In the Upper Midwest, Northeast and parts of the West Coast — areas with historically high rates of lead poisoning — the slide has been the most dramatic, according to the Centers for Disease Control and Prevention. In states such as Michigan, Ohio and Minnesota, testing for the brain-damaging heavy metal fell by 50% or more this spring compared with 2019, health officials report.

“The drop-off in April was massive,” said Thomas Largo, section manager of environmental health surveillance at the Michigan Department of Health and Human Services, noting a 76% decrease in testing compared with the year before. “We weren’t quite prepared for that.”

Blood tests for lead, the only way to tell if a child has been exposed, are typically performed by pricking a finger or heel or tapping a vein at 1- and 2-year-old well-child visits. A blood test with elevated lead levels triggers the next critical steps in accessing early intervention for the behavioral, learning and health effects of lead poisoning and also identifying the source of the lead to prevent further harm.

Because of the pandemic, though, the drop in blood tests means referrals for critical home inspections plus medical and educational services are falling, too. And that means help isn’t reaching poisoned kids, a one-two punch, particularly in communities of color, said Yvonka Hall, a lead poisoning prevention advocate and co-founder of the Cleveland Lead Safe Network. And this all comes amid COVID-related school and child care closures, meaning kids who are at risk are spending more time than ever in the place where most exposure happens: the home.

“Inside is dangerous,” Hall said.

The CDC estimates about 500,000 U.S. children between ages 1 and 5 have been poisoned by lead, probably an underestimate due to the lack of widespread testing in many communities and states. In 2017, more than 40,000 children had elevated blood lead levels, defined as higher than 5 micrograms per deciliter of blood, in the 23 states that reported data.

While preliminary June and July data in some states indicates lead testing is picking up, it’s nowhere near as high as it would need to be to catch up on the kids who missed appointments in the spring at the height of lockdown orders, experts say. And that may mean some kids will never be tested.

“What I’m most worried about is that the kids who are not getting tested now are the most vulnerable — those are the kids I’m worried might not have a makeup visit,” said Stephanie Yendell, senior epidemiology supervisor in the health risk intervention unit at the Minnesota Department of Health.

Lifelong Consequences

There’s a critical window for conducting lead poisoning blood tests, timed to when children are crawling or toddling and tend to put their hands on floors, windowsills and door frames and possibly transfer tiny particles of lead-laden dust to their mouths.

Children at this age are more likely to be harmed because their rapidly growing brains and bodies absorb the element more readily. Lead poisoning can’t be reversed; children with lead poisoning are more likely to fall behind in school, end up in jail or suffer lifelong health problems such as kidney and heart disease.

That’s why lead tests are required at ages 1 and 2 for children receiving federal Medicaid benefits, the population most likely to be poisoned because of low-quality housing options. Tests are also recommended for all children living in high-risk ZIP codes with older housing stock and historically high levels of lead exposure.

Testing fell far short of recommendations in many parts of the country even before the pandemic, though, with estimating that in some states 80% of poisoned children are never identified. And when tests are required, there has been little enforcement of the rule.

Early in the pandemic, officials in New York’s Erie County bumped up the threshold for sending a public health worker into a family’s home to investigate the source of lead exposure from 5 micrograms per deciliter to 45 micrograms per deciliter (a ), said Dr. Gale Burstein, that county’s health commissioner. For all other cases during that period, officials inspected only the outside of the child’s home for potential hazards.

About 700 fewer children were tested for lead in Erie County in April than in the same month last year, a drop of about 35%.

Ohio, which has among the highest levels of lead poisoning in the country, recently expanded automatic eligibility for its to any child with an elevated blood lead test, providing the opportunity for occupational, physical and speech therapy; learning supports for school; and developmental assessments. If kids with lead poisoning don’t get tested, though, they won’t be referred for help.

In early April, there were only three referrals for elevated lead levels in the state, which had been fielding nine times as many on average in the months before the pandemic, said Karen Mintzer, director of Bright Beginnings, which manages them for Ohio’s Department of Developmental Disabilities. “It basically was a complete stop,” she said. Since mid-June, referrals have recovered and are now above pre-pandemic levels.

“We should treat every child with lead poisoning as a medical emergency,” said John Belt, principal investigator for the Ohio Department of Health’s lead poisoning program. “Not identifying them is going to delay the available services, and in some cases lead to a cognitive deficit.”

