL variability, and was associated with a small, but significant BLL increase (0.22 μg/dL). These findings suggest that one or two BLL tests for only infants or toddlers are insufficient for identifying children with Pb poisoning.

Implementation of a pharmacy-based blood lead testing program: A retrospective analysis

In 2014, a change in the water source in Flint, Michigan, exposed residents to dangerous levels of lead in their drinking water. The concern for lead toxicity created the opportunity for pharmacies to provide quick and accessible blood lead testing services. The primary objective was to create a pharmacy-based blood lead testing program through collaboration with the Michigan Department of Health & Human Services and community pharmacies in Flint, Michigan. The partnership was established in 2016 and Magellan LeadCare II blood analyzers were placed at three pharmacies. Walk-in testing was offered from June 2016 to August2016. Community pharmacists aimed to provide more accessible lead screening services to limit health disparities and medical complications. A retrospective analysis using descriptive statistics was conducted to assess the benefits of early blood lead screening and to determine when a patient should seek further evaluation. Blood lead screening values were based on the Center for Disease Control (CDC) and Prevention's blood lead reference value (BLRV). The BLRV at the time of the study was ≥ 5 μg/dL, but this was eventually changed to ≥3.5 μg/dL. A total of 77 individuals were screened in the pharmacies. Four (5%) individuals had lead levels ≥5 μg/dL. Of these, two patients were <6 years of age. Fifteen (19%) patients had lead levels ≥3.5 μg/dL. The highest lead level detected was 24.2 μg/dL in a 70-year-old patient. If the result was ≥5 μg/dL, patients were instructed to follow up with their physician or the Genesee County Health Department. All patients with elevated blood levels were referred to the appropriate health care provider. This model demonstrates the feasibility of a public health/community pharmacy collaborative lead testing program. This program can serve as a template for future crisis-focused collaborative models.

Patterns of Children's Blood Lead Screening and Blood Lead Levels in North Carolina, 2011-2018-Who Is Tested, Who Is Missed?

Background:No safe level of lead in blood has been identified. Blood lead testing is required for children on Medicaid, but it is at the discretion of providers and parents for others. Elevated blood lead levels (EBLLs) cannot be identified in children who are not tested.Objectives:The aims of this research were to identify determinants of lead testing and EBLLs among North Carolina children and estimate the number of additional children with EBLLs among those not tested.Methods:We linked geocoded North Carolina birth certificates from 2011–2016 to 2010 U.S. Census data and North Carolina blood lead test results from 2011–2018. We estimated the probability of being screened for lead and created inverse probability (IP) of testing weights. We evaluated the risk of an EBLL of at of age, conditional on characteristics at birth, using generalized linear models and then applied IP weights to account for missing blood lead results among unscreened children. We estimated the number of additional children with EBLLs of all North Carolina children using the IP-weighted population and bootstrapping to produce 95% credible intervals (CrI).Results:Mothers of the 63.5% of children (402,002 of 633,159) linked to a blood lead test result were disproportionately young, Hispanic, Black, American Indian, or on Medicaid. In full models, maternal age [; 95% confidence interval (CI): 1.13, 1.20] or smoking (1.14; 95% CI: 1.12, 1.17); proximity to a major roadway (1.10; 95% CI: 1.05, 1.15); proximity to a lead-releasing Toxics Release Inventory site (1.08; 95% CI: 1.03, 1.14) or a National Emissions Inventory site (1.11; 95% CI: 1.07, 1.14); and living in neighborhoods with more housing built before 1950 (1.10; 95% CI: 1.05, 1.14) or before 1940 (1.18; 95% CI: 1.11, 1.25) or more vacant housing (1.14; 95% CI: 1.11, 1.17) were associated with an increased risk of EBLL, whereas overlap with a public water service system was associated with a decreased risk of EBLL (0.85; 95% CI: 0.83, 0.87). Children of Black mothers were no more likely than children of White mothers to have EBLLs (0.98; 95% CI: 0.96, 1.01). Complete blood lead screening in 2011–2018 may have identified an additional 17,543 (95% CrI: 17,462, 17,650) children with EBLLs .Discussion:Our results indicate that current North Carolina lead screening strategies fail to identify over 30% (17,543 of 57,398) of children with subclinical lead poisoning and that accounting for characteristics at birth alters the conclusions about racial disparities in children’s EBLLs. https://doi.org/10.1289/EHP10335

Considering Screening When There May Be Minimal Direct Benefit to the Child.

