*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at steve.holve@tchealth.org

IHS Child Health Notes

August 2008

# Quote of the month

*"The beginning is the most important part of any work*."\
Plato

**Introduction**

This spring and summer most IHS clinics have had requests for blood lead
level testing for children entering Head Start. This is an attempt to
explain why blood level testing is mandatory for Medicaid eligible AI/AN
children even if the risk of elevated lead levels is likely small in our
patients.

**Blood Lead Screening in American Indian/Alaska Native Children**

In March of 2008 the Office of Head Start issued an Information
Memorandum that reaffirmed the requirement within the Head Start Program
Performance Standards for all children entering the program to be
screened for lead poisoning as per the schedule of well child care
utilized by the EPSDT program.(1). It appeared that many Head Start
programs that serve American Indian/Alaska Native (AI/AN) children were
encountering difficulty in obtaining documentation of the required
screening blood lead levels (BLLs) performed at 12 and 24 months of age.
The Health Director of the IHS Head Start Program asked the Indian
Health Service for guidance on this issue. This request prompted a
review of current standards for screening BLLs in children \< 6 years
old.

Lead is a potent neurotoxin. At higher levels (\>70ug/dL) lead poisoning
can cause encephalopathy and death. Such extreme lead toxicity is now
rare as primary prevention efforts in the past few decades mandated the
removal of lead from gasoline and consumer products. Lead exposure from
paint in older buildings remains a persistent source of exposure to
lead. Recently there has been concern over lead toxicity in toys
imported from China. Unfortunately, even small amounts of lead can have
irreversible effects on brain development in young children. It is
estimated that every 10ug/dL increment in BLLs can decrease IQ scores by
3 to 7 points (2). At present, the accepted definition for elevated BLLs
is \>10ug/dL. However, there is recent research that BLLs even below
10ug/dL may be deleterious (3). Since BLLs \<25ug/dL are clinically
undetectable only screening can detect these cases.

Who should be screened for lead exposure? Data show that lead poisoning
is overwhelmingly a disease of young children in poverty. In the NHANES
III survey in 1994 the overall prevalence of elevated BLLs (\>10ug/dL)
in 1- 5 year olds was 4.4%. However, the prevalence of elevated BLLs was
only 0.9% in upper income children while the rate was as high as 21% in
poor children who lived in older homes. Further analysis showed that 10%
of children enrolled in Medicaid had elevated BLLs. Medicaid enrollees
also accounted for 60% of the total children with BLL \>10ug/dL and 83%
of the children with BLLs\>20ug/dL (4).

Many AI/AN children potentially would fall into the high- risk group
because of widespread poverty in many AI/AN communities. However, few
AI/AN communities have commercial homes built before the 1950s, which
would tend to diminish the likelihood of exposure to lead paint.

The current prevalence of elevated BLLs in AI/AN children is unclear. A
review of *Pubmed* for the past 20 years with the search terms,
"American Indian", "children" and "lead" disclosed only one article on
mining exposures in Oklahoma. The Indian Health Service has unpublished
data from the mid 1990s on lead levels in 7of 12 Areas. The percentage
of children screened in each area varied widely and not all tribal
groups were included. However, in this limited data set the overall rate
of elevated BLLs after confirmatory testing was \< 1% which was lower
than the national rate.

Given the low prevalence of lead poisoning in AI/AN children tested, it
was agreed that targeted screening of AI/AN children at high risk for
lead exposure was a better strategy than universal testing. Universal
testing was also discouraged by the United States Preventive Services
Task Force (5). No lead screening or targeted lead screening became the
standard in most clinics but was never explicitly made a policy for the
Indian Health Service. A summary of the costs and benefits of lead
screening in AIA/AN children was published in *The IHS Primary Care
Provider* in 1994 (6).

An informal survey of Indian Health Service/Tribal/Urban (I/T/U) clinics
suggests that most practitioners have assumed that lead exposure is not
a problem in their communities. This lack of lead screening is hardly
unique for I/T/U clinics. Despite the demonstrated elevated risk in poor
children only 20% of Medicaid enrollees nationwide were screened for
BLLs in a recent evaluation by the Office of the Inspector General (7).

However, a review of federal standards indicates BLL testing is a
**mandated** service for **all** children eligible for Medicaid and Head
Start. The Center for Medicaid and Medicare Services (CMS) requires that
all Medicaid-eligible children receive a screening blood test at 12
months and 24 months of age (8). Children between the ages of 36 to 72
months must also have a BLL test if lead screening has not been done
previously. Head Start is also required to follow the standard of care
set forth by CMS. CMS made this decision based on the demonstrated risk
of elevated BLL in Medicaid enrollees compared to the general
population.

