VOLUME 90 NO. 11 NOVEMBER 2007
Refugee Health Update:
Lead Exposure in Refugee Children
María-Luisa Vallejo, MA, MEd, MPH, Carrie Bridges, MPH, Magaly Angeloni, MBA, and Peter R. Simon, MD, MPH
RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY JAY S. BUECHNER, PHD
Although there have been dramatic reductions in
blood leadblood lead
blood leadblood lead
levels (BLLs) among children in the United States and Rhode
Island in recent years, childhood lead poisoning remains a sig-
nificant public health concern. In Rhode Island, among chil-
dren entering kindergarten in the fall of 2006, 8% had been
found to have elevated BLLs at some time prior to age three.
Among children living in the state’s core cities (Central Falls,
Newport, Pawtucket, Providence, West Warwick, and
Woonsocket), the prevalence rate was 13% of children.
Over the last decade, an average of 70,000 refugees per
year have resettled in the US, with the proportion of children
ranging between 30% and 40%. During a recent 21-month
period, the majority of the 352 refugees arriving in Rhode
Island came from Sub-Saharan Africa, most notably Liberia,
Ivory Coast, Ethiopia, and Somalia.
Large proportions of
children arriving from those countries have been afflicted by
iron deficiency and chronic and acute malnutrition that put
them at high risk for lead poisoning. Accordingly, the refu-
gee health screening in Rhode Island, which is required for
all refugees within 30 days of arrival, includes a BLL test
among children up to age 6.
Children with a BLL test result
of 10 µg/dL or greater are classified as having elevated blood
lead levels, and children who have a single venous BLL test
result of 20 µg/dL or greater or two tests (capillary or venous)
occurring at least 90 days apart but no more than 365 days
apart with levels of 15 µg/dL or greater are classified as “sig-
nificantly lead poisoned.”
For children in the latter category,
the Department of Health offers a home inspection by certi-
fied lead inspectors to determine whether lead hazards are
present and to work with property owners to mitigate any
Several studies in New England states show the prevalence
of lead poisoning and associated risk factors among refugee chil-
dren. Among Somali-Bantu children ages 0-14 years arriving
in Massachusetts between April 2003 and September 2005,
182 of 290 (63%) were found to be anemic. Among those
under age 12, 21% (33 of 157) had elevated BLLs, with 6 of
those (4%) having levels of 20 µg/dL or greater. More recently
(April 2005-March 2006), among arrivals from all African na-
tions, 26 of 193 (14%) of children were found to have elevated
BLLs, with especially high prevalence rates among Somali (28%)
and Liberian (28%) children.
Another study, conducted by the New Hampshire Depart-
ment of Health and Human Services, examined BLL test re-
sults for 242 refugee children (ages 6 months – 15 years) arriv-
ing in the state during the period October 2003-September
2004, primarily from Africa (238) and primarily resettling in
the city of Manchester (216). Of the 242 children, 210 were
tested for blood lead within 90 days of their arrival and 92 of
them were tested again between 3 and 6 months after their
Among the children who were tested twice, 11%
had elevated BLLs at the time of initial screening only, 14%
had elevated levels at both initial and follow-up screening, 29%
had elevated levels at the follow-up screening only, and 46%
had no findings of elevated blood lead. Thus, many children
had elevated BLLs when they arrived in the US, presumably
from exposures in their home countries, and an even greater
number were found to have acquired elevated levels from ex-
posures after their arrival here.
Although data on BLLs specific to refugees arriving in
Rhode Island are not available, the results from Massachusetts
and New Hampshire can be presumed to extend to them, as
there is substantial overlap in the countries of origin. Many of
these children will arrive with elevated BLLs, and many more
will arrive with risk factors for acquiring elevated levels.
The CDC has developed recommendations for testing, treat-
ing, and preventing lead poisoning among refugee children:
• Identification of Children with Elevated Blood Lead Levels
° Blood lead level testing of all refugee children 6
months to 16 years old at entry to the US.
° Repeat blood lead level testing of all refugee children 6
months to 6 years old (and older children, if warranted)
3 to 6 months after refugee children are placed in per-
manent residences, regardless of initial test results.
