Advocates and State Government Working …...Preventing Childhood Lead Poisoning in New Jersey: Advocates and State Government Working Together to Increase the Lead Screening of Children

Advocates and StateGovernment WorkingTogether to Increasethe Lead Screeningof Children

October 2005

Preventing Childhood Lead Poisoning in New Jersey

Preventing Childhood Lead Poisoning in New Jersey:Advocates and State Government Working Together to Increase the LeadScreening of Children

Published October 2005

Written by Robin L. Dahlberg, Esq.Senior Staff AttorneyRacial Justice Working GroupAmerican Civil Liberties Union

Other contributors:

Mary E. Coogan, Esq.Assistant DirectorAssociation for Children of New Jersey

Nicole DixonParalegalRacial Justice Working GroupAmerican Civil Liberties Union

Linda Garibaldi, Esq.Senior AttorneyLegal Services of New Jersey

Arlene Kohn Gilbert, Esq.AttorneyRacial Justice Working GroupAmerican Civil Liberties Union

Keri E. Logosso, Esq.Senior Assistant Child AdvocateState of New JerseyOffice of the Child Advocate

THE AMERICAN CIVIL LIBERTIES UNION is the nation’s premier guardian of liberty, working daily in courts, legislaturesand communities to defend and preserve the individual rights and freedoms guaranteed by the Constitution and the lawsof the United States.

OFFICERS AND DIRECTORSNadine Strossen, PresidentAnthony D. Romero, Executive DirectorRichard Zacks, Treasurer

National Office125 Broad Street, 18th Fl.New York, NY 10004-2400(212) 549-2500www.aclu.org

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Paid for by the American Civil Liberties Union Foundation.


ADDITIONAL ORGANIZATIONS PARTICIPATING IN THE ON-SITE AND COMMUNITY EDUCATION INITIATIVES

American Academy of Pediatrics, New Jersey ChapterAmerican Civil Liberties Union of New JerseyAmeriChoiceAMERIGROUPCamden County Department of Health and Human ServicesCamden Head StartCamden’s Area Health Education CenterCamden’s Office for Economic Opportunity Lead and Asthma ProgramChildhood Lead Poisoning Emergency Response Team Gateway Maternal and Child Health ConsortiumHealth Net (formerly PHS)Healthy Mothers, Healthy Babies Coalition of Camden CityHorizon/MercyIrvington Board of Education (Abbott Program)Irvington Department of HealthIrvington Family Development CenterNew Jersey Citizen ActionNew Jersey Department of Human ServicesNew Jersey Office for the Prevention of Mental Retardation and Developmental DisabilitiesNew Jersey Poison Information and Education SystemNorthern New Jersey Maternal/Child Health ConsortiumOffice of the Child AdvocatePrograms for ParentsSouthern New Jersey Perinatal CooperativeUHP (University Health Plans)University of Medicine and Dentistry of New Jersey

The Office of theChild Advocate

Partnering Organizations:

Table Of Contents

I. INTRODUCTION ............................................................................................................ 1

II. NEW JERSEY’S CHILDHOOD LEAD POISONING PREVENTION PROGRAM:

A SYSTEM IN CRISIS ........................................................................................................ 1

III. INSTITUTIONAL IMPEDIMENTS TO SCREENING AND TREATMENT ........................ 3

IV. PARTNERING TO ADDRESS BARRIERS .................................................................. 6

V. DHSS ........................................................................................................................14

VI. CONCLUSIONS AND RECOMMENDATIONS................................................................16

ENDNOTES ......................................................................................................................21

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Preventing Childhood LeadPoisoning in New Jersey:Advocates and State Government Working Together toIncrease the Lead Screening of Children

I. INTRODUCTIONDuring the last five years, the number of NewJersey children enrolled in Medicaid who havebeen tested for childhood lead poisoning hasincreased significantly. Working together,advocates and New Jersey’s Medicaid agencyhave shown that targeted outreach and educa-tion to parents and medical professionals canhave a meaningful impact on the identificationand treatment of lead poisoned children.

Although childhood lead poisoning has been amajor public health issue in New Jersey formany years, public health officials paid it littleattention. Of the estimated 18,000 childrenunder the age of six suffering from lead poison-ing in 2000, the state’s public health agency,the Department of Health and Senior Services(DHSS), had only identified one-third. Slightlyless than one-half of those children wereenrolled in Medicaid. Hundreds were notreceiving necessary follow-up treatment.

The American Civil Liberties Union, theAmerican Civil Liberties Union of New Jersey(collectively, the ACLU), the Association forChildren of New Jersey (ACNJ), LegalServices of New Jersey (LSNJ) and, later, theOffice of the Child Advocate threatened tobring suit against DHSS and the state’sMedicaid agency unless they took immediatesteps to improve their lead poisoning preven-tion efforts. In response to that threat, thestate’s Medicaid agency invited the ACLU,ACNJ and other advocates to work with it to

identify those Medicaid-enrolled children suf-fering from lead poisoning and to ensure thatthey received necessary treatment. After fiveyears, this collaboration has resulted in a neardoubling in the lead screening rate ofMedicaid-enrolled children ages one and twofrom 25% to 45%, and the development ofsystems to ensure that lead burdenedMedicaid-enrolled children receive correctivetreatment. This report describes the strategiesemployed by the state’s Medicaid agency, theACLU and ACNJ to improve lead poisoningprevention efforts. It further describes thereluctance of the state’s public health agencyto participate in those efforts and its inabilityto provide effective leadership in this area.

In October 2004, that agency announced as agoal the elimination of childhood lead poison-ing in New Jersey by the year 2010. WhileACLU, ACNJ, Legal Services of New Jerseyand the Office of the Child Advocate applaudthis goal, they call upon DHSS to take anactive role in achieving it by working collabo-ratively with the state’s Medicaid agency toinstitutionalize and expand upon the reformstrategies set forth in this report.

II. NEW JERSEY’S CHILDHOOD LEADPOISONING PREVENTION PROGRAM:A SYSTEM IN CRISISOnce in the body, lead is a powerful toxin. Itcan cause developmental delays, learning dis-abilities, behavioral problems, hyperactivity,and in some cases, convulsions, coma and

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death.1 Children six years old and younger areparticularly vulnerable to the damaging effectsof lead because their central nervous systemsare not fully developed and their bodiesabsorb and retain it to a greater extent than dothe bodies of adults.2

Although children from all socioeconomicgroups can be effected, those from low-income and minority families are at greatestrisk. African American children are almostfive times as likely as Caucasian children tobe lead-burdened. Low-income children areeight times as likely to be lead-burdened aschildren from wealthier backgrounds.3 An esti-mated 60% of all children suffering fromchildhood lead poisoning are enrolled inMedicaid.4

Since at the most common levels of exposurelead poisoning does not present identifiablesymptoms, the only way to determine whethera child is lead burdened is with a blood test.5

In New Jersey, all children under the age ofsix are legally entitled to such testing. Thefederal Medicaid Act requires state Medicaidprograms to provide Medicaid-enrolled chil-dren with a lead blood test at 12 months andagain at 24 months (or between 36 and 72months if the child failed to receive a screenat either 12 or 24 months).6 New Jersey’sLead Poisoning Abatement and Control Act(more commonly referred to as the “UniversalScreening Law”), promulgated in 1996,requires local boards of health to work withmedical professionals to provide all NewJersey children, not just those who areMedicaid-eligible, with lead screening pur-suant to the same time table set forth in theMedicaid Act.7

In 2000, New Jersey’s childhood lead poison-ing prevention program was far from compli-ant with these regulations. An estimated18,600 children under the age of six were

thought to be lead burdened,8 but New Jerseywas doing little to locate these children andeven less to treat them. State screening9 rateswere so low (during state fiscal year 2000,only 25% of one and two-year olds enrolled inMedicaid10 and one third of all one and two-year olds received a lead blood test11) that asof June 2000, state public health officials hadidentified only one third of the 18,600 chil-dren.12 Even worse, of that one third, morethan one half were not receiving any follow-up services.13

The Medicaid Act requires state Medicaidagencies to provide follow-up services toMedicaid-enrolled children with blood leadlevels (BLL) over 10 micrograms of lead perdeciliter of whole blood (µg/dL) in accor-dance with guidelines promulgated by theCenters for Disease Control and Prevention(CDC).14 The CDC recommends that childrenwith persistent blood lead levels (BLLs) ofbetween 15 and 19µg/dL or BLLs over20µg/dL receive regular and periodic follow-up blood lead tests, case managementservices15 and environmental hazard assess-ments to determine the source of their expo-sure. It further recommends that environmen-tal assessments be conducted “as soon as pos-sible” after a confirmatory blood test identify-ing a child as lead burdened.16

The state Universal Screening Law mandatesthat local health departments, under DHSS’supervision, provide follow-up testing, casemanagement services and environmentalassessments to the same groups of childrenidentified by the CDC.17 Because the mostcommon source of exposure for children isdeteriorating lead-based paint in older hous-ing,18 the law also requires local health depart-ments to order the abatement of any home orhousing unit determined to contain a lead haz-ard.19 If a property owner fails to abate, thelocal board may arrange for the abatement at

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the owner’s expense.20 If the local healthdepartment fails to enforce the abatementlaws, DHSS may move to enforce them.21

In 2000, however, children known to have per-sistent BLLs of between 15 and 19µg/dL werenot receiving any case management services.Moreover, by the end of state fiscal year 2000,local health departments had completed only60% of the mandated environmental assess-ments,22 and landlords and property ownershad abated only 22% of the properties withidentified lead hazards.23

III. INSTITUTIONAL IMPEDIMENTS TOSCREENING AND TREATMENTConcerned about the state’s low screeningrates and its failure to provide case manage-ment services and environmental hazardassessments, the ACLU, ACNJ, LegalServices of New Jersey, and later, the Officeof the Child Advocate, began to interviewstate and local officials, to attend inter-agencymeetings and conferences, and to review doc-uments obtained through New Jersey’s PublicRecords Act to determine why children werenot receiving services to which they werelegally entitled. Their investigation revealedthe following:

A. No leadershipAlthough DHSS and DMAHS share respon-sibility for screening and treatment,24 theUniversal Screening Law contemplates thatDHSS will exercise a leadership role. Amongother things, it requires DHSS to: develop,implement and coordinate “a program tocontrol lead poisoning,”25 maintain a “centraldata base which shall include a record of alllead screening conducted pursuant to thisAct,”26 and “conduct a public informationcampaign” to inform parents and health careproviders of the Universal Screening Law’slead screening requirements.27 As of 2000,four years after the law was passed, DHSS

had done none of these things. AlthoughDMAHS theoretically could have steppedforward to fill this void, it had not.

