Millions of California toddlers who should have been tested for lead exposure have not received state and federally mandated blood tests, in part because the health hazard — a particular threat to poor children — has not been prioritized by public health agencies, a recent state audit shows.
In a searing review of a problem that has persisted for years nationally and in California, State Auditor Elaine Howle found some 1.4 million toddlers enrolled in Medi-Cal had gone untested for lead exposure over the past decade, and another 740,000 missed one of two required screenings — a failure encompassing nearly three-quarters of the 3 million toddlers covered by the state's publicly-funded health insurance program.
That includes Humboldt County, which has some of the highest concentrations of childhood lead levels in California, including one section of Eureka with 85 cases, the most of any census tract in the state with the exception of one in Fresno County.
Federal and state laws require the state Department of Health Care Services to make sure blood lead level tests are administered to babies enrolled in Medicaid — known as Medi-Cal in California — when they reach the ages of 12 months and 24 months.
Testing is critical in the Medi-Cal cohort because studies show low-income children are most at risk of being exposed to lead via old paint, contaminated soil or air from lead smelters, tainted drinking water, industrial emissions and other lead sources. The Centers for Disease Control and Prevention has found that no level of lead is safe and that even low levels can affect a child's IQ and cognitive development, and damage the brain and nervous system.
"Many of these children live in areas of the state with high occurrences of elevated lead levels, making the missed tests even more troubling," Howle reported.
The California Department of Public Health had data showing where lead exposure was highest, but failed to meet a statutory deadline for publishing it on its website, Howle wrote. Citing that data, the audit found that between fiscal years 2013 and 2018, among children who actually did get testing, half of those found to have elevated lead levels were located in just 15 percent of the state's census tracts.
That includes parts of Humboldt County, which — along with the counties of Sacramento, Fresno, Los Angeles, Imperial, San Bernardino, Orange, San Diego, Madera and Riverside — has the highest concentration of cases in the state.
According to the report, nearly 850 area children enrolled in Medi-Cal tested positive for an elevated blood lead level over the data's five-year period.
But nearly 50 percent of the tests required for children living in the census tracts with the most cases of elevated lead levels were not done, according to Howle's report, which found that also held true across much of Humboldt County.
Eureka's Old Town and downtown areas were the top two tiers of cases in Humboldt County, with 85 and 74 cases of elevated lead levels in children, which is more than any other California county except Fresno.
But children living in those areas were also not properly tested 50 percent of the time, the audit found.
The southwestern section of McKinleyville — bordered by Murray Road to the north and U.S. Highway 101 to the east — as well as sections of Rio Dell and Scotia, were in the three and four spots on Humboldt census tract list of lead poisoning incidents, with 46 and 41 cases, respectively.
But, according to Howle's report, 52 percent of the tests that should have been given to the McKinleyville children were missed, as were 43 percent in the Rio Dell and Scotia tract.
Neighborhoods with the fewest cases locally include the areas around Freshwater and Trinidad.
Rachel Allen, a public health nurse with Humboldt County's lead prevention program, said she hadn't had an opportunity to review the data Howle used for the report but believes local providers are vigilant about testing children for lead. Overall, she said, the region is "doing a good job of capturing those 1 and 2 year olds for their initial screening."
Allen noted that the test is very sensitive and can be prone to false positives but that in the majority of the "true cases," lead paint is the main cause of elevated blood levels in children.
Howle's report also singles out Humboldt and Fresno counties as example of inequalities in funding levels for the lead prevention program, stating there were "observed differences in the levels of service provided."
The report found Humboldt's prevention program — which received $3,000 per child in CDPH funds — made home visits in six of 10 cases reviewed, while Fresno — which received $6,000 per child — did the visits in 10 out of 10 cases examined.
"Given that the suggested case management is similar for the lead levels of the children whose cases we reviewed in the two programs, we find the differences between the levels of service the children received troubling," the report states.
The audit also states that CDPH was contacted directly "multiple times" about "our conclusions about the Humboldt program" but did not ask to see the reviewed cases discussed in the report.
