Report
Progress in Achieving Universal Blood Lead Screening in
Designated High-risk Areas of Childhood Lead Poisoning
Prepared in Response to the Maine State Legislature
Resolve 2007 Chapter 186
January 9, 2015
Prepared by
Andrew E. Smith, SM, ScD, State Toxicologist
Maine Center for Disease Control and Prevention
Maine Department of Health and Human Services
286 Water Street
Augusta, ME 04333
207-287-5189

Eric Frohmberg, MA, Program Manager
Maine Childhood Lead Poisoning Prevention Program
Maine Center for Disease Control and Prevention
Maine Department of Health and Human Services
286 Water Street
Augusta, ME 04333
207-287-8141

 Table of Contents
Summary ......................................................................................................................................... 1

Introduction .................................................................................................................................... 4
Background on Blood Lead Screening ............................................................................................ 4
Changes to the Elevated Blood Lead Threshold ............................................................................. 5
Identifying High-risk Areas for Childhood Lead Poisoning ............................................................. 6
Blood Lead Screening in High-Risk Areas ...................................................................................... 10
Efforts to Promote Blood Lead Screening..................................................................................... 13
Maine CDC Statewide Efforts to Promote Screening ................................................................... 13
Local Efforts to Promote Screening in High-Risk Areas ................................................................ 14
Lessons Learned and Challenges .................................................................................................. 17
Recommendations ........................................................................................................................ 17

 Summary
The 123rd Maine Legislature enacted Public Law Chapter 186, a Resolve “To Achieve
Universal Blood Lead Level Screening in Maine Children.”1 It directed the Department of Health
and Human Services, Maine Center for Disease Control and Prevention (Maine CDC) to report
annually to the Joint Standing Committee on Health and Human Services on the following:
1) Identification of areas of the State at high-risk for childhood lead poisoning;
2) Progress made in achieving universal blood lead screening in designated high-risk areas
for children age 12 to 24 months of age and children age 25 to 72 months of age who
have not previously been tested for blood lead levels or who have had a change in risk
of exposure; and
3) Lessons learned in attempting to achieve universal blood lead testing and any
recommendations for screening.
This document presents the fifth report to the Maine Legislature and includes updates on
identifying high-risk areas for childhood lead poisoning, progress in promoting screening for
blood lead in these high-risk areas, changes to the threshold for elevated blood lead levels in
children and lessons learned and recommendations for screening.
Identifying High-Risk Areas for Childhood Lead Poisoning
In 2008, Maine CDC identified the communities of Lewiston-Auburn, Biddeford-Saco,
Portland-Westbrook, Bangor and Sanford as high-risk areas for childhood lead poisoning. These
communities were identified by comparing the percentage of young children screened who had
a blood lead level of 10 micrograms lead per deciliter blood or higher (≥ 10 µg/dL) to the
average for the remainder of the State (i.e., statewide, excluding the high-risk areas) over the
years 2003-2007. Most of these high-risk areas had percentages that were two- to three-fold
higher than the rest of the State.
Based on a similar analysis of blood lead screening data for the years 2009-2013, four of
these five communities remain high-risk areas. In contrast, Sanford now has a lead poisoning
percentage nearly identical to the rest of the State. All high-risk areas had decreases in the
percentage of screened children with a blood lead level 10 µg/dL or higher for this more recent
time period, ranging from a 29% drop in Lewiston-Auburn, to a 75% drop in Sanford. The rest of
the State had a drop of 48% during this time period.

1

http://www.mainelegislature.org/ros/LOM/LOM123rd/123S1/RESOLVE186.asp

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 1

 Universal Screening in High-Risk Areas
There has been substantial progress toward universal blood lead screening in most high-risk
areas as follows, and as presented in the table below.
• In four of the five high-risk areas, 73% to 84% of children born in 2010 were screened
for blood lead by 36 months of age.
• There has been a substantial increase in screening of both 1- and 2-year-old children in
Lewiston-Auburn. Screening rates of 1-year-olds increased from 46% to 76% between
2011 and 2013; screening rates for 2-year-olds increased from 29% to 53% during this
period.
• There have also been impressive increases in Biddeford-Saco.
Table: Annual Blood lead screening rates for 12- to 23-month-old and 24- to 35-month-old children for the five
high-risk communities for the calendar year 2013, and ever screened by 36 months for the 2010 birth cohort.