B. No adequate surveillance systemGood data collection is essential to adminis-tering any effective lead poisoning preventionprogram. It enables states to ensure that theyare reaching the children at highest risk, tomonitor physicians and clinics responsible forproviding screening, and to confirm that chil-dren who have been lead poisoned are receiv-ing necessary follow-up care.28 Yet, as of2000, neither DMAHS nor DHSS had func-tional surveillance systems tracking leadscreening and treatment activities.

In the mid and late 1990s, DMAHS calculatedthe screening rates of Medicaid-enrolled chil-dren by counting the number of reimburse-ment claims submitted to it by the laboratoriesanalyzing the blood tests. DHSS tracked thename and location of children with BLLsequal to or greater than 20µg/dL, based onreports from the same laboratories. It alsotracked the completion, but not the initiation,of environmental investigations and abate-ments, using information provided to it bylocal health departments.29

The Universal Screening Law, however, requiresDHSS to track all lead screening activities, notjust those for children with elevated BLLs.Shortly after the Law’s passage, DHSS enteredinto an agreement with the state’s Office ofInformation Technology to develop a moresophisticated surveillance system to enable it tomeet the Universal Screening Law’s data collec-tion and reporting mandates. The Office was tohave completed the system by June 30, 1999,but was unable to do so because of hardwarecompatibility problems, staff turnover, and otherstate priorities. By the end of 2000, some soft-ware had been developed, but the system itselfstill was not in place.30

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Although DHSS had intended to wait untilthe Office of Information Technology hadcompleted the new system before beginningto collect the additional required data, itdecided that it could wait no longer. In June1999, it advised all laboratories analyzinglead blood screens to report all results (notjust those over 20µg/dL) to DHSS. Withoutthe necessary technology to handle the largeinflux of laboratory reports, six temporarydata entry staff and more than two dozenother departmental staff spent much of 2000manually putting approximately 60,000 testresults into the system.31

C. No coordinated statewide educationprogramAs of 2000, neither DMAHS nor DHSS hadany organized plan for educating parents andcaregivers about the importance of blood leadtests. Local health department officials, socialworkers, day care staff, and others whoworked with families in high-risk communi-ties believed that if parents and caretakerswere properly educated, they would have theirchildren screened. Yet educational efforts wereminimal, hampered by a lack of coordinationand funding.

DMAHS periodically sent targeted out-reach letters, health promotion flyers, andlead stuffers to Medicaid-enrollees by mail.In meetings with the ACLU, however, itconceded that education by mail was noteffective. Many letters and mailers werereturned because families had moved.Some parents had limited reading skills.Other parents had more pressing concernsand did not open their mail on a regularbasis.

Under the Universal Screening Law, DHSSis required to conduct a public informationcampaign about the need to test children forlead.32

In 2001, however, DHSS asserted thatstatewide public education was not its respon-sibility. It claimed that it had no budget formass communication and limited funds forprinting educational materials. Instead, it con-tended, statewide education was the responsi-bility of the Office for the Prevention ofMental Retardation and DevelopmentalDisabilities, a division of DMAHS’ parentagency, the Department of Human Services.33

The budget of the Office for the Prevention ofMental Retardation and DevelopmentalDisabilities was so small and its mandate sobroad that its ability to conduct any type ofstate-wide education effort on lead poisoningwas severely limited. In each of fiscal years1999, 2000, and 2001, the state legislature allo-cated slightly less than $1 million to the Officeto enable it to educate the public on sixteen dif-ferent preventable causes of disabilities. Of thisamount, $200,000 was specifically earmarkedfor lead poisoning prevention education. TheOffice disseminated these funds in grants ofbetween $10,000 and $50,000 per year, to localgovernment agencies, community groups andnon-profit organizations.34

D. No strategic lead-screening planResearch has shown that in urban areas, cer-tain zip codes and census tracts are more toxicthan others. Most lead poisoning occurs with-in these neighborhoods, and very little occursoutside of them.35 As of 2000, neither DHSSnor DMAHS had identified these areas; nei-ther DHSS nor DMAHS had identified thechildren at greatest risk of lead poisoning; andneither DHSS nor DMAHS had engaged inany type of focused or strategic planning toensure that those children received the leadblood tests to which they were legally entitled.

In fact, in a letter dated January 23, 2001,DHSS informed the ACLU that although theUniversal Screening Law required DHSS to

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develop a comprehensive plan to control leadpoisoning, DHSS was not responsible fordeveloping a strategic outreach or screeningplan. It claimed that drafting such a plan wasthe responsibility of the Interagency TaskForce on the Prevention of Lead Poisoning.36

Established in 1988, the Interagency TaskForce had been designed to facilitate collabo-ration among the relevant state agencies andcommunity groups involved in lead poisoningprevention.37 Although the group met six timesper year, meetings consisted of little morethan brief presentations by agency and com-munity representatives. Collaborative planningand implementation were inhibited by the factthat agency decision-makers rarely attendedthe meetings.

With respect to strategic screening plans, theInteragency Task Force had produced a docu-ment entitled, “Lead Poisoning PreventionAction Agenda” in 1989 and a second docu-ment entitled, “Recommendations for thePrimary Prevention of Lead Poisoning” in1995.38 Neither was a plan for ensuring thatthe children at greatest risk of lead poisoningreceived lead blood tests.

E. No enforcement activitiesOf 44 states responding to a survey by theNational Conference of State Legislatures in2000, almost all reported that doctors wereone of the most significant barriers to screen-ing. They did not consider lead poisoning tobe a problem in their jurisdiction; they were

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Research has shown that in urban areas, certain zip codes and census tracts are moretoxic than others. Most lead poisoning occurs within these neighborhoods, and very littleoccurs outside of them.

unaware of the federal or state laws mandat-ing screening; or they refused to providescreening in their offices because drawingblood from a young child required too muchstaff time.39

In 2000, sample record reviews conducted bythe Peer Review Organization of New Jersey(PRONJ), data generated by DMAHS for sub-mission to the federal Centers for Medicaidand Medicare Services, and anecdotal infor-mation confirmed that New Jersey’s Medicaidproviders were not testing children for lead.Instead, many doctors were referring childrento off-site laboratories to be screened butneglecting to ensure that the children actuallywent.40 As a result, during state fiscal year1999, 37% of all Medicaid-enrolled childrenages one and two had some contact with amedical professional during state fiscal year1999, but only 14% received a lead screen.During state fiscal year 2000, 42% had at leastone contact with a medical professional, butonly 25% received a lead blood test.41

Despite these statistics, neither DHSS norDMAHS took any meaningful action toenforce the screening and treatment mandatesof the state Universal Screening Law or theMedicaid Act. Neither agency audited healthcare providers to determine who was testingchildren for lead and who was not. In fact,DHSS did not even have a single complete listof New Jersey providers.42 Although 85% ofMedicaid-enrollees received health care serv-ices from Medicaid HMOs,43 the contractsbetween DMAHS and the HMOs did notdescribe in any detail the responsibilities ofthe HMOs and the providers with respect toscreening and treatment and did not imposesanctions for failure to provide such services.44

Although DHSS, DMAHS and the localhealth departments shared responsibility fortreating lead burdened children, there were

no written guidelines setting forth how theagencies were to interface with each other.DHSS only monitored the provision of casemanagement services to children with BLLsover 20µg/dL who had voluntarily enrolledin a Prevention Oriented System for ChildHealth (POrSCHe) program. As of 2000,only 11 of the State’s 114 local healthdepartments had such programs.45 Those 1lprograms were providing services to onlyone-quarter of the 1,309 children identifiedas having BLLs over 20µg/dL during thatfiscal year.46

While DHSS monitored the completion ofenvironmental investigations and abatements,it did not monitor whether either were con-ducted in a timely manner. In fact, there wereno guidelines setting forth the time periodswithin which environmental hazard assess-ments were to occur except for children at thehighest levels of exposure.

DMAHS, on the other hand, did not monitorthe treatment of any lead burdened Medicaid-enrolled children. As of June 2001, DMAHShad no idea whether any of the 653 Medicaid-enrolled children who had been identified ashaving BLLs equal to or greater than 20µg/dLduring FY 2000 were receiving any case man-agement services or environmental hazardassessments.

IV. PARTNERING TO ADDRESSBARRIERSIn response to these findings, the ACLU,ACNJ and other advocates threatened to sueDHSS and the state’s Medicaid agency unlessthey began to take more aggressive steps toidentify and treat lead poisoned children. Thestate’s Medicaid agency, in turn, invited theadvocates to work collaboratively to remedyidentified problems. As a result of this collab-oration, DMAHS made a number of signifi-cant changes.

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Although DHSS participated in early dis-cussions regarding these changes, it did notplay an active role in their implementationand, as will be described in more detail lateron, actually delayed the implementation ofsome initiatives.

