|DATE:||February 4, 1993|
|MEMO CODE:||Policy Memorandum 93-3|
|SUBJECT:||WIC's Role in Screening for Childhood Lead Poisoning|
Supplemental Food Programs
Recently, several regional offices and WIC state agencies have raised questions concerning WIC' s role ·in screening for childhood lead poisoning and allowable costs associated with this screening. These questions were prompted by the October 1991 statement issued by the Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (DHHS), entitled Preventing Lead Poisoning in Young Children. This statement establishes a lower threshold for detecting lead problems and encourages a renewed coordinated society-wide effort to eliminate this disease. one of the most common and preventable health problems today.
The WIC program does not have a specific legislative mandate to screen for lead poisoning. Even so, since 1979 FNS has supported CDC's lead poisoning initiative. This was done primarily by revising WIC regulations to (1) permit the use of free erythrocyte protoporphyrin (EP) as an appropriate blood test for iron- deficiency anemia in determining nutritional risk for WIC eligibility and (2) allow the purchase of the hematofluorometer to perform this test. The intent of these regulatory provisions was to maximize resources and eliminate duplication of effort, particularly invasive testing on children . At that time CDC recommended EP as an effective test not only for determining iron deficiency, but also for lead screening. Therefore, WIC could help detect children with possible lead toxicity and refer them for further testing.
In its 1991 statement, CDC has lowered the threshold of blood lead level at which follow up and intervention are recommended for children from 25 micrograms per deciliter (ug/dl) of whole blood to 10 ug/dL. The statement also explains that the EP test is not sensitive enough to identify most children whose blood lead levels are between 10 and 25 ug/dl and even misses many children whose blood lead levels are equal to or greater than 25 ug /dl. Consequently CDC recommends that measurement of blood lead levels should replace the EP test for lead screening.
Further, CDC has identified the problem of possible contamination with capillary samples from improper blood . drawing techniques, and clarifies that capillary tests are presumptive for lead toxicity and must be confirmed using venous blood samples (the preferred method of lead screening now being encouraged). However , CDC recognizes capillary blood samples to be a feasible method of blood collection provided practitioner errors are kept to a minimum. See Attachment 1 for additional details on WIC's historical involvement with and CDC's latest position on lead screening.
Based on the new guidelines from CDC, we now believe that the focus of WIC's role in lead screening should be that of providing information, making referrals and assisting in an appropriate plan of nutrition intervention. This change in focus is based on comments received on our first draft of this policy memorandum. (See Attachment 2.)
Therefore , the following is FNS policy which emphasizes this focus:
WIC state agencies are encouraged to:
- identify local health programs, e.g., Early and Periodic Screening, Diagnostic and Treatment Program, or local initiatives designed to address lead poisoning;
- establish referral systems for lead screening with identified programs;
- inquire during WIC nutrition screening if a client has had a blood lead test and make the necessary referral to obtain one, when appropriate;
- provide information about lead poisoning prevention to clients;
- encourage identified lead screening programs to assist WIC by sharing information on blood work that could expedite WIC certification; and
- assist in the development of an appropriate nutrition care plan for those children identified as having a blood lead problem, including the provision of nutrition education and counseling.
Further, WIC state and local agencies are also encouraged to change their nutritional risk cut-off levels for blood lead used for WIC certifications to be consistent with CDC's recommendations. CDC states that levels in children as low as 10 ug/dL are associated with growth impairment and levels of 15-19 ug/dL require nutrition intervention. Maternal levels of 10-15 ug/dL may be associated with reduced gestational age and reduced birth weight.
In cases where WIC state and local agencies are interested in being more extensively involved with lead screening than prescribed above, cooperative arrangements should be worked out at the state and local level. However, it is important that ongoing WIC policy concerning allowable and unallowable costs be adhered to as follows:
Allowable WIC Costs
- All costs associated with performing hematological tests used for detecting iron-deficiency, such as hemoglobin, hematocrit or free erythrocyte protoporphyrin (EP). Examples of these allowable costs include:
- Medical supplies, such as lancets, alcohol swabs, latex gloves and capillary tubes.
- Medical equipment, such as spectrophotometers, hematofluorometers and centrifuges.
- Staff time of WIC personnel to draw and analyze blood samples for iron-deficiency.
- o Staff time of WIC personnel to develop a nutrition care plan, provide nutrition education and counseling, and make health care referrals.
In addition, we are aware that some WIC clinics operate in a hospital or other health care setting that has protocols which require blood samples for more complete blood work. In these instances, WIC can pay an agreed-upon amount that approximates the cost that WIC would have incurred if it had conducted its own blood iron screening for WIC eligibility. The WIC state agency would negotiate a "fair share" proration for the labor and materials associated with WIC's blood work expenses.
In order to minimize invasive testing of children, WIC state agencies are also extended the option to allow their local agencies, when drawing blood for WIC eligibility determination, to draw an extra sample(s) for use by other programs in conducting lead screening. The time required by WIC staff and medical supplies could, at state option, be reimbursable from the other program(s).
Nonallowable WIC Costs
- Costs associated with venous blood lead tests which are over and above WIC's fair prorata share cost that approximate the costs WIC would have incurred if doing an iron-deficiency screen using hematocrit, hemoglobin or EP testing. Venous blood lead tests, now being encouraged by CDC for lead screening, are inappropriately comprehensive for determining WIC eligibility.
- Laboratory analyses of blood samples, whether venous or capillary, that are intended for any purpose other than to assess for iron status. Therefore, analyses for lead screening are not WIC-allowable costs.
It is suggested that written agreements be entered into at either the state or local level to clarify roles and responsibilities in all coordination efforts .
Multiple copies of the CDC October 1991 statement are available at no charge by calling CDC's Lead Poisoning Prevention Branch at (404} 488-7330 or by writing to:
Centers for Disease Control and Prevention
Public Information Office
1600 Clifton Road
Atlanta, Georgia 30333
A copy of another new DHHS publication, Childhood Lead Poisoning Prevention: A Resource Directory, is attached for your information. Your WIC state and local agencies may obtain a copy at no charge by contacting the:
National Maternal and Child Health Clearinghouse
8201 Greensboro Drive, Suite 600
McLean, Virginia 22102
Telephone: (703} 821-8955, Ext . 254
Fax : (703 } 821-2098
ALBERTA C. FROST
Supplemental Food Programs Division