Selected Area
Bangor
Biddeford/Saco
Lewiston/Auburn
Portland/Westbrook
Sanford
Rest of State

(c)

Percent
12- to 23-month-olds
(a)
screened

Percent
24- to 35-month-olds
(a)
screened

Percent
< 36-month-olds
(b)
screened

63.8%
70.2%
76.2%
46.6%
63.9%
52.5%

38.0%
58.5%
52.9%
22.0%
33.6%
29.7%

79.3%
81.4%
73.9%
57.9%
84.3%
64.9%

(a)

Percent = number of children screened for blood lead divided by number of children born in that
community for that age cohort.
(b)
Computed for children born in 2010
(c)
Statewide rates excluding the five high-risk areas

Lessons Learned
The substantial progress in blood lead screening for Lewiston-Auburn is due in large part
to a robust effort by one pediatric office to use in-office testing for blood lead. Under Public
Law 2011 Chapter 183, the Lead Poisoning Control Act was amended to allow health care
providers to perform real-time blood lead testing in their offices. In-office testing addresses a
known barrier to blood lead screening – the need for some patients to travel to an off-site
location to have a blood specimen drawn and submitted for analysis. Since November 2012, six
medical practices have requested and been granted approval for in-office testing, including one
serving the Lewiston-Auburn high-risk area. In-office testing now accounts for more than 10%
of annual blood lead screening. Increases in screening rates in Biddeford-Saco have occurred in
Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 2

 the absence of in-office testing, demonstrating that substantial progress can be made by other
means.
Changes to the Elevated Blood Lead Threshold
The U.S. Centers for Disease Control and Prevention has changed its recommended
threshold for an elevated blood lead level for children less than six years of age. Since 1990, an
elevated blood lead has been defined as a level of 10 µg/dL or higher. The new level is 5 µg/dL
or higher. This change in federal policy results from a 2012 recommendation by the national
Advisory Committee on Childhood Lead Poisoning Prevention, and reflects a growing body of
scientific studies concluding that blood lead levels less than 10 μg/dL can harm children. No
safe level of lead exposure has yet to be identified.
Maine CDC has begun analyzing blood lead data using this new threshold of 5 µg/dL in order
to establish surveillance and data analysis protocols and identify challenges associated with
adopting the new threshold. The new threshold will complicate surveillance of blood lead levels
– including the identification of high-risk areas. That is, until it becomes common medical
practice to confirm blood screening results for lead levels down to 5 µg/dL (current guidance is
to confirm all results ≥ 10 µg/dL), it will not be possible to provide a reliable estimate of the
number or percentage of screened children with a confirmed blood lead level of 5 µg/dL or
higher. In early 2015, Maine will issue new blood lead screening guidelines that will recommend
confirmation of all blood lead test results of 5 µg/dL or higher.
The following points related to statewide blood lead levels are from 2013, the most recent
year for which surveillance data are available.
• 79 children were newly identified as having a confirmed blood lead level of >10 µg/dL.
• 169 children were identified as having a confirmed blood lead level of 5-9 µg/dL.
• 549 children were identified as having an unconfirmed blood lead level of 5-9 µg/dL.
Recommendations
At this time, Maine CDC has no additional recommendations for attaining universal blood
lead screening of children living in high-risk areas. Screening rates continue to improve in most
high-risk areas and are near or have surpassed achieving 80% of children tested at least once by
36 months of age.

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 3

 Introduction
The 123 Maine Legislature enacted Public Law Chapter 186, a Resolve “To Achieve
Universal Blood Lead Level Screening in Maine Children.”2 It directed the Department of Health
and Human Services, Maine Center for Disease Control and Prevention (Maine CDC) to report
annually to the Joint Standing Committee on Health and Human Services on the following:
1) Identification of areas of the State at high risk for childhood lead poisoning;
2) Progress made in achieving universal blood lead screening in designated high-risk areas
for children age 12 to 24 months of age, and children age 25 to 72 months of age who
have not previously been tested for blood lead levels or who have had a change in risk
of exposure; and
3) Lessons learned in attempting to achieve universal blood lead testing and any
recommendations for screening.
rd