* Abbreviation: CDC — : Centers for Disease Control and Prevention A core principle of screening is that there should be a direct benefit to the patient. This restriction undervalues the impact that screening could have by not considering the population-level benefits to others, including family members, close contacts of affected individuals, and the broader community. Screening for lead poisoning offers an example of how individual screening has resulted in long-term health improvements for many by identifying and abating lead from the environment. The US Preventive Services Task Force states that the balance of information regarding the benefits and harms of screening for elevated blood lead levels is insufficient to recommend for or against it.1 However, lead screening has been associated with significant overall public health improvement. In this commentary, we identify generalizable lessons about when it might be appropriate to screen even if there may be limited direct benefit to the child being screened. Childhood blood lead testing of asymptomatic children began in the 1970s.2 Initially, most blood lead screening was done through local health departments, maternal and child health programs, and other community-based organizations, with support from the Centers for Disease Control and Prevention (CDC) and other federal agencies. Screening was also recommended to occur within primary care and required for Medicaid-enrolled children at 1 and 2 years or by 6 years if not previously done. Regardless of setting, screening was often inconsistent. As late as 1998, only ∼20% of Medicaid-enrolled children had ever received a blood lead test.3 In addition, many children with elevated blood lead levels did not receive follow-up care.4,5 Specific … Address correspondence to Mary Jean Brown, ScD, RN, 157 Leeder Hill Dr #201, Hamden, CT 06517. E-mail: mbrown{at}hsph.harvard.edu

Blood Lead Levels in U.S. Children Ages 1-11 Years, 1976-2016.

Background:Lead can adversely affect child health across a wide range of exposure levels. We describe the distribution of blood lead levels (BLLs) in U.S. children ages 1–11 y by selected sociodemographic and housing characteristics over a 40-y period.Methods:Data from the National Health and Nutrition Examination Survey (NHANES) II (1976–1980), NHANES III (Phase 1: 1988–1991 and Phase II: 1991–1994), and Continuous NHANES (1999–2016) were used to describe the distribution of BLLs (in micrograms per deciliter; ) in U.S. children ages 1–11 y from 1976 to 2016. For all children with valid BLLs (), geometric mean (GM) BLLs [95% confidence intervals (CI)] and estimated prevalence (95% CI) were calculated overall and by selected characteristics, stratified by age group (1–5 y and 6–11 y).Results:The GM BLL in U.S. children ages 1–5 y declined from (95% CI: 14.3, 16.1) in 1976–1980 to (95% CI: 0.78, 0.88) in 2011–2016, representing a 94.5% decrease over time. For children ages 6–11 y, GM BLL declined from (95% CI: 11.9, 13.4) in 1976–1980 to (95% CI: 0.58, 0.63) in 2011–2016, representing a 95.3% decrease over time. Even so, for the most recent period (2011–2016), estimates indicate that approximately 385,775 children ages 1–11 y had BLLs greater than or equal to the CDC blood lead reference value of . Higher GM BLLs were associated with non-Hispanic Black race/ethnicity, lower family income-to-poverty-ratio, and older housing age.Discussion:Overall, BLLs in U.S. children ages 1–11 y have decreased substantially over the past 40 y. Despite these notable declines in population exposures to lead over time, higher GM BLLs are consistently associated with risk factors such as race/ethnicity, poverty, and housing age that can be used to target blood lead screening efforts. https://doi.org/10.1289/EHP7932

Decreases in Young Children Who Received Blood Lead Level Testing During COVID-19 - 34 Jurisdictions, January-May 2020.

