Anemia and Elevated Lead Levels in Underimmunized Inner-city Children William G. Adams, MD; Judith Geva, MSW; Jerry Coffman, MSc; Sean Palfrey, MD; and Howard Bauchner, MD ABSTRACT. Objective. Underimmunized children are less frequently screened for anemia and elevated lead levels than those who are up-to-date (UTD). However, the association between underimmunization and actual disease (hemoglobin [Hgb] <11 g/dL or blood lead level [PbB] >10 g/dL) has not been reported. The objective of this study was to evaluate the association between un- derimmunization, anemia, and elevated lead levels among children attending an inner-city clinic. Study Design. Data from a computer-based immuni- zation tracking system were integrated with primary care-based laboratory data. Cross-sectional data for im- munization coverage, anemia, and elevated lead levels were evaluated for children who were 1, 2, 3, and 4 years of age. The first Hgb or PbB values obtained within 6 months of the child’s birthday were used. Setting. An inner-city hospital-affiliated pediatric primary care center. Patients. A child was considered to be a pediatric primary care center patient if he/she had at least 3 immu- nizations in the immunization tracking system and at least 1 Hgb or PbB screening test during February 1993 through February 1996. Results. A total of 4045 Hgb tests from 2672 children were available for analysis (1198, 1102, 945, and 800 at 1, 2, 3, and 4 years of age, respectively). Anemia was com- mon during the first 4 years of life (21.2%, 15.8%, 11.0%, and 10.3% at 1, 2, 3, and 4 years of age, respectively). At 2 and 3 years of age, underimmunized children were sig- nificantly more likely to be anemic compared with UTD children (relative risk [RR]  1.49, 95% confidence inter- val [CI]  1.24 –1.79 at 2 years of age; RR  1.43, 95% CI  1.12–1.83 at 3 years of age). Underimmunized children with anemia at 1 year of age were less likely than UTD children to resolve their anemia by 2 years of age (52.5% vs 20.8%, RR  2.39; 95% CI  1.47–3.87). Underimmu- nized children were also significantly more likely to have elevated lead levels at 2 years of age (RR  1.24; 95% CI  1.03–1.5). Conclusion. Underimmunized children in the inner city are at especially high risk for anemia and elevated lead levels. These children need routine preventive health services, as well as immunization. Integrating lab- oratory screening data with immunization tracking sys- tems would be an important step toward improving the health of inner-city children. Pediatrics 1998;101(3). URL: http://www.pediatrics.org/cgi/content/full/101/3/e6; ane- mia, iron deficiency, elevated lead levels, immunization, tracking system. ABBREVIATIONS. UTD, up-to-date; PACC, Pediatric Ambula- tory Care Center; BMC, Boston Medical Center; WIC, Women, Infants, and Children (program); Hgb, hemoglobin; PbB, blood lead level; DPT, diphtheria-tetanus-pertussis vaccine; Polio, oral or inactivated polio vaccine; Hib, Haemophilus influenzae type b vaccine; HepB, hepatitis B vaccine; MMR, measles-mumps-rubella vaccine; MCV, mean corpuscular volume; IDA, iron deficiency anemia; SD, standard deviation; RR, relative risk; CI, confidence interval. I mmunization is cost-effective and prevents seri- ous morbidity and mortality in childhood. 1,2 However, underimmunization continues to be a problem in the United States, especially among inner-city children. 3–6 In addition to the risk of vaccine-preventable diseases, underimmunized chil- dren are also at risk for decreased screening for iron deficiency, lead poisoning, and tuberculosis. 7,8 These children also have fewer preventive maintenance and illness visits, as well as more missed preventive care appointments than children who are up-to-date (UTD) on their immunizations. 7 Iron deficiency and elevated lead levels are also common among urban children and have the poten- tial for long-term morbidity. Iron deficiency is asso- ciated with lower cognitive function and behavioral problems. 9 –11 Anemia is a late manifestation of iron deficiency and is frequently used as an indication for iron therapy. Most anemia in inner-city children is due to iron deficiency. 12 Elevated lead levels have been associated with decreased IQ, impaired atten- tion and speech performance, increased school fail- ure, hyperactivity, and disturbed social behavior. 13–15 Early detection and treatment of both of these con- ditions is important. Although underimmunized children are under- screened for anemia and elevated lead levels, whether they are at higher risk for actual disease is unknown. The purpose of this study was to evaluate the association between immunization status, ane- mia, and elevated lead levels in children attending an inner-city pediatric clinic. METHODS Data were collected for children attending the Pediatric Ambu- latory Care Center (PACC) at the Boston Medical Center (BMC, formerly Boston City Hospital) between the years 1992 through 1996. BMC has over 16 000 pediatric primary care visits annually. The families of the children attending the clinic are primarily poor From the Division of General Pediatrics, Boston University School of Med- icine, Boston, Massachusetts. Received for publication May 29, 1997; accepted Oct 28, 1997. Reprint requests to (W.G.A.) Division of General Pediatrics, Boston Univer- sity School of Medicine, Maternity 412, 818 Harrison Ave, Boston, MA 02118. PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- emy of Pediatrics. http://www.pediatrics.org/cgi/content/full/101/3/e6 PEDIATRICS Vol. 101 No. 3 March 1998 1 of 5 by guest on June 9, 2020 www.aappublications.org/news Downloaded from