This document presents the fifth report to the Maine Legislature and includes updates on
identifying high-risk areas for childhood lead poisoning, progress in promoting screening for
blood lead in these high-risk areas, changes to the threshold for elevated blood lead levels in
children, and lessons learned and recommendations for screening.
Background on Blood Lead Screening
Screening for blood lead identifies children who have elevated blood lead levels, and it
identifies housing that may contain environmental lead hazards. An elevated blood lead level
triggers public health and health-care services to: assess and reduce harm to the child, identify
others that may be at risk from the same environmental lead hazards and identify and mitigate
the source of lead exposure.3 Lead containing dust due to lack of maintenance of lead paint
surfaces or due to wear and tear on lead painted surfaces like windows, doors and floors, is the
most common cause of childhood lead poisoning in Maine.
Screening for blood lead involves collecting a blood specimen either by a venous draw (i.e.,
a blood sample taken directly from a vein) or a capillary draw (i.e., a blood sample obtained by
a finger prick). Because of the potential for external skin contamination with a capillary draw,
elevated capillary test results are usually confirmed with a venous draw. These blood specimens
are shipped to the Maine CDC’s Health and Environmental Testing Laboratory for analysis.
Because of recent changes in State law, lead analyses can now be performed in the office of
health care providers, using technology for an in-office blood lead determination (Public Law

2

http://www.mainelegislature.org/ros/LOM/LOM123rd/123S1/RESOLVE186.asp

3

22 MRSA §1320-1322

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 4

 2011 Chapter 183). The objective of in-office testing is to increase screening rates by removing
barriers (e.g., transportation, scheduling, loss to follow-up, etc.) associated with having to refer
patients to an off-site laboratory to obtain a blood specimen.
Current State law requires that children covered by MaineCare be tested for blood lead at 1
and 2 years of age (22 MRSA §1317-D). All other Maine children are required to be screened for
blood lead at these same ages unless a risk assessment indicates the absence of lead hazards
(22 MRSA §1317-D). These age-specific recommendations are based on the increased risk of
lead exposure from crawling and hand-to-mouth behavior. There are no requirements for
testing children 3 years and older.
Changes to the Elevated Blood Lead Threshold
Until recently, an elevated blood lead level was defined as a level of 10 micrograms of lead
per deciliter of blood or higher (>10 µg/dL). In 2012, the U.S. Centers for Disease Control and
Prevention lowered its recommended threshold for an elevated blood lead level to 5 µg/dL.
This change in federal policy results from a 2012 recommendation from the national Advisory
Committee on Childhood Lead Poisoning Prevention.4 The committee’s recommendation is
based on the weight of evidence that includes studies of large and diverse groups of children
with low blood lead levels and associated IQ deficits. Effects at blood lead levels less than 10
μg/dL are also reported for other behavioral domains, particularly attention-related behaviors
and academic achievement. To date, no safe level of lead exposure has been identified.
Maine CDC has begun analyzing blood lead data using this new threshold of 5 µg/dL in order
to establish surveillance and data analysis protocols, and identify challenges associated with
adopting the new threshold. This new threshold complicates surveillance of blood lead levels –
including identification of high-risk areas. Maine CDC currently recommends that all capillary
blood lead test results of 10 µg/dL and higher be confirmed with a venous draw. Consequently,
Maine CDC can reliably estimate the number and percentage of screened children with a
confirmed blood lead level of 10 µg/dL and higher. Until it becomes common medical practice
to confirm all blood lead screening results 5-9 µg/dL as well, it will not be possible to provide a
reliable estimate of children with a confirmed blood lead level of 5 µg/dL or above. In early
2015, Maine CDC will begin to recommend all blood lead capillary test results of 5 µg/dL and
above be confirmed with a venous draw. Until this new recommendation takes effect, separate
surveillance estimates will be prepared for confirmed (venous) and unconfirmed (capillary)
blood lead results in the 5-9 µg/dL range, due to the large number of children with unconfirmed
blood lead levels of 5-9 µg/dL. In this legislative report, the following surveillance measures will
be reported:
4

http://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 5

 •
•
•

the number and percentage of children with a confirmed blood lead level of 10 µg/dL
and above (≥ 10 µg/dL);
the number and percentage of children with a confirmed blood lead level between 5
and 9 µg/dL (5-9 µg/dL); and,
the number and percentage of children with an unconfirmed blood lead level between 5
and 9 µg/dL (5-9 µg/dL).