Data show that up to 80% of AI/AN children \< 6 years of age in
reservation communities are eligible for Medicaid and Head Start. With
this high percentage of Medicaid enrollees it is likely more efficient
to screen all AI/AN children \< 6 years old for elevated BLLs. The risk
of elevated BLLs in AI/AN children is likely low, but there is no
recent, comprehensive data, and there is no data that includes all
tribal groups.

Given the high incidence of iron deficiency anemia in AI/AN children
many I/T/U clinics already screen for anemia with a complete blood count
(CBC) at 9 months and 18 months. Testing at 9 months of age is
preferable to testing at12 months as this will result in the earlier
detection of iron deficiency anemia earlier treatment. It is also known
that iron deficiency promotes lead absorption and that repletion of iron
stores will diminish absorption of lead (9 & 10). Therefore, timely
treatment of iron deficiency is one of the best preventive measures to
minimize lead poisoning. BLLs tend to peak at age 24 months so this is
the optimal time for the follow-up test to be done. To minimize the
number of blood draws CBC and lead testing could be combined in the
following schedule:

9-12 months: draw a CBC and lead level

24 months: draw a CBC and lead level

36-72 months -- draw a lead level if not done previously

Management of elevated BLLs (\>10ug/dL) is beyond the scope of this
report. Follow-up should be based on the guidelines published in the AAP
Policy statement lead poisoning published in 2005 (2).

Lead testing will cost I/T/U sites money. This test is usually performed
in a reference lab and a BLL usually costs about \$15. Medicaid pays a
global fee for outpatient visits to most I/T/U clinics so the cost of
the test is not recoverable. However, BLL is a CMS mandate: Failure to
perform a mandated test could jeopardize Medicaid reimbursement. Money
may need to be reprogrammed to I/T/U laboratory budgets to cover this
cost.

Lastly, each clinic will need to track BLLs in their patient population
over the next year. This will let us answer the question of which, if
any, AI/AN children are at risk for lead poisoning. Tribal groups with
low lead levels may be able to request a waiver of BLL testing from CMS
in the future. As important, if some tribal groups are found to be at
elevated risk, appropriate environmental investigation and amelioration
can begin.

References

1.  Lead Screening ACF-IM-HS-08-07. Administration for Children and
    Families. U.S. Department of Health and Human Services. Issued
    3/20/08.
    www.acf.hhs.gov/programs/ohs/policy/im2008/acfimhs_08_07.html

2.  Lead Exposure in Children: Prevention, Detection and Management.
    American Academy of Pediatrics Policy Statement. *Pediatrics:* 2005
    Oct;116(4):1036-1046.

3.  Canfield RL, Henderson CRjr, Cory-Slechta DA, Cox C, Jusko TA,
    Lamphear BP. Intellectual Impairment in children with blood
    concentrations below 10ug per deciliter. *N Eng J Med*
    2003:348:1517-1526.

4.  Recommendations for blood lead screening of young children enrolled
    in Medicaid: Targeting a group at high risk. *MMWR* December 08,
    2000 / 49(RR14);1-13.

5.  USPSTF Recommendations for Lead Screening. *Pediatrics*.
    2006;118:e2514-2518.

6.  Batholomew M Vanderwagen C. Lead screening of Native American
    children: Targeted or Screening? *The IHS Primary Care Provider*
    1999 August 24(8):125-126.

7.  Lead Poisoning: Federal Health Care Programs are not Effectively
    Reaching At-Risk Children. U.S. General Accounting Office, January
    1999.

8.  EPSDT Benefits: Accessed on June 12, 2008
    [http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.](http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.   )

9.  Barton JC, Conrad ME, Nuby S, Harrison L Effects of iron on the
    absorption and retention of lead. *J Lab Clin Med*. 1978
    Oct;92(4):536-47.

10. A Bradman, B Eskenazi, P Sutton, M Athanasoulis, and L R Goldman
    Iron deficiency associated with higher blood lead in children living
    in contaminated environments. *Environ Health Perspect*. 2001
    October; 109(10): 1079--1084.

**Infectious Disease Updates**.

Steve Holve, MD

*Pentacel®*: New May not be Better for American Indian/Alaska Native
Infants

A new combination vaccine, *Pentacel®* (DTaP-IPV- Hib \[PRP-T\]), was
recently licensed for use in the United States. This vaccine is not
ideal for American Indian/Alaska Native (AI/AN) infants served in
federal, tribal and urban Indian clinics.