Exposure to lead, a toxic metal, can result in severe effects in children, including decreased ability to learn, permanent neurologic damage, organ failure, and death. CDC and other health care organizations recommend routine blood lead level (BLL) testing among children as part of well-child examinations to facilitate prompt identification of elevated BLL, eliminate source exposure, and provide medical and other services (1). To describe BLL testing trends among young children during the coronavirus disease 2019 (COVID-19) pandemic, CDC analyzed data reported from 34 state and local health departments about BLL testing among children aged <6 years conducted during January-May 2019 and January-May 2020. Compared with testing in 2019, testing during January-May 2020 decreased by 34%, with 480,172 fewer children tested. An estimated 9,603 children with elevated BLL were missed because of decreased BLL testing. Despite geographic variability, all health departments reported fewer children tested for BLL after the national COVID-19 emergency declaration (March-May 2020). In addition, health departments reported difficulty conducting medical follow-up and environmental investigations for children with elevated BLLs because of staffing shortages and constraints on home visits associated with the pandemic. Providers and public health agencies need to take action to ensure that children who missed their scheduled blood lead screening test, or who required follow-up on an earlier high BLL, be tested as soon as possible and receive appropriate care.

A new screening index to better target low-level lead exposure in Atlanta, Georgia

Lead poisoning is often seen as a problem of the past. While acute cases are now rare, there is no known safe level of lead for children and blood lead levels at and below 5 μg/dL are associated with neurological deficits. Previous work has established that risk factors for lead exposure include race/ethnicity, poverty, Medicaid enrollment, housing built before 1950, and age. Efficient blood lead screening is crucial in the greater Atlanta area as pockets of poverty and old housing put some children at particularly high risk for chronic exposure to low levels of lead. Here, 20 years of data on children’s blood lead levels in Georgia were used to create maps to assess the spatial distribution of blood lead screening and blood lead levels in the Atlanta area. ZIP code tabulation area (ZCTA)-level screening rates continue to be associated with relative poverty but not with housing age, a well-established risk factor for lead exposure. Building on previous research, a priority screening index based on poverty and housing age was also created to identify specific high-risk census tracts for screening within Atlanta ZCTAs. This index shows a total of 18 highest-priority census tracts in the greater Atlanta area. Together, these 18 tracts contain 2715 children under six years old, 1.7% of all children under six years old in the entire greater Atlanta area.

Blood Lead Testing Among Medically Underserved and Socially Vulnerable Children in the United States 2012-2017.

Lead poisoning can affect intellectual development, growth, hearing, and other health problems. Children 6 years or younger are particularly susceptible to lead poisoning. Health Resources and Services Administration (HRSA)-funded health centers (HCs) serve lower-income, minority, and vulnerable populations across the United States, who may be at a higher risk for lead exposure. At HCs, blood lead testing is monitored; however, little is known about testing rates and characteristics of children tested by HCs. We assessed the prevalence and characteristics of children who received a blood lead test at HCs from 2012 to 2017. We assessed characteristics of children 12 to 60 months of age who had a blood lead test using available self-reported data from HRSA's Health Center Patient Survey (2014-2015). In addition, using HRSA's Uniform Data System, an administrative performance data set, we calculated the annual percentage change of blood lead testing from 2012 to 2017. During 2014-2015, 1.1 million (72.9%; 95% CI, 64.6-81.3) out of the 1.5 million (n = 365 unweighted) eligible children 12 to 60 months of age self-reported receiving a blood lead test at an HRSA-funded HC. There was a significant higher proportion of children with a blood lead test among urban HCs (74.1%; 95% CI, 59.4-88.8) and among those who reported HCs as their usual source of care (99.9%; 95% CI, 99.7-100) (P ≤ .05).The total HC population of children younger than 72 months increased from 2 674 500 in 2012 to 2 989 184 in 2017, and we observed a 34.4% increase in blood lead testing at HRSA-funded HCs over the same time period. HCs play an important role in providing access to blood lead testing in underserved communities in the United States. While HRSA-funded HCs have made substantial efforts to screen and educate patients on lead exposure, nonetheless continued screening and education efforts with both health providers at HCs and parents/guardians are warranted to continue to improve blood lead screening rates among high-risk groups.