Identifying High-risk Areas for Childhood Lead Poisoning
Maine CDC has recently updated mapping of high-risk areas for childhood lead poisoning.
Prior efforts mapped the number of children with blood lead levels ≥ 10 µg/dL by town for the
time period of 2003 through 2007 as the baseline. These maps were used to identify
communities of the State that had a high number of cases of newly-identified children with
blood lead levels > 10 µg/dL. This mapping effort identified five communities that collectively
represented about 40% of all identified cases of Maine children with a blood lead level > 10
µg/dL. These five communities were Bangor, Biddeford-Saco, Lewiston-Auburn, PortlandWestbrook and Sanford.
In the most recent mapping analyses (Figure 1), this procedure has been updated using data
collected between 2009 and 2013. There were 909 newly identified children with a blood lead
level of ≥ 10 µg/dL during the years 2003-2007, and they were found in 217 towns. For the
years 2009-2013, there were 467 newly identified children with a blood lead level ≥ 10 µg/dL
found in 138 towns. Thus, there has been a substantial decrease in both numbers of new cases
of children with a blood lead level of ≥ 10 µg/dL and the number of towns where a case was
reported. Figure 1 presents a comparison of the number of children with a confirmed blood
lead level of ≥ 10 µg/dL (Figure 1a), with the numbers of children with confirmed (Figure 1b)
and unconfirmed (Figure 1c) blood lead levels of 5-9 µg/dL. The same five high-risk areas
remain apparent in all maps; however, based on blood lead levels of 5-9 µg/dL, several other
communities with higher numbers become apparent (e.g., the corridor that includes Waterville,
Fairfield, Skowhegan and Madison). These additional communities have previously been
identified by Maine CDC as second-tier high-risk areas and have received focused funding to
promote blood lead screening and lead poisoning awareness.

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 6

 Figure 1: Comparison of numbers of screened children with confirmed blood lead levels > 10 µg/dL, confirmed blood lead level 5-9 µg/dL or above, and
unconfirmed blood lead level 5-9 µg/dL or above, by town, for the years 2009-2013.

Bangor

Legend

Lewiston-Auburn
Portland-Westbrook
Biddeford-Saco
Sanford

Figure 1a: Number of screened children with a
confirmed blood lead level > 10 µg/dL by town
for the years 2009-2013.

Legend

Legend

1-5

1-5

1-5

6 - 25

6 - 25

6 - 25

26 - 50

26 - 50

26 - 50

51 - 100

51 - 100

51 - 100

None >100
>100

101 - 165

101 - 225

All other towns

All other towns

All other towns

Figure 1b: Number of screened children with a
confirmed blood lead level 5-9 µg/dL or above by
town for the years 2009-2013.

Figure 1c: Number of screened children with an
unconfirmed blood lead level 5-9 µg/dL or
above by town for the years 2009-2013.

 In the year 2013, the most recent year of surveillance data, there were 79 newly-identified
children statewide with a confirmed blood lead level ≥ 10 µg/dL. There were an additional 169
newly identified children with a confirmed blood lead level 5-9 µg/dL, and another 549 children
with an unconfirmed blood lead level 5-9 µg/dL (Figure 2).5 The trends indicate that it takes six
to ten years for the number of children at each of these blood lead levels to decrease by half.
While progress is clearly being made, we have yet to achieve the statutory goal of eradicating
lead poisoning among Maine children (22 MRSA §1314-A).6
Figure 2. Trends in the number of newly identified children with a confirmed (venous) blood lead level ≥ 10
µg/dL, a confirmed (venous) blood lead level 5-9 µg/dL, or a unconfirmed (capillary) blood lead level 5-9 µg/dL.

Higher counts of children with elevated blood lead levels are to be expected for towns with
higher populations. To determine whether these five communities are indeed high-risk areas,
Maine CDC computes a measure that is comparable across different population sizes: the
percentage of screened children with a confirmed blood lead level ≥ 10 µg/dL. This measure is
5

A preliminary analysis conducted by Maine CDC suggests that approximately 70% of children with unconfirmed
blood lead levels 5-9 µg/dL will have a confirmed (venous) blood lead level 5-9 µg/dL. The assumption of 70% is an
estimate based on a small data set of 29 capillary test results 5-9 µg/dL that were confirmed with a venous draw;
73% of these 29 capillary test results were found to have a venous test result of 5 ug/dL or higher.

