Pandemic lockdowns and postponed visits to the doctor are likely behind a significant drop in lead screenings among kids in Hawaii last year, according to public health experts who fear more cases of lead exposure are going undetected in the islands.

The rate of testing for lead poisoning is already low in the islands, as it is in the U.S. as a whole: just a quarter of Hawaii’s children are tested annually, and among those covered by federal health insurance which requires it, only 40% are tested.

The COVID-19 pandemic prevented even more children from getting tested than normal, according to new data from the Hawaii Childhood Lead Poisoning Prevention program. About 20% fewer tests were conducted in 2020 compared to 2019, especially during spring and summer months. In April, when lockdowns were still in effect, 65% fewer tests were done compared to the same month a year prior.

Kids enjoy some shade at Kapiolani Park.
Any amount of lead in a child’s system can lead to permanent damage, but doctors and public health officials tend to flag anything higher than 5 micrograms per deciliter. Cory Lum/Civil Beat/2017

Hawaii’s testing rate is comparable to national statistics, since lead testing is not legally required in most states, and similar drops were reported in other states during the first half of 2020, according to a new report from the Centers for Disease Control and Prevention.

Deborah Zysman, executive director of the Hawaii Children’s Action Network, said the downtick in testing is likely related to fears of going to the doctor’s office in person.

“It’s not necessarily that the physicians weren’t doing the screening, it’s that the kids weren’t going in for well-child visits. That’s concerning on so many fronts,” she said.

Any amount of lead in a child’s system can cause permanent damage to physical and mental health. But poisoning can be easily overlooked, especially when symptoms are not obvious or do not appear until later.

As a result, thousands of keiki could be slipping through the safety net testing provides, leaving them vulnerable to prolonged exposure to lead, which can be found in relatively common things, such as peeling paint, dishes, soil or ceramics. 

“This is one of few lifelong medical problems that is truly 100% preventable, but not always easily identifiable,” said Diana Felton, the state toxicologist with the Hawaii Department of Health Hazard Evaluation and Emergency Response Office.

Children are also missing learning and developmental screenings, which can serve as a red flag for lead poisoning, according to Derek Priddy, the coordinator of the Hawaii lead program. The people who typically spot developmental issues work at clinics, preschools or child care centers.

When the COVID-19 pandemic shut down schools and day cares, children spent more time at home.

“It’s better to catch these things early as possible to get the needed early interventions,” he said. “This pandemic has put a stop to a lot of that.”

When lead poisoning is not detected, a child’s exposure may be prolonged. One solace is that Hawaii’s weather and outdoor lifestyle may temper that, Felton said. Other states typically record peaks in blood lead levels during winter months when children stay indoors. Adults usually can recover from moderate exposure — lead poisoning is most serious when it occurs during childhood.

About 1 in 100 children tested in Hawaii are found to have elevated blood lead levels. The proportion of children found to have dangerous levels of lead in their blood ticked up slightly from 1.04% in 2019 to 1.09% in 2020, perhaps in part due to the smaller pool of those tested. Of the 14,543 tested for it last year, 159 had dangerous amounts of lead in their blood.

It’s not yet clear if there was an uptick in blood lead poisoning nationally, but CDC researchers reported 500,000 fewer children in 34 states were tested for lead exposure during the first five months of 2020 compared to the same period a year prior. As a result, an estimated 10,000 children with elevated blood lead levels were missed during the first half of last year.

Experts maintain not enough testing is being done in Hawaii to know the true number of children affected by lead poisoning.

The source of lead in homes can be difficult to detect without an expert’s spectrometer gun — equipment the Department of Health was able to purchase for the first time in 2020.

As Civil Beat reported a year ago, in one typical case, it took several weeks for two Kauai parents to determine how their infant daughter was getting exposed to lead. Their house had been built in 2005 so they knew old paint wasn’t the issue. They eventually found that an enameled jar from a garage sale had tainted Q-tips with lead dust — the same Q-tips they had used to administer an oral medication.

The pandemic has also made home investigations more difficult and delayed efforts to remove lead from homes on neighbor islands due to inter-island travel restrictions. The lead prevention program has been able to increase home visits on Oahu, though.

Oahu staff have consulted with neighbor island families by video to try and help them identify the source of lead in their homes.

“There are certainly cases on some of the neighboring islands where we’d like to do residential investigations but haven’t been able to, so we’ve been compensating for that with public health nurses already on the islands and virtual investigations,” Felton said. “It’s not ideal but it’s still working pretty well so far.”

Testing rates appear to be rebounding, but Felton suspects socially and economically vulnerable populations have likely been impacted the most.

On the mainland, lead exposure can be predicted in neighborhoods that have old infrastructure, lead-based paint or aging plumbing. In Hawaii, it’s not as simple, said Kelly Hoffman, an epidemiology specialist for the lead prevention program.

Hawaii’s current system for predicting exposure uses geographical targets and clinical questionnaires that may not catch some cases. In fact, prioritizing geographic areas in Hawaii might be ineffective, which is what Hoffman and fellow researchers hope to analyze.

“On the mainland, where exposure is generally lead-based paint or water, and housing, you can find areas of high risk based on location,” she said. “But in Hawaii, we have a range of other sources as well … Our risk system is relatively similar to what other states have done, but we’re not entirely positive if that’s the best for our state. If we do find with this analysis that blood lead levels aren’t necessarily correlated by location, that really speaks to the need for universal testing in Hawaii.”

Only more testing will reveal the true extent of the problem, Zysman said.

“We know no amount of lead is acceptable,” she said. “That’s a lesson learned from places like Flint and Baltimore. We don’t want to be in that situation.”

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