A. Changes to the Medicaid contractAs previously stated, New Jersey’s MedicaidHMO contracts made no specific references tothe Medicaid Act’s screening and treatmentmandates. In late 2000, after consulting withGeorge Washington University’s Center forHealth Services Research and Policy, howev-er, DMAHS revised the contract to require,among other things, that each HMO:

• Develop a lead screening program thatensures that every Medicaid-enrolled childreceives regular and periodic verbal riskassessments and lead blood screensbetween the ages of 9 and 18 months,again between the ages of 18 and 26months, and as indicated by the results ofthe verbal risk assessment;47

• Pay providers on a fee-for-service basisfor each lead screen performed in theprovider’s office;48

• Reach out by mail at least twice per yearto the parents of children who have not yetbeen screened and implement correctiveaction plans for HMO staff to reach thoseparents who do not respond;49

• On an annual basis, notify providers withlead screening rates of less than 80% oftheir responsibility to provide lead screensand, with those providers, develop correc-tive action plans to increase their screen-ing rates;50

• Establish lead case management programsand written case management plans for

every child with a BLL equal to or greaterthan 10µg/dL;51

• Provide DMAHS with a plan, at the begin-ning of each year, setting forth the stepsthe HMO will take to improve its leadscreening rates.52

It further revised the contract to permitDMAHS to impose financial sanctionsagainst any HMO that failed to screen atleast 80% of their members under the age ofthree during any 12-month contract period.HMOs with screening rates of less than60% are subject to mandatory fiscal sanc-tions. HMOs with screening rates between60 and 80% are subject to discretionarysanctions.53

To assist the HMOs in meeting the abovecontract requirements, DMAHS began toprovide them with monthly lists of childrenwho had not yet been screened and to meetwith them quarterly to discuss contract com-pliance. In 2004, DMAHS levied its first leadtesting-related sanctions against the HMOsbased on fiscal year 2001 data. Additionalsanctions were recently levied based on datafrom 2002.54

B. Annual audits of Federally QualifiedHealth Care CentersIn 2000, DMAHS conducted the first of aseries of annual audits of the state’s 15Federally Qualified Health Care Centers(FQHCs) to determine the extent to whichthose facilities were screening the Medicaid-enrolled children who approached them forservices.55 FQHCs are federally fundedhealth clinics, generally located in medicallyunderserved areas, under contract with thefederal Centers for Medicare and MedicaidServices to provide health care services toMedicaid-enrollees and the uninsured. Aftereach audit, DMAHS reported the results to

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the FQHCs, using the reporting process as anopportunity to educate the FQHC health careprofessionals about the need to test theiryoung patients for lead.

C. Improving treatmentIn 2002, DMAHS developed its own com-puterized information management systemto track and monitor screening and treat-ment activities. Shortly thereafter, it beganto use the system to provide HMOs with thepreviously mentioned monthly lists of chil-dren who had not been screened. By June2005, it had entered into the system theapproximately 2500 Medicaid-enrolled chil-dren under the age of 6 years who hadBLLs equal to or greater than 10µg/dL as ofJanuary 1, 2005.

The Medicaid HMOs are required to putinto the system the results of each child’sinitial and follow-up lead blood tests, thedates of certain case management activities,and the dates of any environmental hazardassessment. DMAHS reviews this data on aregular basis to ensure that all children arereceiving the follow-up services to whichthey are entitled.

DMAHS also audits a random sample ofcase files from each of the Medicaid HMOson a quarterly basis to determine whetherchildren with BLLs equal to or greater than10µg/dL are receiving case managementservices. If deficiencies are noted, the HMOsare required to develop corrective actionplans.

In addition, the PRONJ annually reviews arandom sample of medical records, atDMAHS’ request, to determine whetherMedicaid-enrolled children with BLLs equalto or greater than 20µg/dL are receiving casemanagement services. The results of the mostrecent audit are set forth below:

Table 1Percentage of lead burdenedMedicaid-enrolled children

receiving specific corrective servicesFY 2004

Children identified by the PRONJ as not hav-ing received case management services arereferred directly to DMAHS.

D. Promoting on-site screening: introducingfilter paperBecause so many children referred to off-sitelaboratories for screening never went,DMAHS, the ACLU and ACNJ formed aworking group with representatives from theMedicaid HMOs to identify the reasons whydoctors made such referrals.

When members of the New Jersey Chapter ofthe American Academy of Pediatrics wereasked why they did not test for lead in theiroffices, they complained about the venipunc-ture method of testing, a method that DHSShad promoted after the passage of theUniversal Screening Law. They stated thatthey did not have sufficient staffing resourcesto perform the test; the Medicaid HMOs didnot adequately reimburse them for staff time;the procedure was too difficult; and parentswere resistant to the test.56

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Under the leadership of the Pediatric MedicalDirector of Horizon Mercy, Dr. WilliamSilverman, the group elected to address theseconcerns by piloting the filter paper method oflead testing.

As compared to the venipuncture, the filter-paper method is easier to administer.Instead of drawing blood from a vein, ahealth care professional pricks a child’sproperly cleaned finger or toe and placesthat finger or toe over a square of speciallytreated filter paper, permitting two drops ofblood to fall onto the filter paper. Once thesample dries, the filter paper is sent to alaboratory for analysis. All elevated BLLsmust be confirmed with a venous draw.57 Inthe mid-1990s, CDC expressed some initialconcerns about the reliability of the filter-paper method, but by 1999, the technologyhad improved to such an extent that CDCendorsed the method.58

With the assistance of DHSS, the On-SiteScreening Working Group selected twolocalities in which to pilot the filter papermethod: Camden City, in southern NewJersey, and Irvington, in northern NewJersey. These areas were selected becausethey had many of the high-risk factors asso-ciated with childhood lead poisoning,including a significant percentage of pre-1950 housing, high unemployment, largenumbers of families living in poverty, andlarge minority communities.59

DMAHS and the Medicaid HMOs identifiedapproximately 150 Medicaid primary careproviders with offices in the target areas, 59 ofwhom already did on-site screening using thevenipuncture or capillary method of testing.The 150 were divided into groups of 15 to 25.Each Medicaid HMO assigned provider repre-sentatives to educate the different groupsabout filter paper testing.

Once health care providers had been intro-duced to the method, the New Jersey Chapterof the American Academy of Pediatrics,DHSS, DMAHS, and the Health Officersfrom the Irvington and Camden CountyDepartments of Health sent letters encourag-ing those who did not already do so to provideon-site screening. The laboratory analyzingthe filter paper provided the On-SiteScreening Working Group with periodicreports, identifying the medical professionalswho were using the filter paper method andproviding the number of filter paper sampleseach had submitted for analysis.Representatives from DMAHS and theMedicaid HMOs made phone calls, and insome cases, in-person visits to those practicegroups that continued to refer children to off-site laboratories for testing.

E. Community-based public education:targeting the day care communityBecause DMAHS’ efforts to educate Medicaidfamilies by mail had been largely unsuccess-ful, DMAHS, the ACLU and ACNJ decided topilot a community-based public education ini-tiative. Under this initiative, day care centerstaff would be trained to educate the familiesof the children enrolled in their programsabout the need for a lead screen and how toobtain one.

For the reasons outlined above, the DMAHS,the ACLU and ACNJ chose Irvington andCamden City in which to pilot the initiative.They invited the local health departments,Medicaid offices, local Child Care Resourceand Referral Centers (CCR&R centers),60 andMaternal and Child Health Consortia to forma working group to spearhead the initiative.

The Community Education Working Group tar-geted 36 day care centers in Irvington and 72in Camden City.61 Twenty-seven (27) of theIrvington centers and 35 of the Camden centers

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were Abbott preschool programs, initiated inresponse to the 1998 ruling by the New JerseySupreme Court in the lawsuit, Abbott v.Burke.62 The Abbott preschool programs rec-ommend that all children receive a physicalexamination within 90 days of enrollment andhighly recommend that the examinationinclude a lead blood test. Twelve of theCamden centers were Head Start programs.All Head Start programs mandate that allenrolled children receive lead screens.63

Between August 2002 and January 2003, theCommunity Education Working Group spon-sored numerous training sessions at which daycare directors, staff, and family outreachworkers were trained on the dangers of leadpoisoning and the need to have children testedfor lead. The Chief Nurses for the IrvingtonAbbot preschool programs and the CamdenCounty Head Start programs arranged for theGroup’s trainers to make presentations to theprograms’ staff at their annual pre-servicetrainings in August. Attendance was mandato-ry. The Working Group later received requestsfor and provided additional training on how toassist the families of lead burdened children,how to interpret the results of lead bloodscreens, what steps parents and caretakers cantake to minimize the damage caused by leadpoisoning, and the legal rights of andresources available to children who are leadburdened.

At the training sessions, the CommunityEducation Working Group distributednumerous brochures, charts and resourceguides to the day care staff for distributionto parents. Day care center staff subse-quently reported, however, that the mosteffective written educational tool wouldhave been a simple one-page flyer high-lighting the dangers of childhood lead poi-soning that they could post in their facili-ties or distribute to parents.64

Between September 2002 and January 2004,the Public Education Working Group askedday care directors to report the percentage ofchildren screened, regardless of insurance sta-tus, to their local CCR&R centers. Roughlymid-way through that period, the WorkingGroup asked the local health departments tomodify the manner in which they conductedtheir annual immunization audits to includelead screening. State law requires local healthdepartments to assist preschools and daycarefacilities in implementing and enforcing stateimmunization requirements by conductingannual audits of school health records.65

F. Alternative site testingIn an effort to reach those Medicaid-enrolledchildren who did not visit their primary carephysicians and who were not enrolled in aday care program, a third working group wasformed to investigate the possibility of devel-oping alternative lead testing sites. Thisworking group explored the possibility ofestablishing such sites at WIC centers and inmobile vans that could be parked in front ofday care centers or at neighborhood healthfairs. At the time, however, neither optionproved feasible. New Jersey WIC administra-tors felt that current staff was incapable ofhandling additional tasks and that there wereno funds to hire more staff. The mobile vanswere also too costly.

G. ResultsBy the end of 2004, the various reforms under-taken by DMAHS in response to or with theACLU, ACNJ and other advocacy groups hadresulted in a dramatic increase in the number ofMedicaid-enrolled one and two-year olds whohad been tested for lead. As a result, DMAHSdecided to replicate the on-site screening andcommunity education initiatives in four othermunicipalities — Jersey City, Paterson,Bridgeton, and Millville — using strategiesemployed in Irvington as a model.

