Skip to main content

Lead Poisoning Prevention Efforts in High-Risk Environments: Follow-up Testing Rates among Preschool Children in Flint, Michigan, 2013–2015



Despite the importance of screening in efforts to address lead poisoning, many children in the United States have never been tested for lead, even when required to receive blood lead testing by state and federal healthcare policy. Fewer children gain access to follow-up or confirmatory testing when elevated blood lead levels are detected.


In response to previous research that illustrates the extent to which follow-up treatment services have been underutilized and poorly coordinated, this retrospective cohort study examines follow-up testing trends for lead poisoning among Medicaid-enrolled children 6 years and younger in Flint, Michigan, between 2013 and 2015.


These findings illustrate that compliance with follow-up testing procedures was less than adequate during the period of study.


As illustrated in this bivariate analysis, subpopulations in Flint most likely to have lead poisoning were least likely to receive follow-up testing. Evidence also demonstrates that the likelihood that children with lead poisoning received follow-up testing was overwhelmingly associated with their blood lead concentration level than other indicators including socioeconomic status in this high-risk environment.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig 2


  1. American Academy of Pediatrics. (AAP). Lead exposure in children: prevention, Detection, and Management. Pediatrics. 2005;116:1036–46.

    Article  Google Scholar 

  2. Centers for Disease Control and Prevention. 2012. Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. Report of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention January 4, 2012. Accessed Sept 10, 2019.

  3. Kemper AR, Cohn LM, Fant KE, Dombkowski KJ, Hudson SR. Follow-up testing among children with elevated screening blood lead levels. JAMA. 2005;293(18):2232–7.

    CAS  Article  Google Scholar 

  4. Aoki Y, Brody DJ. WIC participation and blood lead levels among children 1-5 years: 2007–2014. Environ Health Perspect. 2018;126(6):1–6.

    Article  Google Scholar 

  5. Dignam T, Evens A, Eduardo E, Ramirez S, Caldwell K, Kilpatrick N, et al. High-intensity targeted screening for elevated blood lead levels among children in 2 inner-city Chicago communities. Am J Public Health. 2004;94(11):1945–51.

    Article  Google Scholar 

  6. Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). 2000. Recommendations for Blood Lead Screening of Young Children Enrolled in Medicaid: Targeting a Group at High Risk. Accessed Mar 28, 2018.

  7. Centers for Disease Control and Prevention. 2017. Lead. Centers for Disease Control and Prevention. Retrieved March 4, 2018 (

  8. Dickman, J. 2017. Children at risk: gaps in state lead screening policies. Safer Chemicals. Retrieved (

  9. Centers for Disease Control and Prevention. 2013. Blood lead levels in children aged 1–5 years: United States, 1999–2010. Morbidity and Mortality Weekly Report. Retrieved from mmwr/preview/mmwrhtml/mm6213a3.htm?s_cid=mm6213a3_e.

  10. General Account Office. 1999. “Lead poisoning: federal health care programs are not effectively reaching at-risk children.” GAO/HEHS-99-18., Accessed February 27, 2020.

  11. Markowitz ME, Clemente I, Rosen JF. Screening for lead poisoning: is there follow-up? Am J Public Health. 1999;89:1088–90.

    CAS  Article  Google Scholar 

  12. Michigan childhood lead poisoning prevention and control Commission Annual Report 2007: 28.

  13. Highsmith AR. Demolition means Progress: Flint, Michigan, and the fate of the American Metropolis. Chicago: University of Chicago Press; 2015.

    Book  Google Scholar 

  14. Clark A. The Poisoned City: Flint’s Water and the American Urban Tragedy. New York: Metropolitan Books; 2018.

    Google Scholar 

  15. Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. Am J Public Health. 2016;106(2):283–90.

    Article  Google Scholar 

  16. Robbins, Rebecca. 2017. “CDC panel urges new guidelines for diagnosing high lead levels in children.” January 20, 2017, STAT, https://wwwstatnewscom/2017/01/20/cdc-lead-children/ Accessed Jan 3, 2018.

  17. Michigan Department of Health and Human Services. (2019). Medicaid Provider Manual. MDHHS. Medicaid Provider Manual. (2018). Accessed August 1, 2018. Michigan Department of Health and Human Services (MDHHS). (2015). Blood Lead Level Quick Reference for Primary Care Providers. Retrieved March 4, 2018 (

  18. Rosencrants, Troy, Matt McCloskey and Sara McDonnell. 2017. City of Flint Community Profiles by Ward. Map Flint., accessed Feb 12, 2020. Page 3; 44.

  19. Leventhal T, Newman S. Housing and child development. Child Youth Serv Rev. 2010;32(9):1165–74.

    Article  Google Scholar 

  20. Eric Dresden. “Flint residents protest drinking water problems outside City Hall.” January 13, 2015. Mlive.com

  21. City of Flint. 2017. “Mayor weaver presents her second state of the city address October 17, 2017.” Accessed Dec 30, 2017.

  22. “Mayor Karen Weaver: Two more years of water filter use for Flint.” March 13, 2017. Accessed Dec 30, 2017.

  23. Fuller A, Messito MJ, Mendelsohn AL, Oyeku SO, Gross RS. Prenatal material hardships and infant regulatory capacity at 10 months old in low-income Hispanic mother-infant Pairs. Acad Pediatr. 2018;18(8):897–904.

    Article  Google Scholar 

  24. California Department of Health Services. 1997. Guidance manual for implementing fingerstick sampling. Emeryville, Calif: Childhood Lead Poisoning Prevention Branch, California Department of Health Services, Sept. 1997.

  25. GAO 1999. lead poisoning: federal health care programs at not effectively reaching at-risk children. GAO-HEHS-99-18. The United Stated General Accounting Office. Washington, DC. Accessed 10-15-2019.

  26. National Center for Lead Safe Housing. 1999. Another link in the chain: state policies and practices for case management and environmental investigation for lead-poisoned children. June 1999. Accessed Oct 18, 2019.

  27. Flint Registry., Accessed March 1, 2020.

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Katrinell M. Davis.

Ethics declarations

Conflict of Interest

The author declares that he has no conflict of interest.

Research involving Human Participants and/or Animals

This research study received institutional review board approval from the Michigan Department of Health and Human Services and Florida State University. A Health Insurance Portability and Accountability Act (HIPAA) Waiver of Authorization was granted and the private health data was deidentified before the analysis.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Davis, K.M. Lead Poisoning Prevention Efforts in High-Risk Environments: Follow-up Testing Rates among Preschool Children in Flint, Michigan, 2013–2015. J. Racial and Ethnic Health Disparities 8, 199–209 (2021).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Follow-up testing
  • Lead poisoning
  • High-risk
  • Medicaid-enrolled
  • Flint, Michigan
  • Flint water crisis