Pandemic Compounds Worries

One of the big worries about the drop in lead testing is that it’s happening at a time when exposure to lead-laden paint chips, soil and dust in homes may be spiking because of stay-at-home orders during the pandemic.

Exposure to lead dust from deteriorating paint, particularly in high-friction areas such as doors and windows, is the most common cause of lead exposure for children in the U.S.

“I worry about kids in unsafe housing, more so during the pandemic, because they’re stuck there during the quarantine,” said , a pediatrician at Cleveland’s University Hospitals Rainbow Babies & Children’s Hospital.

The pandemic may also compound exposure to lead, experts fear, as both landlords and homeowners try to tackle renovation projects without proper safety precautions while everyone is at home. Or the economic fallout of the crisis could mean some people can no longer afford to clean up known lead hazards at all.

“If you’ve lost your job, it’s going to make it difficult to get new windows, or even repaint,” said Yendell.

The CDC says it plans to help state and local health departments track down children who missed lead tests. Minnesota plans to identify pediatric clinics with particularly steep drops in lead testing to figure out why, said Yendell.

But, Yendell said, that will likely have to wait until the pandemic is over: “Right now I’m spending 10-20% of my time on lead, and the rest is COVID.”

The pandemic has stretched already thinly staffed local health departments to the brink, health officials say, and it may take years to know the full impact of the missed testing. For the kids who’ve been poisoned and had no intervention, the effects may not be obvious until they enter school and struggle to keep up.

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A fever, headaches and body aches soon followed. Then she noticed she’d lost her senses of taste and smell.

By March 23, Laquatra could no longer deny the nagging fear she’d had since first falling ill: She might have COVID-19, the disease caused by the novel coronavirus, which by then had been detected in every state. That day, 351 new cases, 83 hospitalizations and three deaths were reported in Ohio.

The phone call Laquatra made next, to a COVID-19 hotline staffed by the area’s public health system, , likely helped contain the spread of her illness to only her husband, Tony.

MetroHealth’s hotline connected the Laquatras to nurses and doctors who assessed their symptoms and checked in daily while they were ill. MetroHealth also took care of all the family’s immediate needs — including home delivery of prescriptions, groceries, toiletries and diapers for their 2-year-old — so they could safely stay home until they felt better.

MetroHealth has offered the hotline and home assistance free to any Ohioan since mid-March. It said the hotline, which has fielded more than 11,000 calls, has saved the hospital system from being overwhelmed by a surge of COVID patients. It has also paved the way for a new model of health care delivery, one that brings care where patients are — at home.

It’s a model they believe must — and will — last beyond the current crisis, saving money for its health care system and addressing the myriad social needs that keep patients from getting and staying healthy.

The Hotline

It’s a Tuesday in mid-May and Dr. is in his office on MetroHealth’s main campus in Cleveland’s Brooklyn Centre neighborhood, keeping an eye on a screen displaying a list of calls to the hotline.

It’s late afternoon, and about 63 people have called that day. Ten have been referred for testing. Nearly all of the callers have symptoms of COVID-19 and have been counseled to self-quarantine.

Margolius calls a young woman who works as a protection officer at a juvenile detention center, and shares his half of the conversation with a reporter via video call. A nurse flagged the detention officer’s hotline call for follow-up with a doctor because one of the woman’s colleagues had tested positive for the coronavirus that day. While she doesn’t have any clear symptoms (just a scratchy throat), she’s worried about getting sick and exposing others. After hearing that she’s wearing a mask and maintaining social distance at work, Margolius assures her she’s probably fine.

“You’re on top of it,” he tells her. “If things change and you develop symptoms, we’re here if you need us.”

Dr. Noha Dardir, a family medicine specialist who has fielded about 780 hotline calls, said patients were terrified, but they had few options early on because most of the primary care offices at MetroHealth were closed.

“If we’re telling them to call their doctor and not go straight to the emergency room, we had to be there to take those calls. And it had to be 24/7,” she said. “I felt obligated to my patients.”

MetroHealth was prepared for a surge of 1,000 patients, but at the pandemic’s peak in early May, only 13 COVID-positive patients were in intensive care. Only 82 people have been hospitalized with COVID-19 at MetroHealth since the crisis began.

The hotline’s peak came much earlier, on March 17, when nearly 700 people called. In the hotline’s first three days, staffers advised 200 people to quarantine themselves.