*Pentacel®* is a vaccine that protects against five serious infections;
diphtheria, tetanus, pertussis, polio, and haemophilus influenzae type b
(Hib).  It is the first combination vaccine in the United States that
includes both poliovirus and haemophilus antigens.  The vaccine is
administered to children at 2, 4, 6, and 15-18 months of age.   

There are currently several Hib vaccines available which vary in the
protein used to make the vaccine more immunogenic. In *Pentacel®,* the
Hib component of the vaccine is a purified polyribosylribitol phosphate
(PRP) capsular polysaccharide covalently bound to tetanus protein
(PRP-T).  The current Hib vaccine recommended for AI/AN infants has a
meningococcal outer membrane protein (OMP) bound to the PRP molecule and
is designated as a PRP-OMP Hib vaccine.

The Redbook of the American Academy of Pediatrics recommends that for
AI/AN infants the first dose of a Hib conjugate vaccine should contain
PRP-OMP. For AI/AN infants "the administration of a PRP-OMP-containing
vaccine leads to more rapid seroconversion to protective concentrations
of antibody within the first 6 months of life, and failure of use has
been associated with excess cases of Hib disease in young infants in
this population". (1)

 

In 1996 Alaska switched from a PRP-OMP Hib vaccine to combination
HbOC-DTP vaccine (*Tetramune®*).  During 1996-1997, 17 Hib cases
occurred in Alaska Native children \<5 years of age, increasing the rate
of Hib disease from 19 to 91 cases per 100,000 per year.  8 of the cases
occurred in partially vaccinated children who had received 1 or 2 doses
of HbOC.  Since 2001, Alaska has adopted a schedule using PRP-OMP alone,
and the subsequent rate of Hib disease in Alaska Native infants
decreased to 5.4 per 100,000 per year.(2)

Physicians, pharmacists and immunization coordinators who work for
federal, tribal and urban Indian clinics need to be aware of this change
and insure that their state's VFC program continues to supply a PRP-OMP
Hib vaccine to their AI/AN patients.

1\. 2006 Report of the Committee on Infectious Diseases. American
Academy of Pediatrics; Elk Gove, IL page 89.

2\. Singleton et al., The Alaska Haemophilus influenzae type b
experience: Lessons in controlling a vaccine-preventable disease.
*Pediatrics* 2006;118:421-429.

Addendum:

Questions have arisen over whether this recommendation applies to all
AI/AN children. The above update was written for an audience that works
in federal, tribal and urban Indian clinics. Private clinics near
reservation communities may serve significant numbers of AI/AN
patients and may wish to have a PRP-OMP containing Hib vaccine
available. The risk of invasive Hib disease for AI/AN infants who do not
live on or near reservation communities is unknown.

This issue of increased risk for invasive Hib disease was addressed in
the MMWR in December 2007 due to a decrease in the supply of PRP-OMP Hib
vaccine due to production difficulties. The pertinent summary of the
risk for AI/AN infants is below. Each practitioner should make a
decision based on their assessment of risk of invasive Hib for their
patients. The full posting with references is available at:

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5650a4.htm>

American Indian/Alaska Native (AI/AN) children also are at increased
risk for Hib disease, particularly in the first 6 months of life. Before
the use of Hib conjugate vaccines, the incidence of Hib disease among
young AI/AN children in AI/AN communities was approximately 10 times
higher than among children of comparable age in the general population.
Compared with PRP-TT conjugate vaccines, the administration of PRP-OMP
vaccines leads to a more rapid seroconversion to protective antibody
concentrations within the first 6 months of life. Failure to use PRP-OMP
vaccines for the first dose is associated with excess cases of Hib
disease in AI/AN infants living in communities where Hib transmission is
ongoing and exposure to colonized persons is likely. Although PRP-OMP
and PRP-TT vaccines are equally effective after completion of the
primary series, availability of more than one Hib vaccine in a clinic
could lead to administration of the wrong vaccine for the first dose in
these populations. For these reasons, CDC recommends that providers who
currently use PRP-OMP\--containing Hib vaccines (*PedvaxHIB* and
*Comvax)* to serve predominantly AI/AN children in AI/AN communities
continue to stock and use only PRP-OMP\-- containing Hib vaccines not
affected by the recall and vaccinate according to the routinely
recommended schedules, including the 12\--15 month booster dose. In its
vaccine stockpile, CDC has PRP-OMP\--containing Hib vaccines not
affected by the recall and will prioritize distribution of available
PRP-OMP vaccines for use in AI/AN communities. AI/AN children not in
AI/AN communities or who already receive PRP-TT conjugate vaccines
should continue to be vaccinated with available vaccines according to
the routinely recommended schedules, including the 12\--15 month booster
dose.