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1. Increased screening ratesAccording to several different measures, thelead screening rate of Medicaid-enrolled chil-dren increased substantially between 2000 and2004. As Table 2 illustrates, statewide screeningrates of Medicaid-enrolled children, as reportedby DMAHS to the federal Centers for Medicaidand Medicare, rose from 14% in federal fiscalyear 1999 to 45% in federal fiscal year 2004.

Table 266

Percentage of Medicaid-enrolledchildren between the ages ofone and two tested for lead

during the year indicated

As Table 3 illustrates, Medicaid HMO screeningrates also increased during the same time period:

Table 367

Percentage of children betweenthe ages of 18 and 29 months,enrolled in a Medicaid HMO,

and screened for leadduring the year indicated

In state fiscal year 2000, individual HMOscreening rates ranged between 23% and39%.68 In fiscal year 2004, they rangedbetween 46% and 60%.

As Table 4 illustrates, FQHC screening ratesof Medicaid-enrolled children rose. Only oneof the 11 centers audited in 2000 had ascreening rate of over 90%. Eleven of the 14centers audited in 2005 had screening rates ofover 90%.69

Table 4FQHC lead screening rates

for Medicaid-enrolled children2000 vs. 2005

As Tables 5 and 6 illustrate, the number ofchildren screened in the two cities targeted forthe on-site and community education initia-tives increased.70

Table 5Percentage of Medicaid-enrolled

children 72 months old or youngerwho were screened during the year

indicated below

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Table 6Percentage of Medicaid-enrolled

children 72 months old or youngerwho, as of the year indicated

below, had been screened at leastonce in their lifetime

Because neither the on-site screening nor thecommunity education initiatives were con-ducted pursuant to formal social science pro-tocols, the Working Groups could not deter-mine precisely the extent to which each con-tributed to the above increases. With respectto the on-site screening initiative, however, asurvey conducted by DMAHS revealed a criti-cal increase in the number of health care pro-fessionals testing for lead on-site. As of June2002, 59 of the 150 Irvington and CamdenCity doctors included in the initiative providedscreening on-site. As of January 2004, 121tested for lead on-site.

Unfortunately, the Working Group was unableto determine whether the use of the filterpaper method resulted in an increase inprovider screening rates. Although DMAHSattempted to calculate provider screeningrates, it could not do so in any reliable mannerbased on the data supplied to it by theMedicaid HMOs. DMAHS subsequently mod-ified its contract with the HMOs to requirethem to maintain more specific provider data.

With respect to the community education ini-tiative, 35 day care centers — the 23 IrvingtonAbbott preschools and the 12 Camden County

Head Start programs — reported their screen-ing results either to the ACLU or theirCCR&R. In each of those centers, a signifi-cant number of the children enrolled duringthe 2002-03 academic year were tested forlead.71 Eighty percent (80%) of the 1430 chil-dren in the Irvington Abbott preschool pro-grams and 60% of the more than 1000 chil-dren enrolled in the Camden County HeadStart programs were screened. Sixteen of the23 Irvington centers had screening rates ofover 80%. Seven of the 12 Camden CountyHead Start programs had screening rates ofover 50%. Three of the seven had screeningrates of over 70%.

2. Expanding the on-site and communityeducation initiatives using Irvington as amodel

By late 2004, DMAHS made the filter papermethod of testing available to every healthcare provider with a Medicaid panel of 50 ormore children. It is currently exploring waysto further encourage its use.

At the same time, DMAHS moved to replicatethe on-site screening and community educa-tion initiatives in three other localities —Jersey City, Paterson and Bridgeton/Millville— beginning in June 2004. In so doing, itused Irvington, and the strategies developedthere, as a model.

When interviewed by the ACLU at the con-clusion of the community education initia-tive, the Irvington Abbott preschool pro-grams attributed their successes to the factthat the day care center directors insistedthat the children in their programs bescreened for lead. Although Abbott pre-school programs do not mandate lead bloodtests like Head Start programs do, theIrvington Abbott preschool program direc-tors voluntarily adopted center-specificscreening policies. No child was excluded

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from the program because he or she was notscreened, but parents and caretakers werecontinuously reminded of the need to screenuntil their children were tested for lead.

The Irvington directors felt empowered toadopt these policies because of the strongsupport and encouragement they receivedfrom the Chief Nurse of the Irvington Abbotpreschool programs and the Health Officerof the Irvington Health Department. TheChief Nurse and her staff provided all par-ents who enrolled children in an Abbott pre-school program during the spring enroll-ment period with a health form. As of 2004,New Jersey did not require day care centersto use one standardized health form.Unfortunately, many of those in circulation,including the one distributed by the CamdenCounty Abbott preschool programs, did nothave a designated area in which providerswere to record lead screening results. Tocircumvent this impediment, the ChiefNurse created her own form which did havesuch an area.

As they handed over the form, the Nurseand her staff informed parents that prior tothe commencement of school in the fall,their children needed a comprehensive med-ical exam that included a lead screen. Theyhighlighted with a yellow marker the area ofthe health care form on which the primarycare provider was to record the results ofthe lead test. According to the Nurse,emphasizing the need to obtain a leadscreen at this particular time was critical.Many families scheduled medical exams fortheir children during the summer monthsand asked providers to complete the formsat that time. If a lead screen was not includ-ed in that initial visit, the families wereoften reluctant or too pressed for time toreturn to the provider a second time later inthe year simply for the lead screen.

The Chief Nurse maintained a computerizeddatabase that she used to track, among otherthings, immunizations and lead screens. Ifhealth forms were returned in the fall withoutlead results, the Chief Nurse informed thedirectors of the centers in which the childrenwere enrolled. The directors, in turn, assignedto specific individuals within their centers —a nurse or in some cases a family outreachworker — the responsibility for ensuring thatthose children were screened. The ChiefNurse continued to monitor health forms andto provide the directors with the names ofunscreened children throughout the course ofthe academic year.

To reinforce the importance of lead testing,the Irvington Health Department included leadin its immunization audits of the day care cen-ters. Prior to the commencement of the audit,the Irvington Health Officer sent letters to theday care directors reminding them thatIrvington was a high-risk area and informingthem that lead would be included in the audit.She then contracted with the local CCR&Rcenter, Programs for Parents, to conduct theaudit. According to Programs for Parents, theimmunization audits were most effective if theauditors prepared lists of the children at eachday care facility who had not received thenecessary immunizations or screens, providedthose lists to the day care center directors, andasked the directors to inform the auditorswhen the children had obtained the vaccina-tions or screens. They believed that requiringday care center directors to report back onchildren without immunizations or screenswas critical to ensuring the effectiveness ofthe audit.

To expand into Jersey City, Paterson andBridgeton/Millville, DMAHS began trainingday care directors and staff in the summer andfall of 2004. With the assistance of Scholastic,Inc., it developed written educational materi-

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als and posters which were distributedthroughout the state to day care centers, fami-ly day care providers, WIC centers, doctor’soffices, the Medicaid HMOs, and other com-munity organizations for use during NationalLead Awareness Week in October 2004. Inaddition, it persuaded local health departmentsto include lead in their immunization audits.At the same time, DMAHS’ parent agency,the Department of Human Services (DHS),adopted a regulation requiring all day carefacilities licensed by DHS’ Division of Youthand Family Services to use DHSS’ newUniversal Health Form, which contains a des-ignated space for lead test results.

DMAHS also began working with Medicaidproviders in the localities. Specifically, itasked the Medicaid HMOs to determine thescreening rates of the pediatric practice groupswith the largest Medicaid-enrolled client-basein each locality (five in Bridgeton/Millville;six in Paterson and eight in Jersey City), andif their screening rates were less than 80%, toeducate those groups on the need to screen allchildren for lead.

Preliminary results indicate improvement. Atthe end of state fiscal year 2004, the JerseyCity, Paterson, and Bridgeton/Millville prac-tice groups had screening rates of 58%,58%, and 54%, respectively. By the end ofthe first quarter of fiscal year 2005, theirrates had increased to 72%, 66%, and 68%,respectively.

V. DHSS

DHSS initially refused to play anactive role in DMAHS’ reforms or toinitiate any of its own. In fact, duringthe ACLU’s five-year history withNew Jersey’s childhood lead poisoningprevention program, DHSS’ actionsfrequently frustrated DMAHS’ abilityto move forward. In late 2003, for

example, the single individual responsible forDHSS’ surveillance system moved to anotherposition within DHSS. His position remainedvacant for approximately nine months beforeDHSS hired a replacement. During that peri-od, DMAHS had no access to data maintainedby the system to determine the numbers ofMedicaid-enrolled children who had or hadnot been screened.

In late 2002, the one nurse who purportedlyoversaw the provision of case managementand environmental assessments by local healthdepartments and POrSCHe programs retired.Her position remained vacant until late 2004.During that period, no one at DHSS exercisedany oversight over those programs. Herreplacement reportedly discovered, amongother things, that some local health depart-ments were not conducting environmentalhazard assessments in the manner contemplat-ed by the Universal Screening Law and thatothers were using environmental hazardinspectors, instead of trained social workers ornurses, to provide case management services.

Again in 2003, the ACLU asked DHSS tomodify index cards it distributed to day carecenters to facilitate immunization audits.Because, at that time, different day care pro-grams and pediatric groups used differenthealth forms, directors and staff were encour-aged to transfer immunization informationfrom the health forms onto the index cards.When conducting the audit, the auditors only

14


Preliminary results indicateimprovement. Within a few months,the screening rates of medicalpractice groups in Jersey City,Paterson and Bridgeton/Millvillehad increased an average of 13%.

reviewed the cards, not the original healthforms. The card, however, did not contain aspace for lead test results. While the IrvingtonHealth Officer, acting on her own initiative,modified the cards to include lead withoutprior DHSS approval, the Camden HealthOfficer would not act without authorizationfrom DHSS. DHSS considered the issue foralmost one year before finally agreeing tomodify the cards.