• Early Post-arrival Evaluation and Therapy
° Upon US arrival, all refugee children should have nu-
tritional evaluations performed, and should be pro-
vided with appropriate nutritional and vitamin supple-
ments as indicated.
° Evaluate the value of iron supplementation among
• Health Education / Outreach
° CDC and its state and local partners should develop
health education and outreach activities that are cultur-
ally appropriate and sensitive to the target population.
° CDC and its state and local partners should develop
training and education modules for health care pro-
viders, refugee and resettlement case workers, and
partner agencies (e.g., WIC) on the following:
– Effects of lead poisoning among children.
– Lead sources in children’s environments and ways
to reduce the risk of exposure.
MEDICINE & HEALTH/RHODE ISLAND
– Nutritional and developmental interventions that
can mitigate the effects of lead exposure.
– Ways to provide comprehensive services to chil-
dren with elevated blood lead levels.
Under the leadership of Paul Geltman, MD, MPH, of
the Massachusetts Department of Public Health, a retrospec-
tive cohort study to examine the relationship between BLL,
behavioral practices, and world region of origin in refugee chil-
dren has been developed.
This study addresses the relative
lack of data on the subject during the past five years, a period
when the demographics of the refugee population entering
the United States have been changing.
This research is designed to contribute to the overarching
goal of describing the distribution of lead exposure in refugee
children resettled throughout the US. There will be a focus
on refugees from Africa, who have accounted for a large pro-
portion of incoming refugees in recent years, as well as on iden-
tifying the cultural and behavioral practices that can influence
the risk of lead exposure. Participating states and localities will
be asked to identify a sample of 30 refugees from their juris-
dictions to be included in the study so that it will represent the
situation of refugee children nationally.
In Rhode Island, the Refugee Health and the Childhood
Lead Poisoning Prevention Programs have put in place a sys-
tem to ensure that refugees are screened for lead upon their
arrival to the United States. Some refugees have already been
exposed to lead sources in their own countries, but some oth-
ers are potentially exposed to lead once they are here. While
lead screening is a test that verifies the presence of lead in a
child’s blood stream, what is really important is to eliminate
the sources that cause lead poisoning in young children. The
key is to conduct primary prevention, so no child is exposed to
lead and its deleterious effects. Strategies to permanently re-
move lead hazards from homes and provide healthy housing to
families, along with resources to implement them, must be put
in place and be continuously supported.
For additional information on lead and lead poisoning,
visit the Rhode Island Department of Health’s web site,
1. Childhood Lead Poisoning Prevention Program. Providence, RI: Rhode Is-
land Department of Health.
2. Julme T, Bridges C, Simon PR. Refugee health in Rhode Island. Medicine &
Health / Rhode Island 2006; 89: 347-9.
3. Refugee Health Program website. Rhode Island Department of Health. http:/
4. Unpublished data from the Refugee and Immigrant Health Program, Massa-
chusetts Department of Public Health.
5. Kellenberg J, DePentima R, et al. Elevated blood lead levels in refugee children
— New Hampshire, 2003-2004. MMWR 2005; 54:42-6.
6. Centers for Disease Control and Prevention. Recommendations for Lead Poison-
ing Prevention in Newly Arrived Refugee Children. http://www.cdc.gov/nceh/
7. Geltman PL. Lead Exposure in Refugee Children in the US: Research Plan. Bos-
ton, MA: Massachusetts Department of Public Health. January 2006.
María-Luisa Vallejo, MA, MEd, MPH, is Coordinator of
the Refugee Health Program, Rhode Island Department of Health.
Carrie Bridges, MPH, is Team Lead for Health Disparities
in the Division of Community Health and Equity, Rhode Island
Department of Health.
Magaly Angeloni, MBA, is Program Manager, Childhood
Lead Poisoning Prevention Program, Rhode Island Department
Peter Simon, MD, MPH, is Assistant Medical Director, Di-
vision of Family Health, Rhode Island Department of Health,
and Clinical Associate Professor, Departments of Community
Health and Pediatrics, Warren Alpert Medical School of Brown
Disclosure of Financial Interests
The authors have no financial interests to disclose.