Allen said every Humboldt County household with a child who tests positive for elevated lead levels is contacted by the prevention program, which "does require a tremendous amount of time and effort."
In some cases, she said, if the lead level is low, that may be a letter or call to remind them to follow up with their provider for additional tests. But Allen said staff always make home visits in the more serious cases.
"I think an increase in funding always would help our ability to make this program more successful ... in terms of follow up, just having resource to do that," she said.
Children with lead poisoning often don't show symptoms, which is why testing is so important. Allen said she encourages families who are unsure if their children have been tested to contact their medical provider, noting the test is "simple and easy to do."
The Department of Health Care Services agreed with most of the audit's findings and promised to do more "to ensure that required blood lead tests are occurring."
In a statement, Acting Director Richard Figueroa said the agency expects to implement outreach campaigns by March to better inform Medi-Cal families about lead testing. By June, he said, managed plans will be required to identify all the children who have not been tested and remind their medical providers about the testing requirement. By the end of the year, Figueroa said the agency expects to have established a plan to improve and better enforce screening requirements.
Department of Public Health Director Sonia Angell also released a statement promising to take "corrective" measures, including releasing a map of areas with high rates of lead exposure, helping counties create plans to address the problem, improving oversight of local programs and enhancing data reporting and screening requirements.
The CDC defines elevated blood lead level to measure 5 micrograms per deciliter — five millionths of a gram per 3 fluid ounces. In California, the Childhood Lead Poisoning Prevention Branch defines lead exposure even more strictly, rounding up to 5 any measure above 4.5 micrograms per deciliter. A child is considered "poisoned" if they measure at 15 micrograms per deciliter.
"Because we know that lead has such harmful effects on kids and the impacts last a lifetime, the state has a responsibility to want to eliminate all exposures so kids are not exposed in the first place," said Jill Johnston, assistant professor of preventive medicine in the Division of Environmental Health at the University of Southern California Keck School of Medicine. "It's important to do screenings as widespread as we can, especially for those who are the most vulnerable."
Lead testing is not a new issue in California or nationally. In 1999, the state auditor released a similar report finding that only 25 percent of the required testing was being done.
A 2017 study by the Public Health Institute found that one-third of children poisoned by lead in the U.S. aren't being captured because of testing gaps and loopholes. And in 2018, the nonprofit Environmental Working Group found, based on Health Care Services billing data, that about three-quarters of California toddlers on Medi-Cal had not undergone the required lead testing.
Democratic Assemblymember Christina Garcia of Bell Gardens said she is "disappointed but not surprised" that agencies failed to implement a law she and Assemblymember Bill Quirk got passed in 2017 that doubled down on testing and accountability.
"All of these issues are those that affect low-income communities, that affect our most vulnerable populations, and it concerns me that the agencies don't prioritize these communities," Garcia said. "We have no problem treating these communities, like where I live, as wastelands. All of this needs to change."
She plans to hold a hearing on the audit and how the state budget could be leveraged.
"Passing a law and mandating the audit is not going to change the culture," Garcia said. "So how do we use the budget and work with the governor to change the culture at agencies?"
Others echoed the auditor's call for more aggressive oversight and outreach.
"Lead exposure impacts on a child are irreversible," said Susan Little, senior advocate for California government affairs for the Environmental Working Group, a non-partisan nonprofit focused on environmental safety. "It is something a child will have to live with and that emphasizes the importance of preventing the exposure in the first place."
Little said managed care plans and local counties also have a role in the problem but need to be managed by the state to meet requirements or create better response plans. Medi-Cal managed care plans are supposed to make sure providers screen kids, a mandate that Health Care Services reinforced in 2018.
Counties also are responsible for responding to elevated levels of lead but action has been inconsistent. The audit specifically dings Public Health for not having better oversight.
James Dahlgren, a Sunnyvale physician who specializes in toxicology and environmental exposures, called the current system "criminal" and said the state should respond even to low levels of lead exposure.
"Every child in the state needs to be tested and it needs to be paid for by government funds," said Dahlgren. "It is a public health responsibility."
The Journal's Assistant Editor Kimberly Wear contributed to this report.
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