In 2003, three years after the ACLU’s initialinvolvement with New Jersey, the CDCincreased its programmatic demands on statesthat received CDC funding for lead poisoningprevention, including New Jersey. Amongother things, it required recipients of funds forfiscal year 2003 to develop a plan to eliminatechildhood lead poisoning by 2010; a targetedstatewide screening plan; a statewide child-hood lead surveillance system; and a writtencase management plan to reduce injury to leadburdened children. In return, it offered to pro-vide these states with additional technical andscientific assistance.72

The presence of the CDC, continued pressurefrom the ACLU, the visible success ofDMAHS’ collaboration with the ACLU andACNJ and a 2004 change in the leadership ofits lead program resulted in DHSS finally tak-ing action. In 2003, DHSS established fourregional coalitions to coordinate lead educa-tion activities throughout the state under thesupervision of a full-time lead educator hiredin 2000.73 In 2004, it published the ChildhoodLead Poisoning Elimination Plan mandated bythe CDC and called for an increase in the per-centage of children screened by two years ofage from 40% to 85%.

Also in 2004, DHSS:

• Required local health department recipi-ents of State Public Health Priority

Funding to use some of that money topromote or provide lead screening andtreatment;74

• Purchased 100 portable lead analyzers fordistribution to walk-in and community-based health clinics in 16 high-risk munic-ipalities;75

• Announced its intention to purchase44,000 lead dust testing kits for distribu-tion to pregnant women and new mothersliving in pre-1978 housing;76

• Funded and/or participated in two differ-ent pilot projects to provide on-site leadtesting at WIC sites in Newark;77

• Developed and piloted a tool kit for physi-cians and their staffs to encourage pedi-atric practices to conduct on-site bloodlead testing;78 and

• Abandoned its efforts to work with theState’s Office of Information Technologyto develop a functional surveillance sys-tem. Instead, it entered into a contract withan outside vendor to install a system simi-lar to that used by North Carolina’s leadpoisoning prevention program.79

While DHSS is to be commended for takingaction, it has permitted some of these initia-tives to stagnate. For example, at least two ofthe four regional lead coalitions flounderedbecause DHSS, while providing them withfunding, failed to provide them with neces-sary direction and guidance. They had littleunderstanding of their mission or how toobtain the cooperation of necessary localagencies, organizations and advocates.Recently, the lead health care educator statedthat these two coalitions have spent most ofthe last two years coaxing coalition membersto the table.

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16


With respect to the Elimination Plan, DHSShas yet to publish an implementation plan set-ting forth the steps that it and other state agen-cies will take to achieve the goals set forth inthe Plan, the individuals responsible for thosesteps, the time periods within which they willbe accomplished and the cost of those steps tothe state. With respect to Public HealthPriority Funds, DHSS has not adequatelyemphasized to the local health departmentsthe degree to which they are to prioritizechildhood lead poisoning prevention in theirexpenditure of such funds. In fiscal year 2005,local health departments allocated to child-hood lead poisoning prevention only $77,000of the more than $2,400,000 available tothem.80 With respect to the portable lead ana-lyzers and dust wipe kits, DHSS has failed todistribute them in a timely manner. In May2005, some portable lead analyzers wererecalled because recent tests showed theirresults to be only 75% accurate.81 As ofSeptember 2005, only 5,000 of the 44,000lead dust wipe kits had been distributed, 230had been returned for analysis, and 59 hadtested positive for lead.82 With respect to thephysician tool kits, DHSS does not have thefunding to reproduce and distribute them.

In addition, DHSS has made little meaningfuleffort to coordinate its activities and the activ-ities of the regional lead coalitions withDMAHS’ attempts to expand its on-sitescreening and community education initia-tives. There can be no doubt that if DHSS andDMAHS simultaneously promoted an on-sitescreening initiative, the availability and use ofportable lead analyzers, a community educa-tion initiative capitalizing on the local expert-ise and contacts of the regional lead coali-tions, and the availability of dust-wipe kits inthe same high-risk towns and municipalities atthe same time, DHSS and DMAHS wouldhave a far greater impact than they have act-ing alone.

VI. CONCLUSIONS ANDRECOMMENDATIONSChildhood lead poisoning in New Jerseyremains as much a problem today as it wasin 2000. The CDC estimates that approxi-mately 1.6% of all children between the agesof one and five living in the United Stateshave elevated BLLs.83 In October 2004,DHSS reported that 3% of all children testedduring state fiscal year 2003 had elevatedBLLs — almost twice the national average.In Newark and Trenton, 8% of all childrentested were lead burdened. In the city ofEast Orange, and the municipality ofIrvington, approximately 9% of all childrentested were lead burdened.84

Despite the progress that has been made todate, New Jersey has much work to do if itwishes to meet its goal of screening 85% ofall one and two-year olds by 2010.Unfortunately, some of the institutional barri-ers described earlier continue to exist. Thosebarriers must be addressed and resolved ifNew Jersey is to continue to increase itsscreening rates.

A. Continued lack of leadershipThe most significant impediment is thecontinued lack of state leadership. There isno entity or individual within state govern-ment to hold DHSS accountable for its fail-ure to implement the Universal ScreeningLaw in a timely manner. There is no entityor individual within state government toensure the institutionalization of thechanges made in response to pressure fromthe ACLU or the CDC and to continue topush for reform. There is no entity or indi-vidual within state government to ensurecoordination between DHSS, DMAHS, andthe other state agencies engaged in child-hood lead poisoning prevention. TheACLU, ACNJ, LSNJ, and the Office of theChild Advocate recommend that:

Recommendation 1: In early 2006, the gov-ernor elected in November 2005 proclaimthat the elimination of childhood lead poi-soning by 2010 will be a priority of hisadministration.

Recommendation 2: Early in 2006, the newgovernor designate an individual in hisoffice to assume leadership of the state’schildhood lead poisoning prevention pro-gram, to coordinate the efforts of DHS,DMAHS, and other state agencies involvedin childhood lead poisoning prevention andto move those efforts forward.

B. Continued lack of meaningful dataAlthough DHSS recently contracted with anoutside vendor to develop a surveillance sys-tem, DHSS anticipates that the system will notbe fully operational until June 2006. Thus,almost ten years after the New Jersey StateLegislature passed a law requiring DHSS todevelop a surveillance system, DHSS still doesnot have one. As a result, the type of dataDHSS generates and makes public is extremelylimited, as is its understanding of the trendsand patterns of exposure within the state.

According to DHSS’ most recent statistics,almost three-quarters of all reported cases ofchildhood lead poisoning fall within the juris-diction of the following 13 local healthdepartments: Newark, Paterson, Irvington,East Orange, Jersey City, Middlesex County,Elizabeth, Passaic City, North Bergen,Trenton, Plainfield, Cumberland, and CamdenCounty.85 Yet DHSS has not publicly identifiedthe most toxic neighborhoods and communi-ties within those jurisdictions. According to itsElimination Plan, this data will not be madepublic until June 2007.86

In addition, DHSS appears to have littleunderstanding of the children being screenedand the children with elevated BLLs.

DMAHS reports that approximately one-third of the children who were identified aslead burdened in state fiscal year 2003 wereMedicaid-enrolled. Who are the other chil-dren? Are they privately insured, uninsured,or eligible for Medicaid and simply notenrolled?87 Are they African-American, WestIndian, Caucasian, or recent immigrants fromother localities?

Are DHSS and DMAHS even targeting theright age groups? According DHSS, theresults of lead tests administered during statefiscal years 2000 and 2001 reveal that three,four, and five year olds are more likely to belead burdened than one and two-year olds.DHSS has not made similar data for fiscalyears 2002 and 2003 publicly available.

Table 788

Percentage of children tested dur-ing the year indicated who hadBLLs equal to or greater than10µg/dL, categorized by age

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Childhood lead poisoning inNew Jersey remains as mucha problem today as it was in2000. The percentage of leadburdened children residingin New Jersey is almosttwice the national average.

18


Data generated by DMAHS at the end of fiscalyear 2002 for Medicaid-enrolled children inCamden City and Irvington reveals the same:

Table 8Percentage of Medicaid-enrolledchildren tested for lead who had

BLLs equal to or greater than10µg/dL, categorized by age

May 2002

The ACLU, ACNJ, LSNJ and the Office of theChild Advocate recommend that:

Recommendation 3: The governor makeimmediately available to DHSS theresources necessary to ensure that it has afunctional information management systemcapable of producing necessary data nolater than June 30, 2006.

Recommendation 4: With the data theycurrently have, DHSS and DMAHS makeavailable to the public, by January 1, 2006,the zip codes within the jurisdictions of the13 local health departments that have thehighest incidents of childhood lead poison-ing, and a demographic profile of thosechildren who are being screened and thosechildren known to have elevated BLLs.

C. Continued lack of meaningful targetedoutreach planBecause the risk for lead exposure is not dis-tributed evenly throughout the population,

the CDC recommended in 1997 that statestarget high risk neighborhoods and childrenfor additional educational and screeningactivities.89 Yet neither DHSS nor DMAHShas developed a targeted education or screen-ing plan. On more than one recent occasion,DHSS has commented that New Jersey doesnot need such a plan because the UniversalScreening Law requires that all children bescreened.

Such a comment ignores the purpose behindtargeted plans. Even in a state that requiresuniversal screening, not all children are equal-ly at risk of lead poisoning. Targeted plans,among other things, ensure that limited stateand local financial and administrativeresources are wisely and strategically spent sothat the public health officials reach thelargest number of children at the greatest riskand that taxpayers, who are funding the state’slead poisoning prevention efforts, receive thegreatest return for their money.

As previously mentioned, DMAHS andDHSS have not effectively collaborated onefforts to educate the public and increasescreening. The Elimination Plan acknowl-edges that educational efforts have been dis-jointed and have not reached “New Jersey’sdiverse ethnic and cultural populations.”90

While DMAHS is promoting filter paperscreening, DHSS is promoting portable leadanalyzers and dust wiping kits. WhileDMAHS is auditing Medicaid providers todetermine which ones need to be educated onthe screening and treatment mandates of theMedicaid Act, DHSS is doing little to edu-cate those recalcitrant doctors who servicethe privately insured and the uninsured aboutthe screening and treatment mandates of theUniversal Screening Law.

