Hawaii

About the program

The State of Hawaii received $592,273 through cooperative agreement EH21-2102 from the Centers for Disease Control and Prevention (CDC) in FY 2022. The funds address childhood lead poisoning prevention and surveillance programmatic activities being conducted from September 30, 2023, to September 29, 2024.

The strategies focus on:

• Ensuring blood lead testing and reporting
• Enhancing blood lead surveillance
• Improving linkages to recommended services

To learn more about these efforts in Hawaii, contact the program below.

Hawaii State Department of Health

Childhood Lead Poisoning Prevention Program

1250 Punchbowl St.

Honolulu, HI 96813

Phone: 808-733-9058

Success story: funding year 3

New ideas and strategies to reengage communities in Hawaii after COVID-19

Challenge

The percentage of children in Hawaii under 3 years tested for lead dropped from 28.6% in 2019 to 24.2% in 2020. Online messaging and outreach were substituted for in-person outreach events and training sessions that typically create more connection and conversations. COVID-related news overshadowed communication regarding the hazards of lead exposure. As Hawaii emerged from the most disruptive stages of the pandemic, new ideas and strategies to reengage the community were required to increase blood lead testing rates and promote behaviors that reduce lead exposure.

Intervention

The Hawaii Childhood Lead Poisoning Prevention (HI-CLPPP) staff implemented the following activities from October 2022 to September 2023:

• Redesigned and simplified educational material with more engaging graphics
• Translated core educational material into 14 languages
• Increased the number and type of outreach and training events while including non-traditional events like the Earth Day Beach Cleanup Festival, which draws a more diverse audience
• Partnered with local non-profit organizations and federal agencies, like the US Environmental Protection Agency (EPA) and the Agency for Toxic Substances and Disease Registry (ATSDR), in a high-profile, large-scale Earth Day Beach Cleanup Festival using the lead testing station concept described below
• Developed a lead testing station concept that combines the traditional distribution of educational material and one-to-one conversations with testing of household objects and soil for lead and point-of-care blood lead testing for young children
• Promoted events and protective behaviors through multiple media channels, ranging from TV morning show appearances to social media messaging
• Updated program website with simplified wording and more localized images

Impact

The percentage of children under 3 years tested for lead increased from 27.8% in 2022 to 29.3% in 2023. This surpassed the baseline of 28.1% established in 2021 and marked a 5.1 percentage point increase in children tested from the low of 24.2%, marking a 16% increase during COVID-19. From 2022 to 2023, the number of educational materials distributed more than doubled from 3,544 to 8,988, and program website unique views more than tripled from 1,976 to 6,433.

Funding for this work was made possible in part by Cooperative Agreement NUE2EH001450 from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of CDC; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Success story: funding year 2

Implementing rapid changes in response to CDC's updated blood lead reference value in Hawaii

Challenge

CDC updated the blood lead reference value (BLRV) from 5 µg/dL to 3.5 µg/dL in October 2021. In response, the Hawaii State Department of Health (DOH) Childhood Lead Poisoning Prevention Program (CLPPP) required rapid changes across multiple systems and processes to better align with the updated BLRV. Beginning January 1, 2022, the changes would ensure all children up to age 16 with initial blood lead levels (BLLs) at or above the BLRV were provided with confirmatory venous lead tests and case management services as needed. Most children tested for lead exposure were younger than age 6 years.

Intervention

The CLPPP staff implemented the following activities to rapidly update its processes:

• Distributed updates to healthcare providers through the DOH Provider Alert Network.
• Updated healthcare provider guidelines and educational materials on the CLPPP website.
• Reduced the number of questions on initial phone interviews for families of children with an initial capillary result between 3.5 and 4.9 µg/dL to balance early engagement of families with the possibility of a false positive capillary result.
• Worked with DOH public health nurses to expand follow-up with home visit clients until BLLs decline below the new BLRV.
• Updated workflows in DOH surveillance systems to capture new cases at or above the updated BLRV.
• Consulted with the Department of Housing and Urban Development (HUD) on the impact of the new CDC BLRV on HUD rules requiring environmental investigations in public housing.
• Worked with laboratories to ensure the BLRV was updated on lab reports.

Impact

Laboratories, healthcare providers, service providers, and community organizations also shared information on the new BLRV with families. The interventions resulted in access to follow-up services for 102 additional children with BLL between 3.5 µg/dL and 4.9 µg/dL in 2022 (140 children with BLL above or equal to 3.5 µg/dL had previously received follow-up services). The following actions were completed:

• Coordinated care with 100 healthcare providers
• Attempted contact with 96 families by phone (Six of these children received a venous confirmatory test result below the BLRV before contact was attempted.)
• Completed 75 phone interviews and lead sources assessments with families

Funding for this work was made possible in part by NUE2EH001450 from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of the CDC; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Success story: funding year 1

Strengthening lead testing and surveillance in Hawaii's high-risk neighborhoods

Challenge

In Hawaii, most community health centers located in high-risk neighborhoods conduct blood lead testing using point-of-care machines that report the results directly in-house. In a survey conducted by a Hawaii Childhood Lead Poisoning Prevention Program (HI CLPPP) partner, doctors reported only sending results for patients with venous follow-up blood lead tests greater than or equal to 10 µg/dL to the Hawaii Department of Health. Doctors are required by state law to send all blood tests to the Hawaii Department of Health. Additionally, doctors at these health centers often did not follow protocols for determining which children should receive a blood lead test.

Intervention

The Kalihi Palama Health Center (KPHC) is a community health center located in Hawaii's highest risk area for lead poisoning, an urban community of approximately 65,000 residents, many of whom are low-income, live in older housing, and face significant barriers to access medical services. KPHC was selected for this intervention because they were reporting the highest number of children tested with point-of-care machines and the highest prevalence of elevated blood lead levels (BLLs) compared to the state average.

HI CLPPP partnered with KPHC's Director of Clinical Operations, their Quality and Compliance Coordinator, and several of their healthcare providers to:

• establish a lead screening protocol following the state recommended guidelines
• establish a reporting system to report in-house blood lead test results from all locations to the Hawaii Department of Health
• implement quality control measures to ensure continued compliance

Through these efforts, in-house blood lead testing results at KPHC can now be added from KPHC records into a validated spreadsheet and reported directly to HI CLPPP.

Impact

From January 2018 through February 2019, KPHC reported that 895 children were tested, which is a 44% increase in children tested over that period. Over 96% of the children tested were members of minority populations: 50% Native Hawaiian or Pacific Islander, 36% Asian, and 10% Other. Many children were either enrolled in Medicaid (40%) or uninsured (18%). Of all children tested at KPHC, 2.8% had elevated BLLs, three times the state average.

Because KPHC started reporting all blood test results to HI CLPPP, all children with elevated BLLs became eligible to receive HI CLPPP's case management services, including educational information, telephone follow-ups by a public health nurse, home visits with the public health nurse, and environmental investigations. Improvement in screening rates and referral to follow-up services at KPHC following HI CLPPP's intervention will be a model for future partnerships to prevent high-risk children who potentially have elevated BLLs from going undetected.

Funding for this work was made possible in part by the NUE2EH001360 from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.