New Hampshire

About the program

The State of New Hampshire received $550,000 through cooperative agreement EH21-2102 from the Centers for Disease Control and Prevention (CDC) in the third funding year. 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 New Hampshire, contact the program below.

New Hampshire Department of Health and Human Services

Healthy Homes and Lead Poisoning Prevention Program

29 Pleasant Street

Concord, NH 03301

Phone: 603-271-4507

Success story: funding year 3

Increasing completion of consent forms to facilitate linkages to services for lead-exposed children in New Hampshire

Challenge

During the COVID-19 pandemic, New Hampshire's (NH) nurse case management team transitioned from in-home visits to interviewing families of children with higher blood lead levels (BLLs) over the telephone. Without the in-person home visits that allowed the nurses to obtain a signed consent form allowing the release of information, there were barriers to making successful referrals to the Women, Infants, and Children (WIC) Nutrition Program and Early Support and Services. NH quickly learned that few families had the computer technology necessary to receive a PDF consent form attached to an email and return a signed form to the nurse case managers via email. Referrals of families to the Special Supplemental Nutrition Program for WIC and Early Support and Services Program was rapidly declining, and in 2022 nurse case managers were only successful in obtaining 78% of completed consent forms.

Intervention

In late 2022, NH's Healthy Homes and Lead Poisoning Prevention Program (HHLPPP) obtained funding and collaborated with the NH Department of Health and Human Services' privacy officer and NH's Department of Information Technology (DoIT) to onboard DocuSign® as a mechanism for obtaining electronic signatures on legal documents. DocuSign® provided a secure and HIPPA-compliant method for nurse case managers to obtain legal consent forms from families with limited computer technology through the use of a smartphone. In early 2023, the HHLPPP worked to develop standard operating procedures and implemented a workflow that would allow nurses to successfully engage with parents/guardians of children with higher BLLs to gain their consent for referrals to the WIC Nutrition Program and Early Support and Services. DocuSign® was successfully implemented in March 2023.

Impact

Nurse case managers report DocuSign® to be a reliable and easy-to-use way to gain legal consent from parents/guardians to allow referrals to WIC programs. Connecting families to the WIC programs is easier and faster. Since March 2023, the return rate of completed consent forms has increased 11 percentage points from 78% in 2022 to 89% in 2023). This allows NH's nurse case managers to rapidly link more lead-exposed children to services improving their long-term health and development.

Funding for this work was made possible in part by NUE2EH001457from 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

Innovation in outreach and education using children's literature: Happy, Healthy, Lead-Free Me!

Challenge

Most families do not engage with lead poisoning prevention education materials until after their children have been exposed to lead. Research has demonstrated that children's literature can be a very effective education vehicle for anticipatory guidance due to the emotional engagement when reading, its use of simple language, and potential for repeated readings. A children's board book on lead poisoning prevention and the importance of pediatric blood lead level testing, distributed to families before their children are exposed, would be a valuable primary prevention tool. After completing an extensive review of children's literature, the New Hampshire Healthy Homes and Lead Poisoning Prevention Program (NH HHLPPP) identified that none existed.

Intervention

The NH HHLPPP staff developed a children's board book, Happy, Healthy, Lead-Free Me!, with technical support from contracted vendor JSI, and clinical support provided by both the NH Chapter of the American Academy of Pediatrics and Region 1 Pediatric Environmental Health Specialty Unit at Boston Children's Hospital. The goal of developing this children's board book was to educate families on lead poisoning prevention and the importance of blood lead testing in children. The plans for the book included engaging illustrations and rhyming children's text, along with using subtitles on each page. Internal and external partners reviewed the draft book. Beta editions, printed in English and Spanish, were distributed to families statewide, to read to their children and provide feedback. A webpage (www.leadfree.me) was developed to accompany the book which included additional resources and information. A social media toolkit, which includes graphics, sample posts, and video content, is available to partners to promote their use of the book, along with messaging on lead exposure prevention and the importance of pediatric blood lead testing.

Impact

In December 2021, 13,000 books were distributed to pediatricians statewide, at no cost, for them to provide to children at the 9-month well child check (WCC) appointments. This is an optimal time to introduce lead exposure prevention and the importance of blood lead testing education as children become more mobile and in advance of a 12-month WCC appointment when the first blood lead level test takes place. NH's Women, Infant and Children program and Maternal and Child Health Program purchased 14,000 printed books for distribution to young children through their community-based programs. A total of 27,000 books were printed. The book is available to download from the webpage in seven additional languages, including Chuukese, Dari, Nepali, Portuguese, Somali, and Swahili.

Response to the book has been robust and positive, followed by a nationwide demand for printed editions. A partnership was established with a non-profit organization, Cribs for Kids, LLC, to handle book orders and fulfillment logistics. This has allowed for easy and affordable access to ordering printed books in multiple languages and by the case (40 books). Books may be ordered from the book's website www.leadfree.me.

Funding for this work was made possible in part by NEU EH001408-02 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. Additional funding was provided by the United States Environmental Protection Agency, under assistance agreement BG-00A00731™ 0 to NH DHHS. The contents do not necessarily reflect the views or policies of the Environmental Protection Agency (EPA).

Success story: funding year 1

Collaborating with the New Hampshire chapter of American Academy of Pediatrics to increase blood lead level testing rates

Challenge

In 2015, 660 (5%) children under the age of 6 in New Hampshire were reported to have blood lead levels (BLLs) ≥ 5µg/dL, the level then recommended for public health action by the Centers for Disease Control and Prevention (CDC). Yet, statewide, only 53% of one-year-olds and 26% of two-year-olds were tested in 2015, suggesting that the actual number of children under 6 years old with elevated blood lead levels (BLLs) is likely much higher.

Intervention

Using state blood lead surveillance data, the New Hampshire's Healthy Homes and Lead Poisoning Prevention Program (HHLPPP) identified the five largest communities with lowest testing rates: Concord, Dover, Nashua, Manchester, and Rochester. The program then worked with the New Hampshire Chapter of the American Academy of Pediatrics (NH-AAP) and pediatric healthcare providers to identify barriers to blood lead testing and opportunities to improve testing rates for one- and two-year-olds. Through collaboration with providers, the HHLPPP discovered two major obstacles to blood lead testing of young children: (1) a heavy reliance on venous blood lead testing and (2) a lack of understanding in the medical community about the importance of blood lead testing.

To address these obstacles, the HHLPPP developed a collaborative partnership with the NH-AAP to educate pediatric healthcare providers about current surveillance data and testing rates, BLL testing options, information about the best practices in clinical evaluation, and guidance for medical management of children with elevated BLLs. Additionally, HHLPPP held four regional pediatric medical education dinners from July 2016 through April 2018. These dinners were held in the five communities mentioned above and featured medical experts.

Impact

As a result of the intervention, HHLPPP educated 375 medical and public health professionals, resulting in an increase of BLL testing rates in the five target communities for one- and two-year-olds: a 10% and 12% increase in these ages in Manchester, respectively; a 16% and 41% increase in these ages in Nashua, respectively; a 13% and 73% increase in these ages in Concord, respectively; an 84% and 184% increase in these ages in Dover, respectively; and a 3% and 16% increase in these ages in Rochester, respectively.

Funding for this work was made possible in part by EH14-1408 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.