6

http://legislature.maine.gov/legis/statutes/22/title22sec1314-A.html

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 8

 computed by dividing the number of children with a blood lead level of ≥ 10 µg/dL by the total
number of children screened for blood lead in a particular community and a specific age group.
Using this measure, we previously determined that the percentage of screened children with a
blood lead level ≥ 10 µg/dL was significantly higher in these five communities as compared with
the rate for the rest of Maine (i.e., statewide excluding these five communities). Thus, these
five communities were designated as high risk.
Table 1 presents updated estimates of the percentage of screened children who had a
blood lead level ≥ 10 µg/dL for the 2009-2013 time period, as compared to our baseline years of
2003-2007. Sanford no longer appears to be a high-risk area based on its percentage; its
percentage of screened children with a blood lead level ≥ 10 µg/dL is essentially the same as
the rest of the State. Bangor is approaching this point; its percentage is higher, but no longer
statistically different than the rest of State (0.88% vs 0.54%, p=0.06).7 Lewiston-Auburn has
seen the smallest drop in percentage of screened children with a blood lead level ≥ 10 µg/dL,
and its percentage is nearly four-fold higher than the rest of the State. The communities of
Lewiston-Auburn, Biddeford-Saco and Portland-Westbrook remain high-risk areas for lead
poisoning. Maine CDC is continuing to designate Bangor as a high-risk area due to its higher
percentage relative to the rest of the State, despite the fact that it cannot be viewed as
different from the rest of the State with a high degree of statistical confidence.
Table 1. High-risk communities based on percentage of newly identified children under 6 years of age with a
blood lead level (BLL) ≥ 10 µg/dL relative to the number of children screened.

Selected Area

2003-2007
Number of Children
(a)
Percent
with BLL ≥ 10 µg/dL

2009-2013
Number of Children
(a)
Percent
with BLL ≥ 10 µg/dL

(5 year total)

(5 year total)

Bangor

40

1.90%

21

0.88%

Biddeford/Saco

44

1.98%

25

0.97%

119
110

2.86%

97

2.02%

2.14%

43

0.92%

34

2.04%

8

0.51%

Lewiston/Auburn
Portland/Westbrook
Sanford
(b)

Rest of State
563
1.04%
273
(a)
Percent = number of children with BLL ≥ 10 µg/dL divided by number screened
(b)
Statewide rates excluding the five high-risk areas

0.54%

7

It is common practice to use a statistical probability value (p-value) of less than or equal to 0.05 as a threshold of
statistical significance (i.e., no more than a 5% probability that the observed result could occur by chance alone).

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Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 9

 Figure 3 shows the relative change in percentage of children with a blood lead level ≥ 10
µg/dL for each of the high-risk areas for the two five-year time periods. These two time periods
correspond to before and after the launch of primary prevention efforts in the high-risk areas.
Four of the five high-risk areas had larger drops in the percentage of children with a blood lead
level ≥ 10 µg/dL than seen for the rest of the State.
Figure 3. Changes in percent of children with a blood lead level ≥ 10 µg/dL for the five high-risk areas for
childhood lead poisoning for the five-year periods before and after prevention initiatives were launched. “Rest
of Maine” refers to the remainder of the state excluding the high-risk areas.

29%↓

54%↓

51%↓

57%↓
75%↓

Blood Lead Screening in High-Risk Areas
The major objective of Resolve 2007 Chapter 186 was to promote progress toward
achieving universal blood lead screening in high-risk areas for children 12 to 24 months of age,
and children 25 to 72 months of age who have not previously been screened for blood lead or
whose risk of exposure has changed. In contrast to the resolve, current State law does not
require universal screening in any specific area, but does require screening according to health
insurance status. Maine law requires blood lead screening for 1- and 2-year-old children
covered by MaineCare. All other Maine children are required to be screened for blood lead at
these same ages unless a risk assessment indicates the absence of exposure to lead hazards (22