The ACLU, ACNJ, LSNJ, and the Office ofthe Child Advocate recommend that:

Recommendation 5: By April 1, 2006,DHSS and DMAHS, working together,develop and publish a plan to increasethe educational and screening activitiesin the high-risk zip codes identified inresponse to Recommendation 4, withparticular emphasis on those groups ofchildren, defined by Medicaid-status,age, gender, race, and ethnicity, whoreside within the zip codes and are notbeing screened.

At a minimum, the plan should set forth asone of its goals the screening of all childrenenrolled in a day care program or who visita health care professional in the targetedareas, and describe the specific steps thatDHSS and DMAHS will take to build onthe lessons learned from DMAHS’ reforminitiatives. Specifically, it should describethe steps that DHSS and DMAHS will taketo:

a. Ensure that licensed day care programsthat enroll children residing in the high-risk zip codes adopt screening policiesand a uniform record keeping system totrack those who have been screened andthose who have not; collaborate withlocal school districts to mandate that allchildren enrolling in Abbott pre-schoolprograms receive lead screens; and lobbyfor the passage of legislation that wouldrequire all children attending day careprograms to be tested for lead.91

b. Ensure that regional lead coalitionsdevelop and implement programs to pro-vide regular and periodic training to allday care directors, staff, family outreachworkers, and any other interested organi-zations and entities in the high-risk zipcodes on how to educate parents aboutthe dangers of lead poisoning and theneed for a lead screen.

c. Ensure that the 13 local health depart-ments previously identified include lead intheir immunization audits, conduct thoseaudits on an annual basis and follow audit-ing protocols utilized by the IrvingtonHealth Department and Programs forParents.

d. Identify medical practice groups, commu-nity health clinics, FQHCs and FQHC-look-alikes that service the Medicaid-enrolled and the uninsured in each of thetargeted areas and make available to themall reputable methods of testing for lead,including the filter paper method and theportable lead analyzers. (To date, DHSShas refused to make the filter papermethod of testing available to local healthdepartments.)

e. Audit, or in the case of DMAHS, continueto audit health care providers, FQHCs,community health centers, FQHC look-alikes, and local health departments on aperiodic and regular basis to determinetheir screening rates, and provide remedialand continuing education to those profes-sionals, practices, clinics, and centers thathave screening rates lower than 80%. Thestate Universal Screening Law requiresdoctors to screen. Their failure to do so isa violation of that law.

f. Explore the possibility of withholdingof monetary reimbursement fromMedicaid health care professionals whofail to screen at least 80% of the

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An ACLU Rep ort

Lead burdened childrenare still not receiving thecorrective treatment andservices to which they arelegally entitled.

20


Medicaid-enrolled one and two-yearolds who come to them for medicalservices.

In addition, the plan should provide foraggressive outreach to those families whosechildren do not visit health care professionalsor are not enrolled in childcare or day pro-grams.

Recommendation 6: Starting in October2006, DHSS and DMAHS issue semi-annu-al progress reports to the public settingforth the steps they have taken to date withrespect to the implementation of the plan.

D. Failure to treatLead burdened children are still not receivingthe corrective treatment and services to whichthey are legally entitled. There are still nowritten guidelines instructing local healthdepartments how to interface with theMedicaid HMOs with regard to the provisionof case management services. There are stillno written guidelines defining best practicesfor local health departments in terms of fol-low-up blood testing, case management serv-ices and environmental hazard assessments.

In direct violation of the Universal ScreeningLaw, children known to have persistent BLLsof between 15 and 19µg/dL are still not receiv-ing case management services from their localhealth departments. Although the EliminationReport states that DHSS will seek to obtain theresources to provide such children with servic-es, it does not state when or how.92

The degree to which children with BLLs equalto or greater than 20µg/dL are receiving fol-low-up testing and case management servicesfrom local health departments is unclear. As ofApril 2005, less than one-half of the roughly800 children known to have BLLs over20µg/dL were enrolled in POrSCHe programs.

By the end of the most recent state fiscalyear for which data is available, localhealth departments had completed only71% of the mandated environmental assess-ments,93 and landlords and property ownershad abated only 35% of the properties withidentified lead hazards.94 As Table 9 illus-trates, of the 13 local health departments inhighest risk areas, several had significantbacklogs.

Table 9Percentage of environmental haz-

ard assessments outstanding atthe end of fiscal year 200395

The ACLU, ACNJ, LSNJ and the Office ofthe Child Advocate recommend that:

Recommendation 7: By April 1, 2006,DHSS and DMAHS, working together,develop and publish a plan to ensure thatall lead burdened children receive, in atimely manner, the follow-up blood testing,case management services, and environ-mental hazard assessments to which theyare legally entitled.

Recommendation 8: Starting in October2006, DHSS and DMAHS issue semi-annual progress reports to the public set-ting forth the steps they have taken todate with respect to the implementationof the plan.

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1 See Shilu Tonig, “Declining Blood Lead Levels and Changes in Cognitive Function During Childhood,” 280JAMA 1915 (Dec. 9, 1998).

2 http://www.manbir-online.com/diseases/lead.htm. See Carrie Farmer, Lead Screening for Children Enrolled inMedicaid: State Approaches, Forum for State Health Policy Leadership, National Conference of State Legislatures,at 2 (2001).

3 Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials, Centers forDisease Control and Prevention, at 41-42 (Nov. 1997).

4 Another Link in the Chain, State Policies and Practices for Case Management and Environmental Investigationfor Lead-Poisoned Children, Alliance to End Childhood Lead Poisoning and The National Center for Lead-SafeHousing, at 23 (June 1999).

5 The Foundations of Better Lead Screening for Children in Medicaid, Alliance to End Childhood Lead Poisoning,at 3 (April 2001). Generally, symptomatic lead poisoning does not develop until a child’s blood lead level exceeds80 micrograms of lead per deciliter of whole blood (µg/dL) - an extremely dangerous level. See http://www.man-bir-online.com/disease/lead.htm.

6 42 U.S.C. §§ 1396a(a)(43)(B), 1396d(r)(1)(B)(iv); 42 C.F.R. 441.56(b), 441.59(a); State Medicaid Manual,Centers for Medicaid and Medicare Services, United States Department of Health and Human Services, at § 5123(1993).

7 N.J.S.A. § 26:2-137.4; N.J.A.C. § 8:51A-2.2. As of 2000, New Jersey was one of three states that had passed leg-islation requiring universal lead screening. The other two were Rhode Island and Massachusetts. Carrie Farmer,Lead Screening for Children Enrolled in Medicaid: State Approaches, Forum for State Health Policy Leadership,National Conference of State Legislatures, at 6 (2001).

8 Lead burdened, in this context, means having a blood lead level equal to or greater than 10µg/dL. 2003 ProgramAnnouncement, Centers for Disease Control and Prevention, at App. IV

9 Throughout this report, the term “screening” is used interchangeably with “lead blood test” or “blood test” or“lead test.”

10 Anne M. Wengrovitz, Stuck in Neutral, States Neglect Lead Testing Duty to Children Served by Medicaid,Alliance for Healthy Homes, at Appendix D (July 2005).

11 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1, 1999 to June 30, 2000, NewJersey Department of Health and Senior Services, at 14 (undated).

12 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1,1999 to June 30, 2000, NewJersey Department of Health and Senior Services, at 11 (undated).

13 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1,1999 to June 30, 2000, NewJersey Department of Health and Senior Services, at 11 (undated).

14 42 U.S.C. §§ 1396a(a)(43)(C), 1396d(a)(19), 1396d(r)(5); 42 C.F.R. 441.61; State Medicaid Manual, Centers forMedicaid and Medicare Services, United States Department of Health and Human Services, at § 5123. Becauserecent studies have found that even small amounts of lead can result in harm, some health care professionals advo-cate that any child with a BLL equal to or greater than 5µg/dL receive follow-up treatment. The CDC, however,has not altered its recommendations. Julie Gerberding, et. al., Preventing Lead Poisoning in Young Children, AStatement by the Centers for Disease Control and Prevention, United States Department of Health and HumanServices, Public Health Services, at 2 (Aug. 2005).

15 The Medicaid Act defines case management services as those that will “assist individuals eligible under the[Medical Act] in gaining access to needed medical, social, educational, and other services.” 42 U.S.C. §1396n.

Endnotes

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16 Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the AdvisoryCommittee on Childhood Lead Poisoning Prevention, Centers for Disease Control and Prevention, at 22 (Mar.2003).

17 N.J.A.C. §§ 8:51-2.4, 8:51-3.1 to 8:51-4.5.

18 As it deteriorates, lead-based paint peels and flakes, creating lead-contaminated dust that can adhere to walls,floors, carpets, toys, furniture, hands, and fingers. Carrie Farmer, Lead Screening for Children Enrolled inMedicaid: State Approaches, Forum for State Health Policy Leadership, National Conference of State Legislatures,at 2 (2001). An estimated 92% of all housing built before 1950 contains some lead-based paint. See Putting thePieces Together: Controlling Lead Hazards in the Nations Housing, Report of the Lead-Based Paint HazardReduction and Financing Task Force, HUD-1547-LBP (July 1995). Among the 50 states, New Jersey ranks 8th innumber and 13th in percentage of pre-1950 housing. At the end of state fiscal year 2000, 35% of New Jersey hous-ing units had been built prior to 1950. Every one of the state’s 21 counties had at least 10,000 pre-1950 housingunits. Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July, 1999, to June 30, 2000,New Jersey Department of Health and Senior Services, at 5 (undated).