Elevated Blood Lead Screening in Asymptomatic Young Children and Pregnant Women

The adverse health effects of lead toxicity in children and pregnant women are well known. The U.S. Preventive Services Task Force has reexamined the

Blood Lead Screening and the Ongoing Challenge of Preventing Children’s Exposure to Lead

Blood Lead Screening and the Ongoing Challenge of Preventing Children’s Exposure to Lead

CDC's Lead Poisoning Prevention Program: A Long-standing Responsibility and Commitment to Protect Children From Lead Exposure.

The Centers for Disease Control and Prevention's (CDC's) Childhood Lead Poisoning Prevention Program (CLPPP) serves as the nation's public health leader and resource on strategies, policies, and practices aimed at preventing lead exposure in young children. CDC supports and advises state and local public health agencies and works with other federal agencies and partners to achieve the Healthy People 2020 objective of eliminating childhood lead exposure as a public health concern. Primary prevention-the removal of lead hazards from the environment before a child is exposed-is the most effective way to ensure that children do not experience the harmful effects of lead exposure. Blood lead screening tests and secondary prevention remain an essential safety net for children who may be exposed to lead. CDC's key programmatic strategy is to strengthen blood lead surveillance by supporting state and local programs to improve blood lead screening test rates, identify high-risk populations, and ensure effective follow-up for children with elevated blood lead levels. Surveillance plays a central role in helping measure the collective progress of federal, state, and local public health agencies in protecting children from lead, as well as enhancing our ability to target population-based interventions for primary prevention to those areas at highest risk. The CDC CLPPP has been at the front line of efforts to protect children from lead exposure and the resulting adverse health effects over the last 3 decades. As we chart our path for the future, we will continue to learn from past successes and challenges, incorporate new evidence and lessons learned, and work closely with federal, state, local, and nonprofit partners, experts in academia, and the community to advance the overarching goal of eliminating lead exposure in children.

Using Medicaid Data to Improve Childhood Lead Poisoning Prevention Program Outcomes and Blood Lead Surveillance.

Wisconsin-specific data revealed that not all Medicaid providers were testing children appropriately for blood lead levels and not all blood lead tests were reported to the Department of Health Services, Childhood Lead Poisoning Prevention Program. The Medicaid program requires blood lead screening for all Medicaid-enrolled children at specific ages. Wisconsin state law requires reporting of all blood lead test results. Projects were implemented to encourage appropriate testing for Medicaid-enrolled children and improve blood lead surveillance. Medicaid billing data were linked to blood lead data to identify Medicaid-enrolled children who had not received the required tests. Medicaid provider report cards were distributed annually from 2006 to 2011 to inform providers of their compliance with federal testing requirements and of the names of children within their practice who had not been tested. Blood lead tests billed to Medicaid but not in the blood lead database were identified and billing providers were contacted to obtain the test report. The number of children tested increased from 81 834 children per year in 2006 to 106 003 children per year in 2010. Testing of Medicaid-enrolled children increased by 31% from 2006 to 2010. The percentage of Medicaid-enrolled children receiving an age-appropriate test increased from 46% in 2004 to a high of 55% in 2010. There were 9035 blood lead tests identified in the Medicaid billing data that had not been reported from 2007 to 2015. There were 468 billing providers who had unreported tests. All sites with unreported tests were contacted, 84% of test results were obtained, and 14% of test records could not be retrieved. Outpatient clinics accounted for the majority of all unreported tests (72%) and irretrievable test records (74%). Childhood lead poisoning prevention programs can effectively utilize Medicaid data to increase testing and improve blood lead surveillance. Primary health care providers should ensure that Medicaid-enrolled children in their care receive the age-appropriate tests. Many Wisconsin health care providers lack awareness of blood lead test reporting requirements. Outpatient clinics account for the largest proportion of unreported tests and highest priority should be given working with these sites to improve reporting practices.