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 10

 MRSA §1317-D). Maine CDC consequently tracks screening rates for 1-year-olds (12-23 months)
and 2-year-olds (24- 35 months), as well as whether a child is likely to have had at least one
lead test by 36 months of age.8
Maine CDC tracks screening of children for blood lead by computing the percentage of
children screened for blood lead relative to the number of children living in a given area (e.g.,
the state, county, town) for a particular age group. This approach makes use of the number of
reported tests divided by the population of children in a particular age group for a particular
location. The advantage of this approach is that it puts screening rates on a common scale so
different locations with differently sized populations can be compared, or locations with
changing populations can be compared over time. Complicating this approach, however, is
uncertainty in estimating the population of children of a particular age group and town. Since
U.S. Census counts are only available every ten years, and intercensal estimates at the town
level for a specific age group have proven difficult to reliably obtain, Maine CDC recently began
using births as estimates for the population of 1- and 2-year-olds at the town level.9 Because of
this change, screening rates reported in this legislative report cannot be directly compared with
prior reports.
Table 2 presents the percentage of children living in the high-risk areas that have received a
blood lead test at age 12 to 23 months, at age 24 to 35 months, or at least one screening test by
36 months of age. With the exception of Portland-Westbrook, all high-risk areas have screening
rates that are above rates for the rest of the State. Screening rates for children 24 to 35 months
are generally increasing, but are lower than screening rates of 1-year-olds. For three of the
high-risk areas, 79% or more of children have received at least one lead test by age 36 months.
This analysis is based on children born in 2010. We expect that Lewiston-Auburn has attained
this milestone for children born in 2011 and later (based on recent increased screening rates for
1- and 2-year-olds), though it will take one or more years of follow up to confirm.

8

These measures along with others are available on the Maine Tracking Network:
https://data.mainepublichealth.gov/tracking/
9

Actual Census counts at the town level are only available every 10 years. Intercensal estimates are uncertain and
in the past have been difficult to obtain. Annual birth counts are always available, but also have uncertainty as a
proxy for 1-year-olds and 2-year-olds due to emigration. Maine CDC now uses births as the most readily available
and reliable denominator for computing estimates.

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 11

 Table 2. Annual blood lead screening rates for 12- to 23-month-old and 24- to 35-month-old children for five
high-risk communities for the calendar year 2013, and ever screened by 36 months for the 2010 birth cohort.

Selected Area
Bangor
Biddeford/Saco
Lewiston/Auburn
Portland/Westbrook
Sanford
Rest of State

(c)

Percent
12- to 23-month-olds
(a)
screened

Percent
24- to 35-month-olds
(a)
screened

Percent
< 36-month-olds
(b)
screened

63.8%
70.2%
76.2%
46.6%
63.9%
52.5%

38.0%
58.5%
52.9%
22.0%
33.6%
29.7%

79.3%
81.4%
73.9%
57.9%
84.3%
64.9%

(a)

Percent = number of children screened for blood lead divided by number of children born in that
community for that age cohort
(b)
Computed for children born in 2010
(c)
Statewide rates excluding the five high-risk areas

Lewiston-Auburn and Biddeford-Saco have had noteworthy increases in screening rates in
recent years (Figure 4). The timing of the increase for Lewiston-Auburn coincides with the
introduction of in-office testing by a major pediatric provider and a strong effort by this practice
and others to increase screening rates for their high-risk community. In contrast, the increase in
screening rates for Biddeford-Saco between 2009 and 2012 was not associated with the
introduction of in-office testing, but nonetheless represents a concerted effort by local health
care providers.
Figure 4. Trends in blood lead screening of 1- and 2-year-olds for Lewiston-Auburn and Biddeford-Saco for the
years 2003 to 2013.