19 N.J.S.A. § 24:14A-7; N.J.A.C. ‘ 8:51-6.1. For purposes of the Universal Screening Law, abatement is defined asany activity or process designed to either mitigate or permanently eliminate lead-based paint or any other lead-related hazards on a premises, including, but not limited to, the removal of lead-based paint and lead-contaminateddust, the enclosure or encapsulation of lead-based paint, the replacement or removal of lead-painted surfaces, etc.N.J.A.C. § 8:51-1.3

20 N.J.S.A. § 24:14A-9; N.J.A.C. ‘ 8:51-6.7.

21 N.J.S.A. § 24:14A-10.



24 In addition to DMAHS and DHSS, the Department of Community Affairs (DCA), the Department of EnvironmentalProtection (DEP), the Department of Education and other divisions within DMAHS’ parent agency, the Department ofHuman Services are involved in childhood lead poisoning prevention. See New Jersey Childhood LEAD PoisoningElimination Plan, New Jersey Department of Health and Senior Services, at 3-4 (Oct. 2004). This report, however,only discusses DMAHS and DHSS, and only in connection with lead screening and treatment.

25 N.J.S.A. §§ 26:2-132, 26:2-134.

26 N.J.S.A. § 26:2-137.6(a).

27 N.J.S.A. § 26:2-137.4(g).

28 Carrie Farmer, Lead Screening for Children Enrolled in Medicaid: State Approaches, Forum for State HealthPolicy Leadership, National Conference of State Legislatures, at 10 (2001).

29 Fifteen of the state’s 114 local health departments maintain more detailed information on the types of servicesreceived by children with BLLs equal to or greater than 20µg/dL, New Jersey Childhood Lead PoisoningPrevention Project, Application for Continued Funding of Cooperative Agreement, #US7/CCU218464-01, inresponse to CDC Program Announcement 01020, Part B, New Jersey Department of Health and Senior Services, atSection C, Narrative Description of Proposed Project, p. 8 (April 2001), but DHSS did not make public use of theinformation. Two of these local departments (Newark and East Orange) have categorical lead programs. Anothereleven (Burlington County, Camden County, Gloucester County, Irvington, Jersey City, Middlesex County,Monmouth County, Paterson County, Plainfield, Trenton, and Warren County) operate Prevention Oriented Systemfor Child Health (POrSCHe) programs. These programs, which are funded by DHSS, are designed as “outreachcase management models to assist primary health care providers.” Enrolled families receive parenting skills train-ing and counseling; specialized health education; regular health supervision visits to a primary care provider; assis-

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tance in identifying health, nutritional, and developmental problems; and assistance in accessing communityresources such as WIC, family planning, housing, education, job training, and other social services. New Jersey2004 Application/Annual Report Maternal and Child Health Services, Title V Block Grant Program, New JerseyDepartment of Health and Senior Services, at 73 (April 2003).


31 New Jersey Childhood Lead Poisoning Prevention Project, Application for Continued Funding of CooperativeAgreement, #US7/CCU218464-01, in response to CDC Program Announcement 01020, Part B, New JerseyDepartment of Health and Senior Services, at Section C, Narrative Description of Proposed Project, pp. 10-11(April 2001).

32 N.J.S.A. § 26:2-137.4(g). See N.J.S.A. ‘ 26:2-132(c) (requiring DHSS to stimulate “professional and public edu-cation concerning the need to test, detect and control lead poisoning . . .”).

33 See Ltr from Celeste Wood, Assistant Commissioner, DHSS, to Robin L. Dahlberg, Senior Staff Attorney, ACLU,Jan. 23, 2001; Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2001, July 1, 2000 to June 30,2001, New Jersey Department of Health and Senior Services, at 30 (undated).

34 These groups have included, among others, the Citizen Policy and Education Fund, the Camden County Councilon Economic Opportunity Head Start, Rutgers Cooperative Extension, the University of Medicine and Dentistry ofNew Jersey, LSNJ, ACNJ, New Jersey Citizen Action, the Burlington County Health Department, and the City ofTrenton. Strategic Plan 2003-2008, New Jersey Interagency Task Force on the Prevention of Lead Poisoning, at18-23.

35 N. Tips, A Brief Guide to Options for Improving Medicaid Lead Screening, Alliance to End Childhood LeadPoisoning, at 3 (Nov. 2002), citing M.J. Brown, E. Shenassa, and N. Tips, Small Area Analysis for Childhood LeadPoisoning, Alliance to End Childhood Lead Poisoning (2001).

36 Ltr from Celeste Wood, Assistant Commissioner, DHSS, to Robin L. Dahlberg, Senior Staff Attorney, ACLU,Jan. 23, 2001.

37 New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department of Health and SeniorServices, at 4 (Oct. 2004).


39 Carrie Farmer, Lead Screening for Children Enrolled in Medicaid: State Approaches, Forum for State HealthPolicy Leadership, National Conference of State Legislatures, at 6 (2001). See Recommendations for Blood LeadScreening of Young Children Enrolled in Medicaid: Targeting a Group at High Risk, Advisory Committee onChildhood Lead Poisoning Prevention, Centers for Disease Control and Prevention, Morbidity and MortalityWeekly Report, 49 (RR14) (Dec. 8, 2000); Nancy Tips, A Brief Guide to Options for Improving Medicaid LeadScreening, Alliance to End Childhood Lead Poisoning, at 15 (Nov. 2002).

40 More than 50% of those members of the New Jersey Chapter of the American Academy of Pediatrics surveyedby the PRONJ in 2000 stated that they did not provide screening services in their offices. 2001 Pediatric HealthCare Provider Lead Screening Survey, Technical Report R147, PRONJ, at 11 (Mar. 2001). A survey of largeMedicaid pediatric practices in Camden and Irvington concluded that 29% of the children in Camden and 45% ofchildren in Irvington referred off-site for screening were never tested for lead. Camden/Irvington Lead ScreeningAudits, Technical Report R226, PRONJ, at 2, 4 (Aug. 2002). A similar survey of Medicaid pediatric practices inJersey City and Paterson concluded that 51% of the children in Jersey City and 43% of the children in Patersonreferred off-site for screening were never tested for lead. JerseyCity/Paterson Lead Screening Audits, TechnicalReport R323, PRONJ, at 3, 4 (Oct. 2003).

41 Anne M. Wengrovitz, Stuck in Neutral, States Neglect Lead Testing Duty to Children Served by Medicaid,Alliance for Healthy Homes, at Appendices C and D (July 2005).

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42 New Jersey Childhood Lead Poisoning Prevention Project, Application for Continuation of Funding ofCooperative Agreement, #US7/CCU218464-01, in response to CDC Program Announcement 01020, Part B, NewJersey Department of Health and Senior Services, at Section C, Narrative, p. 12 (April 2001).

43 Form HCFA-416: Annual EPSDT Participation Report, New Jersey, Federal Fiscal Year 2000.

44 According to the CDC, doctors and HMOs are more likely to view the Medicaid Act’s screening and treatmentrequirements as enforceable legal obligations if the contracts between the HMOs and state Medicaid agencies explicit-ly require lead blood testing and treatment. Recommendations for Blood Lead Screening of Young Children Enrolledin Medicaid: Targeting a Group at High Risk, Advisory Committee on Childhood Lead Poisoning Prevention, Centersfor Disease Control and Prevention, Morbidity and Mortality Weekly Report, at 49 (RR14) (Dec. 8, 2000).

45 See Endnote 29.

46 POrSCHe Grant Progress Reports, 1/1/00-6/30/00, 7/1/00-12/31/00; Childhood Lead Poisoning in New Jersey,Annual Report, Fiscal Year 2000, July 1, 1999 to June 30, 2000, New Jersey Department of Health and SeniorServices, at 12 (undated).

47 Contract Between State of New Jersey, Department of Human Services, Division of Medical Assistance andHealth Services, and _________ , (“HMO Contract”), at IV-31. The contract can be found athttp://www.state.nj.us/humanservices/dmahs/about_dmahs.html.

48 HMO Contract, at IV-29.





53 HMO Contract, at VII-30, 31.

54 HMO EPSDT Sanction Tracking Report, revised 7/27/05.

55 Where an FQHC has multiple offices, DMAHS audits the office serving the largest number of Medicaid-enrolledchildren.

56 2001 Pediatric Health Care Provider Lead Screening Survey, Technical Report R147, PRONJ, at 6 (Mar. 2001).

57 N.J.A.C. § 8:51-2.3

58 In 1995, the CDC issued a “Dear Colleague” letter recommending against filter paper lead testing because themethod resulted in a high number of false positives. Among other things, the filter paper itself contained unaccept-ably high levels of lead. Ltr. from Dayton T. Miller, Ph.D. and Robert L. Jones, Ph.D., Division of EnvironmentalHealth Laboratory Sciences, National Center for Environmental Health, dated July 18, 1995. In response to the let-ter, laboratories improved both the quality of the filter paper and the manner in which it was analyzed. At the sametime, CDC established a proficiency-testing program at the Wisconsin State Laboratory of Hygiene (WSLH) tooversee laboratory practices and procedures. In 1999, CDC revised its position and issued a second “DearColleague” letter stating that “filter paper techniques [were] acceptable” as long as physicians sent their samples tobe analyzed at laboratories participating in a certified proficiency-testing program. Ltr. from Dayton T. Miller,Ph.D. and Robert L. Jones, Ph.D., Division of Environmental Health Laboratory Sciences, National Center forEnvironmental Health, dated February 25, 1999. As of May 2002, there were five laboratories that analyzed filterpaper, each of which participated in WSLH’s proficiency-testing program. Ltr. to Arlene Gilbert, Attorney, ACLU,from Noel Stanton, Program Supervisor, Wisconsin State Laboratory of Hygiene, dated April 16, 2002. One ofthese laboratories analyzed the filter paper used in this initiative.

59 Forty-two (42) percent of the housing in Irvington and 54% of the housing in Camden City was constructed priorto 1950. Each city had an unemployment rate more than twice that of the state. 44% of Camden City=s families

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with children under the age of five and 22% of Irvington’s families with children under the age of five lived inpoverty. Between 80 and 90% of each city’s population was minority. New Jersey Childhood Lead PoisoningPrevention Project, Application for Continued Funding of Cooperative Agreement, #US7/CCU218464, in responseto CDC Program Announcement 0300 for Childhood Lead Poisoning Prevention Programs, New JerseyDepartment of Health and Senior Services, at Section II, Narrative, pp. 2-3 (March 2003).