The Flint Water Crisis: A Coordinated Public Health Emergency Response and Recovery Initiative.

The City of Flint was already distressed because of decades of financial decline when an estimated 140 000 individuals were exposed to lead and other contaminants in drinking water. In April 2014, Flint's drinking water source was changed from Great Lakes' Lake Huron (which was provided by the Detroit Water and Sewerage Department) to the Flint River without necessary corrosion control treatment to prevent lead release from pipes and plumbing. Lead exposure can damage children's brains and nervous systems, lead to slow growth and development, and result in learning, behavior, hearing, and speech problems. After the involvement of concerned residents and independent researchers, Flint was reconnected to the Detroit water system on October 16, 2015. A federal emergency was declared in January 2016. The Centers for Disease Control and Prevention provided assistance and support for response and recovery efforts including coordinating effective health messaging; assessing lead exposure; providing guidance on blood lead screening protocols; and identifying and linking community members to appropriate follow-up services.In response to the crisis in Flint, Congress funded the Centers for Disease Control and Prevention to establish a federal advisory committee; enhance Childhood Lead Poisoning Prevention Program activities; and support a voluntary Flint lead exposure registry. The registry, funded through a grant to Michigan State University, is designed to identify eligible participants and ensure robust registry data; monitor health, child development, service utilization, and ongoing lead exposure; improve service delivery to lead-exposed individuals; and coordinate with other community and federally funded programs in Flint. The registry is also collaborating to make Flint "lead-free" and to share best practices with other communities. The Flint water crisis highlights the need for improved risk communication strategies, and environmental health infrastructure, enhanced surveillance, and primary prevention to identify and respond to environmental threats to the public's health. Collecting data is important to facilitate action and decision making to prevent lead poisoning. Partnerships can help guide innovative strategies for primary lead prevention, raise awareness, extend outreach and communication efforts, and promote a shared sense of ownership.

Successfully Changing a State's Climate to Increase Blood Lead Level Testing.

Childhood lead poisoning continues to be a persistent environmental pediatric health problem in New Hampshire (NH). In 2015, 660 (4.9%) children younger than 6 years had blood lead levels of 5 µg/dL or more, the Centers for Disease Control and Prevention's recommended level for public health action. Yet, only 16.8% of NH children younger than 6 years were tested. NH's Healthy Homes and Lead Poisoning Prevention Program (HHLPPP) identified 2 barriers to blood lead testing and the opportunities to resolve them: (1) venous testing had lower compliance and resulted in costly follow-up time for providers and (2) lack of understanding in the medical community about the importance of blood lead testing. Strategies to engage pediatric providers needed to recognize the realities of this rural state. In 2016, a strategy with goals of increasing blood lead screening and testing rates statewide with focus on high-risk communities was developed and implemented. The 5-part integrated strategy included the following: (1) implement a medical education program for pediatric providers; (2) increase provider awareness of point-of-care testing equipment; (3) create and distribute medical reference materials; (4) develop parent reminders for blood lead tests; and (5) increase the availability of point-of-care testing equipment. During 2016, NH's HHLPPP presented 25 medical education sessions. Blood lead testing rates improved dramatically, especially at medical sites where both face-to-face education and point-of-care testing were implemented. NH's success serves as a model for other rural areas seeking to improve lead screening rates.

WIC Participation and Blood Lead Levels among Children 1-5 Years: 2007-2014.