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

Page 12

 Efforts to Promote Blood Lead Screening
Blood lead screening is being promoted by continued statewide outreach aimed at
increasing awareness of the importance of blood lead screening, and is augmented by local
efforts in the high-risk communities. These initiatives are largely made possible by
the Lead Poisoning Prevention Fund, established by the Legislature in 2005 (22 MRSA §1322E).10 Additionally, health care providers can now conduct in-office analysis of blood lead, which
is intended to reduce barriers to blood lead testing. Each of these efforts is briefly discussed
below.
Maine CDC Statewide Efforts to Promote Screening
Maine CDC conducts an annual, statewide, targeted mailing to all families with children
between the ages of 12 and 23 months of age. The mailing consists of a brochure that includes
information for families about lead paint hazards; an offer of a free home lead dust test kit; and
a postage-paid return card to request more information, including how to get a child’s blood
tested for lead.11 Approximately 12,000 brochures were sent out statewide in October 2014 to
all Maine families with 1-year-old children as identified through the Maine Birth Certificate
Registry.
Under Public Law 2011 Chapter 183, the Lead Poisoning Control Act was amended to allow
health care facilities to perform blood lead testing in their offices. Prior to this legislation, by
law, all blood lead specimens were required to be submitted to the Maine CDC’s Health and
Environmental Testing Laboratory for analysis. In-office testing is intended to address a known
barrier to blood lead screening – the need for some patients to travel to an off-site location to
have a blood specimen drawn and submitted to for lead analysis. In-office testing makes use of
a portable instrument that provides near real-time measurement of lead levels in a capillary
blood specimen. The child and their guardians learn the result of the blood lead test during
10

The Lead Poisoning Prevention Fund is a non-lapsing fund established for the following purposes: a) Contracts
for funding community and worker educational outreach programs to enable the public to identify lead hazards
and take precautionary actions to prevent exposure to lead; b) An ongoing major media campaign to fulfill the
purposes of the educational and publicity program required by section 1317-B; c) Measures to prevent children's
exposure to lead, including targeted educational mailings to families with children that occupy dwellings built prior
to 1978; d) Measures to prevent occupational exposures to lead for private and public employees; e) Funding an
assessment of current uses of lead and the availability, effectiveness and affordability of lead-free alternatives; f)
Funding for educational programs and information for owners of rental property used for residential purposes; and
g) Implementation of the lead-safe housing registry by the Department of Environmental Protection pursuant to
Title 38, chapter 12-B. The Fund is supported by a 25 cent per gallon annual fee imposed on manufactures and
wholesalers of paint sold in the State of Maine.
http://www.mainelegislature.org/legis/statutes/22/title22sec1322-E.html.
11

The brochure is available for viewing online: http://www.maine.gov/dhhs/mecdc/environmentalhealth/eohp/lead/documents/leadmailerweb.pdf

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Progress Toward Universal Blood Lead Screening in High-risk Areas
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 their visit. If elevated, a confirmatory blood lead specimen (i.e., a venous specimen) can be
collected at that visit or a referral can be made to a laboratory capable of obtaining a venous
draw from a young child.
Public Law 2011 Chapter 183 authorized Maine CDC to approve testing for blood lead level
by a health care provider, health care facility, WIC clinic or Head Start facility, as long as the
facility can perform in-office blood lead analyses for purposes of improving blood lead
screening and the facility has demonstrated the ability to electronically submit all blood lead
testing results and associated information to Maine CDC. In 2012, Maine CDC promulgated the
required rules establishing an approval process for in-office testing. To date, six medical
practices have requested and been granted approval for in-office testing, including one serving
the Lewiston-Auburn high-risk area. In-office testing now accounts for more than 10% of all
blood lead screening tests performed annually; more than 1,000 in-office blood lead tests were
performed in 2013.
Local Efforts to Promote Screening in High-Risk Areas
Funds from the Lead Poisoning Prevention Fund are used to provide contracts to
community coalitions (Healthy Maine Partnerships) in the five high-risk areas to promote
identification of lead hazards, support landlord and tenant education and outreach and
promote blood lead screening. Approximately $30,000 or more is being allocated to each highrisk area annually. The first funds were provided to communities beginning in the summer of
2009. Examples of local education and outreach efforts specific to increasing screening rates
are described below:
Targeted YouTube Video PSA: The Healthy Maine Partnership in Portland developed a
15-second YouTube video public service announcement (PSA) that has been available
since late 2012.12 The PSA addresses the dangers of lead dust and encourages parents to
find out more about preventing childhood lead poisoning. In total, there have been
more than 17,000 views of the PSA which was geo-targeted to a 20-mile radius around
the high-risk areas of Portland, South Portland and Westbrook. Within this geographic
area, the PSA was targeted to women between the ages of 25-45 with an interest in
children and families.
Outreach through WIC Clinics: In Bangor, Sanford and Biddeford-Saco, community
partners have developed relationships with local clinics of the Women Infants and
Children Nutrition Program (WIC). Clinic staff have been distributing informational
12