**Recent literature on American Indian/Alaskan Native Health**

Michael L. Bartholomew, MD

Brim SN, Rudd RA, Funk RH, Callahan DB. Asthma prevalence among US
children in underrepresented minority populations: American
Indian/Alaska Native, Chinese, Filipino, and Asian Indian. *Pediatrics*.
2008 Jul;122(1):e217-22.

http://www.ncbi.nlm.nih.gov/pubmed/18595967?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Asthma continues to be a prevalent childhood disease in the United
States. Recent studies estimate that 8.9% of US children ages 0 to 17
years of age have asthma^1^. Asthma prevalence among Asian Americans,
specifically subgroups of Asian Americans, and American Indians and
Alaska Natives (AI/AN) has largely been unknown.

Anecdotal reports of the 1960's and 1970's suggested that asthma in
American Indians was rare^2^. In the 1990s, Clark et al showed that
asthma was more prevalent than once believed when he documented the
asthma burden in Jemez Indian childhood population^3^. Between
2004-2005, the prevalence of asthma in AI/AN children was estimated to
be 9.9%^1^.

Many recent studies defining asthma prevalence rates among children have
yielded varied results in regards to age, race, socioeconomic and ethnic
backgrounds. Due to small sample sizes in large scale studies, the
national prevalence of diseases has thus far been difficult to determine
for certain ethnic groups or subgroups.

This study investigates the prevalence of current asthma, lifetime
asthma, and asthma attacks among subpopulations (Chinese, Filipino, and
Asian Indian) of Asian American and AI/AN children ages 2 to 17 years
and place of birth by analyzing aggregate data from the 2001-2005
National Health Interview Surveys. The prevalence of lifetime and
current asthma and the prevalence of 12-month asthma attacks were
calculated from responses to questions posed during the survey. Logistic
regression models were used to determine the association of current
asthma prevalence with race and place of birth by controlling for
certain confounding demographic variables.

Estimates of current asthma prevalence according to race and place of
birth ranged from 4.4% for Asian Indian children to 13.3% in black
children. AI/AN children had an asthma prevalence of 13.0%, while
Filipino and Chinese children had a prevalence of 10.7% and 5.1%,
respectively. White children had a current asthma prevalence of 8.4%.

Lifetime asthma prevalence estimates among races showed a similar trend.
The lifetime prevalence among the races ranged from 9% in Chinese
children to 18.1% for black children. The lifetime asthma prevalence
estimates for AI/AN children was 18 % and for Asian Indian and Filipino
was 9.4% and 15.7% respectively. A high prevalence of current and
lifetime asthma was noted in children born in the United States than in
children born outside the United States (Current asthma: 9.4% vs. 4.3%;
Lifetime asthma: 13.6% vs. 7.3%). The prevalence of asthma attack in the
past 12 months did not vary among races or place of birth.

After controlling for place of birth, gender, age, ethnicity, region,
household income, and health insurance coverage, AI/AN children are 1.82
times likely to report having asthma than their White counterparts.
Black children are 1.57 times likely while Filipino children are 1.64
times likely. Additionally, children born inside the United States were
twice as likely to report having asthma as children born outside the
United States.

This study is not without limitations. The authors cite small sample
sizes of the study populations to be problematic, requiring aggregate
data of 5 years to provide limited statistical power. There is also the
potential for selection bias since the survey was administered in either
the English or Spanish language. Lastly, additional risk factors (BMI
and environmental tobacco smoke exposure) for asthma were not analyzed
due to lack of inclusion in the survey model. Despite these limitations,
the authors concluded that the results support previous assertions that
certain ethnicities including black, AI/AN, and Filipino children as
well as those born in the United States tend to have a
disproportionately higher prevalence of asthma.

Reference:

1.  Akinbami L; Centers for Disease Control and Prevention, National
    Center for Health Statistics. The state of childhood asthma, United
    States, 1980-2005. *Adv Data*. 2006;(381):1-24.

2.  Galloway JM, Goldberg BW, Alpert JS. 1999. *Primary Care of Native
    American Patients: Diagnosis, Therapy, and Epidemiology*. Boston:
    Butterworth-Heinemann

3.  Clark D, Gollub R, Green WF, Harvey N, Murphy SJ, Samet JM. Asthma
    in Jemez Pueblo schoolchildren. *Am J Respir Crit Care Med*. 1995
    May;151(5):1625-7.