Five-year-old Jada sits on Dr. Olushola Fapo’s exam table, ruffled socks dangling a couple feet from the floor. She’s calm, after doodling a portrait of herself and her mom, Jennifer, minutes earlier.
Fapo tells her that she’s going to prick her finger just a tiny bit, that there will be a little bit of blood, and that, afterward, Jada will get a Barbie sticker.
It’s an exciting premise, and her mom tells her to be brave. But Jada’s tranquil demeanor grows slightly panicked as Fapo pokes the needle, and she cries. Luckily, it’s over in literally a second. Wails quiet into whimpers as Fapo dispenses compliments and an extra My Little Pony sticker.
“You are the best, Jada!” she coos. “Jada, you were amazing.”
Why the hassle for a little bit of blood? It’s part of a new effort amongst Cleveland health systems to screen more kids for lead poisoning, which can cause irreversible damage to a child’s brain resulting in delays and behavior issues. Twenty-one practices around Northeast Ohio — including University Hospitals Rainbow Ahuja Center for Women & Children, where Fapo works — began screening kids for lead with finger pricks during wellness visits as part of the collaborative. The Cleveland Clinic, MetroHealth, Neighborhood Family Practice and Care Alliance also participated.
The change is a shift from the prior norm: sending kids to a lab to get blood taken from their veins. By adding a finger prick into the check-up, it’s easier for families to complete. They don’t have to tote their child to another building, wait in another line or witness a blood draw on a baby. That seems to have paid off. Over the last year, the rate of kids under two who went to well-child appointments and got screened or tested for lead in Cleveland ZIP codes rose from 69% last June to about 78% by the end of May. About 14% of the kids who got tested had elevated blood lead levels.
For doctors like Fapo, the numbers are a sign that the hours she’s dedicated and nurses she’s trained and parents she’s coaxed and fingers she’s pricked are worth it.
“We need to give the children of Cleveland a chance at living successful lives in the future,” Fapo said.
Still, the shift is a delicate tradeoff. Finger prick tests are less accurate, so the state of Ohio won’t accept them as proof a child is lead poisoned. That means those who are poisoned at a level that requires public health officials to step in won’t get connected with resources or have the source of their lead exposure investigated. Instead, children with screens above a certain level have to go to the lab for a blood draw to get their result confirmed. About two-thirds of kids screened at the five participating health systems who needed to go back and get a lab test followed through.
Ensuring kids with elevated levels return to the lab is one of several challenges some group members would love to keep chipping away at. Another is expanding the experiment to all kids who need to be screened for lead exposure. Right now, the pilot is narrow: It doesn’t include kids aged 3 to 6, who are still supposed to be tested for lead poisoning in certain circumstances. And it leaves out the estimated thousands of youngsters who don’t go to their annual check-ups. Overall, lead testing rates in Cleveland remain low. About a third of kids under six are tested each year.
Gloria Blevins, the executive director of the Black Child Development Institute and a co-chair of the project’s steering committee, said she would like to see more community testing options to reach kids. Black and brown families historically trust hospital systems less, she said.
“How do we build that bridge between community and hospital systems?” Blevins said. “We have to do a better job of that.”
Limited funding could make addressing these next steps difficult. The Lead Safe Cleveland Coalition — a group of nonprofits, philanthropies and local government — invested $1 million to create the collaborative. Those dollars dry up Sept. 30, and it’s not yet clear whether each of the five participants will be able to sustain their higher testing rates without it. It wouldn’t be the first time local efforts to improve lead testing stalled. A 2017 program to send Case Western nursing students to test kids at Cleveland public schools no longer exists.
Why lead screening and testing is so important
Cleveland families contend with some of the highest lead poisoning rates in the nation, largely attributed to the aging housing stock. The ultimate goal is to prevent kids from getting lead poisoned in the first place by fixing up homes, but the city is nowhere near that yet. So testing is a backstop that triggers involvement by Cleveland’s health department.
But historically, testing rates in Cuyahoga County flopped, despite federal guidelines designed to prop them up. Medicaid is required to screen children for lead at 12 and 24 months. Ohio law also requires primary care providers to order lead tests for one- and two-year-olds from certain high risk ZIP codes, which encompass much of the county. Yet a 2019 study by Case Western Reserve found one in two kids in the county on Medicaid didn’t get tested before age two.
“There were some practices that we wanted to target where it was a flip of a coin whether or not a kid was going to be tested,” said Chris Mundorf, who works with Better Health Partnership, a regional health improvement collaborative that oversaw the lead testing project.
For years, doctors and other healthcare leaders saw the need to improve that, Mundorf said. But there isn’t a lot of incentive to do so. Hospitals and clinics can get financially rewarded for improving certain health metrics, like better blood pressure readings. There’s not a similar payoff — or unifying metric — to track lead testing, Mundorf said.
“It’s not a moneymaker, but it was seen universally as the right thing to do,” Mundorf said.
With the $1 million investment, hospitals and clinics could get compensated financially for investing time and energy into lead testing.
Case Western researchers also theorized that the low testing rate could be due to how many kids miss their check-ups in the first place. Still, the collaborative decided to start with a focus on well-child visits because doctors there have “no excuse not to test” kids, said Dr. Matt Tien, a pediatrician at MetroHealth and a leader of the project.
Different systems, different norms
Before the partnership kicked off, each health system in the city tackled lead testing in a vacuum. Neighborhood Family Practice had been testing patients in its offices at high levels long before the partnership. Care Alliance did not have a reliable lead testing program. The Cleveland Clinic primarily sent kids to get a blood draw at a lab.