The PSA may be viewed on YouTube: http://youtu.be/UJsPP4pSzKU

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

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 packets or displaying posters with lead poisoning prevention and blood lead screening
information with tear-off sheets for more information. In Bangor, a poster (see Figure 5
below) is displayed in a central waiting room that serves people waiting for
appointments in the WIC and Childhood Immunization programs, as well as the General
Assistance Office. Additional posters are found in WIC-only waiting rooms. In BiddefordSaco and Sanford, WIC participants receive packets of information with tipsheets
promoting blood lead screening. Partners in Lewiston-Auburn will begin working with
WIC sites in 2015. Working with WIC clinics is one specific outlet for promoting lead
poisoning prevention and screening and is similar to outreach efforts Healthy Maine
Partnerships conduct at other locations such as laundromats, childcare centers and
YMCAs.
Targeted outreach to minorities/ethnic groups: The Healthy Maine Partnerships in
Portland and Lewiston-Auburn are continuing to conduct free classes for recent
immigrants. These classes provide lead poisoning prevention and screening education
both in the attendees’ native language and through translated visual materials. In
Lewiston-Auburn, the Healthy Maine Partnership has collaborated with the City of
Lewiston and the Neighborhood Housing League for the past two years to distribute a
DVD with lead poisoning prevention and screening information hundreds of residences
in downtown Lewiston near 82 residential building demolition sites. The DVD used in
this door-to-door campaign provides information in English, Spanish, and Somali to
meet the needs of the residents, many of whom are English language learners.
Lewiston-Auburn is also continuing their “Neighbor to Neighbor” outreach program. In
the Neighbor to Neighbor program, Somali and Somali Bantu women receive training
about lead poisoning prevention and the importance of screening, either directly or
through a train-the-trainer model. The women who are trained then do outreach to
their friends and neighbors in their community.

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Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

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 Figure 5: Screen shots from the 15 second lead poisoning prevention PSA developed for the high-risk areas in
and around Portland.

Figure 6: WIC poster with tear-off contact information

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

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 Lessons Learned and Challenges
Lessons learned: The substantial progress in blood lead screening for Lewiston-Auburn is
believed to be due to the use of in-office testing and a robust effort by a pediatric office to use
this new technology, along with sustained effort by other providers and the Healthy Maine
Partnership serving this area. Similar progress on blood lead screening in Biddeford-Saco in the
absence of in-office testing indicates that this new technology is not necessary to improve
screening rates. Nonetheless, in-office testing has clearly been a catalyst for progress in
Lewiston-Auburn.
Challenges: As Maine CDC has yet to develop a means to support electronic submission of
in-office test results, the more than 1,000 test results now submitted annually must be hand
entered into an electronic database. Maine CDC is monitoring the growth of in-office testing to
determine whether the volume of submitted results warrants the significant investment to
develop an informatics system that will support electronic submission of in-office test results to
eliminate the need for hand entry.
The new federal blood lead reference level of 5 µg/dL used for identifying an elevated blood
lead level will complicate surveillance of blood lead levels, including the identification of highrisk areas, for another year or two. Until it becomes common medical practice to confirm all
blood lead screening results 5- 9 µg/dL, it will not be possible to provide a reliable estimate of
children with a confirmed blood lead level of 5 µg/dL or above. Maine CDC expects to issue
revised screening guidelines in February 2015 that will recommend all capillary test results of 5
µg/dL and higher be confirmed with a venous draw.
Recommendations
At this time, Maine CDC has no additional recommendations for attaining universal
blood lead screening of children living in high-risk areas. Screening rates continue to improve in
most high-risk areas, and are near, or have surpassed, achieving 80% of children tested at least
once by 36 months of age. Maine CDC is continuing to support local partners in their efforts to
promote awareness of lead paint hazards and the importance of blood lead screening with
resources from the Lead Poisoning Prevention Fund. We will continue to promote blood lead
screening statewide through a mailing to all Maine families with a 1-year-old child. Maine CDC
also will continue supporting health care providers who want to perform in-office blood lead
analyses.

Report to Joint Standing Committee on HHS for Resolve 2007 Chapter 186
Progress Toward Universal Blood Lead Screening in High-risk Areas
January 9, 2015

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