60 The CCR&R centers work with the New Jersey Department of Human Service’s Division of FamilyDevelopment to administer child care subsidies, provide resource and referral services, take steps to raise the quali-ty of child care operations, and promote the development of additional child care capacity. Seehttp://www.state.nj.us/humanservices/dfd/chldca.html.

61 Of Irvington’s roughly 4,900 children under the age of 5, approximately 1600 were enrolled in the 36 centers. OfCamden City’s roughly 7,300 children under the age of 5, approximately 2,800 were enrolled in the 72 centers.

62 Filed in 1981, the Abbott case challenged the inequality in funding between New Jersey’s urban school districtsand its affluent suburban districts. The Supreme Court’s 1998 ruling mandated that the state establish high-qualitypreschool programs in the state’s 30 highest-poverty school districts. While administered by the school districts inwhich they are located, the preschool programs were required to adhere to certain court-ordered mandates regard-ing classroom size, teacher qualification, and the provision of social and health services. The Abbott PreschoolProgram: Fifth Year Report on Enrollment and Budget, October 2003, A Report of the Abbott Indicators Project,Education Law Center, at iv (2003).

63 45 C.F.R. 1304.20 (requiring Head Start programs to obtain from a health care professional a determination as towhether every enrolled child has received age appropriate preventive and primary health care, including screens requiredby the Medicaid Act and the latest immunizations recommended by the Centers for Disease Control and Prevention).

64 Materials distributed included those previously developed under the auspices of the state’s Office for thePrevention of Mental Retardation and Developmental Disabilities, pamphlets and posters available free of costfrom the Lead Awareness Program of the federal Environmental Protection Agency, see www.epa.gov/lead/leadpbed.htm, and booklets and growth charts developed by the Channing-Bete Company, a publishing companythat produces easy-to-read, culturally sensitive, and competent educational materials on a wide range of publichealth issues. See www.channingbete.com.

65 N.J.A.C. § 8:52 App. State administrative regulations require that preschools and day care centers maintainhealth and immunization records on every enrolled child. N.J.A.C. § 8:57-4.7

66 Anne M. Wengrovitz, Stuck in Neutral, States Neglect Lead Testing Duty to Children Served by Medicaid,Alliance for Healthy Homes, at Appendix D (July 2005); Form CMS-416: Annual EPSDT Participation Report,New Jersey, Federal Fiscal Year 2004.

67 HMO lead screening rates are based on both the number of lead screens reported to DHSS by the laboratoriesanalyzing the results and HMO encounter data. See HMO EPSDT Sanction Tracking Report, dated July 14, 2005.

68 Comprehensive Lead Screening Study, Technical Report R225, PRONJ, at Table 1, p. 12 (Apr. 2003).

69 The DMAHS audit is a review of 50 randomly chosen records from each center. Some centers have more thanone location.

70 Performance Measures 2 and 4 for Lead Screening Pilot Project Conducted in Camden and Irvington (June2002-January 2004), PRONJ, at 3-4 (June 2005) (Draft). The screening rates for Irvington and Camden were cal-culated by comparing the laboratory reports submitted to DHSS with DMAHS Medicaid enrollment lists.According to DMAHS, 50-60% of the matches that result from these comparisons are exact matches (i.e., birthdate, name, and address correspond exactly). The remaining 40-50% are “probable” matches (some data corre-sponds exactly while other data might be slightly off).

71 The Working Groups were unable to obtain any data from the Camden Abbott preschool programs. In 2003, par-ents filed suit against the Camden County Board of Education, which oversees the programs, alleging that theBoard had failed to inform them that several schools had dangerously high levels of lead in their drinking water.

Under the federal Drinking Water Act, school districts must test their water for lead quarterly and remedy anyproblems. According to the suit, test results from 1999 through 2000 revealed unsafe lead levels. See LaviniaDeCastro, “Camden residents file lawsuit over lead in water at schools,” Courier Post (March 13, 2003). Becauseof the suit, the Abbott preschool programs’ Chief Nurse refused to speak publicly on any issue relating to lead.While she attended some Working Group planning meetings, she did not participate in those meetings.

72 2003 Program Announcement, at www.cdc.gov./nceh/lead/grants/pgmAnnouncement/PA2003.htm.

73 The four coalitions are the Passaic/Bergen Regional Lead Poisoning Prevention Coalition (target areas are Bergenand Passaic Counties); the LEAP (Lead Education, Advocacy, and Prevention) Regional Coalition (target areas are10 counties in northern and central New Jersey); the Monmouth/Ocean County Lead Poisoning PreventionCoalition (active in Monmouth and Ocean Counties); and the Southern Region Childhood Lead PoisoningPrevention Coalition (active in seven south Jersey counties, including Atlantic, Burlington, Camden, Cape May,Cumberland, Gloucester, and Salem).

74 New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department of Health and SeniorServices, at 25, 26 (Oct. 2004); Guidelines and Requirements, Public Health Priority Funding, Eligible Activities -CY 2005, Attachment A, at 3 (funds are to be used by local health departments to “[a]ssure that all children areappropriately screened for lead poisoning” in accordance with Universal Screening Law; “[i]nclude lead screeningin the audits of child immunization records at licensed child care facilities;” and “[p]rovide environmental investi-gations and case management follow-up of children with reported elevated blood lead levels . . .”)

75 New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department of Health and SeniorServices, at 21-25 (Oct. 2004). The 100 lead analyzers are to be distributed in Atlantic City, Bridgeton, Camden,East Orange, Elizabeth, Irvington, Jersey City, Montclair, Newark, New Brunswick, Orange, Passaic, Paterson,Perth Amboy, Plainfield, and Trenton.

76 In January 2004, then-Governor McGreevey announced the allocation of $1 million to purchase the lead dust testkits. DHSS hopes to distribute the kits in 20 cities through a non-profit agency, Family Health Initiatives, and pri-vate providers. Those cities include Bridgeton/Millville, Vineland, East Orange, Irvington, Newark, Trenton,Orange, Paterson, Plainfield, New Brunswick, Montclair, Camden, Atlantic City, Passaic City, Elizabeth, JerseyCity, and Perth Amboy. New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department ofHealth and Senior Services, at 29 (Oct. 2004).

77 The Childhood Lead Poisoning Prevention Program of the Newark Department of Health and Human Servicesorganized a pilot project using portable lead analyzers to screen children during visits to a designated WIC center.The University of Medicine and Dentistry of New Jersey organized another project using a phlebotomist to drawblood venously at another Newark WIC center. New Jersey Childhood LEAD Poisoning Elimination Plan, NewJersey Department of Health and Senior Services, at 23-4 (Oct. 2004).

78 New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department of Health and SeniorServices, at 24-5 (Oct. 2004).

79 This system has been sited as a model by the National Conference of State Legislatures’ Forum for State HealthPolicy Leadership. Carrie Farmer, Lead Screening for Children Enrolled in Medicaid: State Approaches, Forum forState Health Policy Leadership, National Conference of State Legislatures, at 10 (2001).

80 E-mail from Kevin McNally, Division of Local Public Health Practice and Regional Systems Development, NewJersey Department of Health and Senior Services, to Arlene Gilbert, ACLU Attorney, dated Sept. 13, 2005. Seealso http://nj.gov/health/lh/phpfform.htm.

81 Ltr. from ESA, Biosciences, Inc., entitled “Product Recall Notice, LeadCare Blood Lead Testing System,” datedMay 19, 2005.

82 E-mail from Maggie Gray, Coordinator, Primary and Preventive Health Care Services, New Jersey Department ofHealth and Senior Services, to Arlene Gilbert, ACLU Attorney, dated September 19, 2005.

83 Blood Lead Levels - United States, 1999-2002, Centers for Disease Control and Prevention, Morbidity andMortality Weekly Report, Vol. 25, No. 20, at 513-516 (May 27, 2005).

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84 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2003, July 1, 2002 to June 30, 2003, NewJersey Department of Health and Senior Services, at 17-18, 43-44 (Oct. 2004).



87 Roughly 10% of New Jersey’s children under the age of 18 are uninsured. Going Without: America’s UninsuredChildren, prepared for the Robert Wood Johnson Foundation by the State Health Access Data Assistance Centerand the Urban Institute, at 5 (Aug. 2005).

88 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1, 1999 to June 30, 2000, NewJersey Department of Health and Senior Services, at Table 5, p. 15 (undated); Childhood Lead Poisoning in NewJersey, Annual Report, Fiscal Year 2001, July 1, 2000 to June 30, 2001, New Jersey Department of Health andSenior Services, at Table 5, p. 15 (undated).

89 Carrie Farmer, Lead Screening for Children Enrolled in Medicaid: State Approaches, Forum for State HealthPolicy Leadership, National Conference of State Legislatures, at 10 (2001).


91 In Maryland, state law requires that the parent or guardian of any child under the age of six in a child care pro-gram submit evidence that the child has been screened for lead within 30 days of the date of the child’s entry intothat program. Md. Code Ann. [Fam. Law], §§ 5-556.1, 5-580.2, 5-589.1.

92 New Jersey Childhood LEAD Poisoning Elimination Plan, New Jersey Department of Health and SeniorServices, at 26-27 (Oct. 2004).

93 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2003, July 1, 2002 to June 30, 2003, NewJersey Department of Health and Senior Services, at Appendix 2, p. 49 (Oct. 2004).

94 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1, 2002 to June 30, 2003, NewJersey Department of Health and Senior Services, at 17 (Oct. 2004).

95 Childhood Lead Poisoning in New Jersey, Annual Report, Fiscal Year 2000, July 1, 2002 to June 30, 2003, NewJersey Department of Health and Senior Services, at Appendix 2, pp. 46-49 (Oct. 2004).

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The Office of theChild Advocate

Partnering Organizations:

Documents

Advocates and State Government Working …...Preventing Childhood Lead Poisoning in New Jersey: Advocates and State Government Working Together to Increase the Lead Screening of Children