In 2023, the Cleveland Clinic revamped its strategy as the hospital zeroed in on lead poisoning as a top community priority. Leaders like Dr. Roopa Thakur, the medical director for youth strategies in community health at the Cleveland Clinic, noticed that only about 40% of kids who were sent to the lab actually completed their test.
Thakur wanted to come up with a simpler way. She landed on a method called filter paper — the same needle prick Jada received. The droplet of blood from the finger is squeezed onto a piece of paper, which is then sent to a lab.
By November 2024, Thakur’s team trained Cleveland Clinic offices across Northeast Ohio to do the filter paper tests, and the hospital saw its lead testing rates tick up.
When the new partnership began, MetroHealth, Care Alliance and University Hospitals decided to use the same method. Not only had it worked at the Clinic, Fapo saw it already working within her hospital system. When she began pulling data across its 35 pediatric offices at the project’s start, she found the ones with the highest screening and testing rates used the finger prick method.
The filter paper test isn’t perfect. False positives are a frequent challenge. But they offer parents a first peek at their kids’ lead levels, which can inspire them to go to the lab for the follow-up test.
“If that is high, it changes the conversation with the family around why they need to go to the lab and get this confirmatory test done,” Thakur said. “Because now we have something that’s really concerning.”
How one practice added lead screening
Adding in-office lead screening might sound simple. Order the supplies. Give them to the nurses. But Fapo said a change like this is a major workflow shift that requires resources. Nurses have to be trained on how to use the new materials. They also need time in the exam room to complete the screen, which is tough with limited staffing.
“We needed leadership support and engagement,” Fapo said.
She got it. UH Rainbow Ahuja Center for Women & Children added more nurses to the clinic to make it possible
She also needed time to train staff on how to use the filter paper. Normally, that’s tough. The day Fapo saw Jada, she was running between her computer monitor, patients and other providers. The grant from the coalition gave her protected time to focus on lead work.
It paid off. After the Rainbow Ahuja Center implemented in-office testing last September, the rates of kids under two who were screened or tested bumped up from the mid-50s to near 100%.
Fapo isn’t just focused on the Rainbow Ahuja Center. As part of the collaborative, she added in-office lead screening to 10 University Hospital practices last year. Three are already on board this year with more to come. The practices span Northeast Ohio because lead poisoning isn’t confined to city limits, and many Cleveland kids go to doctor’s offices in the suburbs.
The bulk of the million dollar grant was spent paying the various hospital systems and clinics for time their staff spent learning about or working on lead testing efforts, Mundorf said, to replace the revenue they otherwise would have brought in from seeing patients.
Checking up on patients
And then there’s what happens if a child is confirmed to have lead poisoning. In some cases, a lower level of exposure will mean the city’s health department calls the family and sends mailers to educate them. At more elevated levels, the city inspects the home, sends orders to make it safe and can even make the owner vacate it.
The coalition recognized the flurry of logistics that come after the test when funding the program, said Wyonette Cheairs, who helps lead the Lead Safe Cleveland Coalition. In addition to more testing, they wanted better case management for families who test for high blood lead levels.
To assist with this, the grant program is helping pay several staff salaries, including for Kim Webb at the Rainbow Ahuja Center. She’s a community health worker who acts as the offices’ lead navigator. She calls parents whose kids’ screening results require them to come back into the office for a blood draw. She helps them schedule transportation through the hospital’s ride service or offers them at-home cleaning kits.
Webb also helps families navigate the tricky situations that arise after a child tests positive for lead. Recently, one of her patients was struggling to get her landlord to make the necessary home repairs, and she connected them with the Legal Aid Society of Cleveland.
The future of lead testing in Cleveland
Doctors, hospitals and health care leaders are celebrating their collaborative success getting more children tested. At the same time, most recognize there’s a long way to go. While the metric Better Health Partnership tracked got better, the raw number of kids tested in Cleveland shrunk after the pandemic and hasn’t bounced back.
There’s a few reasons for that. For one, the city’s birth rate is shrinking. For another, pediatric patient populations haven’t rebounded following the pandemic, Mundorf said.
Many working on the project agree that reaching kids who aren’t coming to check-ups is a vital next step. There’s some disagreement about what that could look like. Blevins would like to see health systems offer more community testing at places like parks and children’s museums in partnership with trusted organizations. Over the past two years, her organization partnered with MetroHealth and a Cleveland lead advocacy group called CLASH to offer testing at public housing — a success that just needs more investment, she said.
“Being in the community is like that first introduction to say, ‘Hey, our best interest is about you and your child, and we are here to support that,’” she said.
But Tien, who does much of the mobile lead testing for MetroHealth, said the community events present their own challenges. It’s a lot of effort to bring the equipment and team, while there’s no guarantee how many kids will show up, especially those who haven’t been tested before.
It would also likely take more funding, which will run out September 30. Tien, Thakur and Fapo said the collaborative has plans to sustain the progress that’s been made, like dashboards tracking testing rates and partnerships between hospitals. And Cheairs, with the Lead Safe Cleveland Coalition, wrote in an email that she is “confident” that the project “laid the foundation for systemic change.”
Still, Fapo worries that without the funding, she won’t be able to dedicate as much time to keep the momentum going.
“My fear is if the grant is not continued, then most of the gains we’ve made could be lost,” Fapo said.