Background:The CDC recommends a targeted strategy for childhood blood lead screening based on participation in federal programs, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Yet, there is scarcity of data on blood lead levels (BLLs) among WIC participants.Objective:Our objective was to investigate whether children participating in WIC and not enrolled in Medicaid, who have not been targeted in the historical Medicaid-focused screening strategy, have higher BLLs than children in neither of these programs.Methods:The analysis included 3,180 children 1–5 y of age in the National Health and Nutrition Examination Surveys conducted in 2007–2014. Log-binomial regression, which allows direct estimation of prevalence ratios, was used to examine associations between WIC participation (in conjunction with Medicaid enrollment) and having BLLs with adjustment for age (1–2 vs. 3–5 y).Results:The percentage of children participating in “WIC only,” “Medicaid only,” “both WIC and Medicaid,” and “neither” were 18.9%, 10.8%, 25.4%, and 44.9%, respectively. “WIC only,” “Medicaid only,” and “both WIC and Medicaid” children were more likely to have BLLs than children who were not enrolled in either program, with adjusted prevalence ratios of 3.29 [95% confidence interval (CI): 1.19, 9.09], 4.56 (95% CI: 2.18, 9.55), and 2.58 (95% CI: 1.18, 5.63).Conclusions:Children participating in WIC but not Medicaid were more likely to have BLLs than children who were not enrolled in either program. These findings may inform public health recommendations and clinical practice guidelines. https://doi.org/10.1289/EHP2384

Sources, symptoms and characteristics of childhood lead poisoning: experience from a lead specialty clinic in China

Objectives: This study explored the sources of lead exposure, identified patients’ geographic distribution and evaluated the symptoms of children with elevated blood lead levels (BLLs) referred to a pediatric lead specialty clinic in China.Material and methods: Data were collected from 515 consecutive outpatients attending the Pediatric Lead Poisoning Clinic in Xinhua Hospital, Shanghai, China, between 2011 and 2016, referred for BLLs ≥5 μg/dL. Atomic absorption spectrometry was used to measure venous BLLs.Results: The mean ± standard deviation age of the patients was 4.1 ± 3.2 years. Their BLLs ranged from 5 to 126 μg/dL. The geometric mean and median BLLs were 24 and 26 μg/dL, respectively. Two hundred and twenty-two children (43.1%) were exposed to industrial lead pollution—mainly from Zhejiang, Jiangsu, Hunan, Henan and Anhui provinces; whereas, 41.4% (213 cases) were induced by folk medicines used widely throughout China. Other nonindustrial sources of lead exposure included lead-containing tinfoil and tin pots. Household lead paint was a rare source. Most patients exhibited nonspecific symptoms, such as hyperactivity, attention difficulty, aggressiveness, constipation and anorexia.Conclusions: Industrial pollution and folk medicines are important sources of lead exposure in China. Childhood lead poisoning may be difficult to diagnose clinically as symptoms are nonspecific. Thus, blood lead screening may be necessary to identify children at high risk of exposure. Education to raise the awareness of potential sources of exposure resulting in their elimination would be expected to decrease the incidence of children with elevated BLLs.

Trend of childhood blood lead levels in cities of China in recent 10years.

The adverse effects of lead on human especially childhood have been well established. Largely due to the phase out of lead in gasoline, blood lead levels (BLLs) had declined substantially all over the world including China. In 2004, 2007, 2010, and 2013, we conducted a continuous project including 47,346 children aged 0-6years old from 11 cities all over China to show how the decline happened and to explore what to do next to improve the BLLs of children of China. Our data shown the BLLs of Chinese children decreased from 46.38, 43.58, 38.95 to 37.17μg/L, but the decline was not enough. These decline was mainly because of the number decrease of children with high BLLs. Integrated strategy should be used to promote the BLLs of Chinese children, like striving to improve the environment, setting new cutoff for high BLLs, and establishing routine blood lead screening.