“We just couldn’t keep up,” said Dr. Nabil Chehade, MetroHealth’s senior vice president for population health. “At one point, we had to have 12 physicians working to answer these calls.”

Cuyahoga County Health Commissioner , who has worked closely with hospitals to trace and contain COVID cases, believes the public hospital’s quick work in advising quarantines for those with symptoms — even mild ones — helped to contain the outbreak.

“We joked early on that if you had a paper cut, we’d tell you to stay home for two weeks,” Allan said. “But that helps to reduce people from potentially being part of the chain of transmission.”

As of early June, about 300 of Cuyahoga County’s 1.3 million residents had died of COVID-19. While the county, Ohio’s second most populous, has had a high proportion of the cases in the state, it has fared much better than hard-hit counties with similar demographics in other parts of the country.

Nine weeks in, call volume has slowed. Now, about 100 people call daily and about three-quarters talk to a doctor. Still, MetroHealth’s hotline remains available round-the-clock, and Margolius said it’s clearly still needed. The county recently saw its highest rate of infections since the pandemic started, likely due to the partial reopening of Ohio’s economy, which began in mid-May.

“This is obviously so far from over,” Margolius said.

A New Model

When MetroHealth’s doctors told Andrea Laquatra to quarantine at home in late March, she and her husband weren’t sure how they’d manage. They were already low on diapers and wipes, and had been grocery shopping for Tony Laquatra’s parents.

“We always take care of my mom and dad. We couldn’t do nothing for them because we didn’t want to get them sick,” Tony Laquatra said.

Many others the hospital told to quarantine were in the same boat. So the MetroHealth team added a social worker check-in and same-day delivery of groceries and other basic supplies through the hospital’s Institute for H.O.P.E. (health, opportunity, partnership, empowerment), launched last year with the goal of finding and addressing the causes of health disparities in the community.

As of May 22, institute staff members had delivered food and supplies to 620 households. In the early days of the pandemic, as the team scrambled to respond to the influx of calls, even members of the hospital’s executive team pitched in on those deliveries. So did some doctors.

The health system also started screening for loneliness and stress and has since referred 700 people for calls from the hospital’s behavioral health team, Chehade said.

MetroHealth also connected the Laquatras to a church group that could shop for his their parents.

“I just cried, I was so grateful,” Andrea Laquatra said. They have since recovered, and because they were never tested, are among the hundreds of probable COVID cases in the county.

The pandemic proved to be the perfect opportunity for MetroHealth to deliver on a long-discussed but only partly implemented plan to treat patients at home while addressing the basic social needs that sometimes prevent them from staying healthy, Chehade said.

“We were forced to really transform our care overnight,” he said.

No Going Back?

The health system has vowed not to return to business as usual when the pandemic eases.

“This is an inflection point in the delivery of health care, and it would be a tragedy if we didn’t learn from it,” said Dr. Brook Watts, MetroHealth’s vice president and chief quality officer. “The health care system will try to go back because there were a lot of incentives for the system to deliver care the way we did. We’re not going to go back. I’m not going back.”

For now, MetroHealth is paying for this new model of care through donations, its own funds and payment from Medicare and Medicaid, which have expanded reimbursement for telehealth in response to the pandemic. The health system estimates 30% to 60% of its visits in the future will be managed through telehealth, compared with just 0.5% pre-pandemic.

And a new program, Hospital at Home — which delivers Bluetooth-enabled equipment such as heart rate, blood pressure and blood-oxygen monitors to patients with chronic illnesses to manage their recovery at home — could deliver hospital-quality care at 60% of the cost for half of all medical-surgical admissions.

It remains unclear if insurers, including the Centers for Medicaid & Medicare Services, will continue to pay for expanded health care delivered via telephone or video calls after the pandemic eases. If they return to pre-pandemic rules for reimbursement, it could make maintaining the current model difficult, or even impossible.

For the model to be viable and adopted widely, MetroHealth CEO Dr. said, the nation’s health care system will have to reinvest these savings, and redirect the money it wastes on unnecessary tests and procedures, repeated hospitalizations for chronic, manageable diseases and overpriced medications and high-tech devices.

“It may take some shaming of nonprofit medical institutions to bring them to this same area of focus,” said Boutros. But if they don’t want to do it, he added, they should financially support the health systems that do.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).