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The Evaluation of the US Department of Housing and Urban Development Lead-Based Paint Hazard Control Grant Program studied the effectiveness of the housing intervention performed in reducing the blood lead of children at four post-intervention times (6-months, 1-year, 2-years, and 3-years). A repeat measures analysis showed that blood lead levels declined up to three-years post-intervention. The results at each successive collection time were significantly lower than at the previous post-intervention time except for the difference between the levels at two and three years. At two-years post-intervention, geometric mean blood lead levels were approximately 37% lower than at pre-intervention. Children with pre-intervention blood lead levels as low as 10 μg/dL experienced substantial declines in blood lead levels. Previous studies have found substantial improvements only if a child's pre-intervention blood lead level was above 20 μg/dL. Individual interior lead hazard control treatments as grouped by Interior Strategy were not a significant predictor of post-intervention blood lead levels. However, children living in dwellings where exterior lead hazard control interventions were done had lower blood lead levels at one-year post-intervention than those living in dwellings without the exterior interventions (all other factors being equal), but those differences were only significant when the mean exterior paint lead loading at pre-intervention was about the 90th percentile (7.0mg/cm(2)). This observation suggests that exterior lead hazard control can be an important component of a lead hazard control plan. Children who were six to eleven months of age at pre-intervention had a significant increase in blood lead at one-year post-intervention, probably due to other exposures., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Modern epidemiological studies face opportunities and challenges posed by an ever-expanding capacity to measure a wide range of environmental exposures, along with sophisticated biomarkers of exposure and response at the individual level. The challenge of deciding what to measure is further complicated for longitudinal studies, where logistical and cost constraints preclude the collection of all possible measurements on all participants at every follow-up time. This is true for the National Children's Study (NCS), a large-scale longitudinal study that will enroll women both prior to conception and during pregnancy and collect information on their environment, their pregnancies, and their children's development through early adulthood-with a goal of assessing key exposure/outcome relationships among a cohort of approximately 100 000 children. The success of the NCS will significantly depend on the accurate, yet cost-effective, characterization of environmental exposures thought to be related to the health outcomes of interest. The purpose of this paper is to explore the use of cost saving, yet valid and adequately powered statistical approaches for gathering exposure information within epidemiological cohort studies. The proposed approach involves the collection of detailed exposure assessment information on a specially selected subset of the study population, and collection of less-costly, and presumably less-detailed and less-burdensome, surrogate measures across the entire cohort. We show that large-scale efficiency in costs and burden may be achieved without making substantive sacrifices on the ability to draw reliable inferences concerning the relationship between exposure and health outcome. Several detailed scenarios are provided that document how the targeted sub-sampling design strategy can benefit large cohort studies like the NCS, as well as other more focused environmental epidemiologic studies., (Published in 2010 by John Wiley & Sons, Ltd.)

In Part I in this issue, modeling was used to identify a Housing Assessment Tool (HAT) that can be used to predict relative intervention effectiveness for a range of intervention intensities and baseline dust lead loadings in occupied dwellings. The HAT predicts one year post-intervention floor and windowsill loadings and the probability that these loadings will exceed current federal lead hazard standards. This article illustrates the field application of the HAT, helping practitioners determine the minimum intervention intensity needed to reach "acceptable" one year post-intervention levels, with acceptability defined based on specific project needs, local needs, regulations, and resource constraints. The HAT is used to classify a dwelling's baseline condition as good or poor. If the average number of interior non-intact painted surfaces per room is >/=2, then the dwelling is rated as poor. If exterior windows/doors are deteriorated and the average number of exterior non-intact painted surfaces per building side is >/=5, then the dwelling is rated as poor. If neither of these conditions is true, then the dwelling's HAT rating is good. The HAT rating is then combined with baseline average floor loading to help select the treatment intensity. For example, if the baseline floor loading is 100 mug/ft(2) (1,075 mug/m(2) and the HAT rating is poor, the probability that the one-year floor loading exceeds the federal standard of 40 mug/ft(2) (430 mug/m(2) is 27% for a high-intensity strategy (i.e., window lead abatement with other treatments) but is 54% for a lower-intensity strategy (i.e., cleaning and spot painting). If the HAT rating is good, the probability that the one-year floor loading exceeds 40 mug/ft(2) is approximately the same for low- and high-intensity strategies (18% for window lead abatement with other treatments compared with 16% for cleaning and spot painting). Lead hazard control practitioners can use this information to make empirically based judgments about the treatment intensity needed to ensure that one year post-intervention loadings remain below federal standards.

A methodology was developed to classify housing conditions and interior dust lead loadings, using them to predict the relative effectiveness of different lead-based paint hazard control interventions. A companion article in this issue describes how the methodology can be applied. Data from the National Evaluation of the HUD Lead Hazard Control Grant Program, which covered more than 2800 homes in 11 U.S. states, were used. Half these homes (1417) met the study's inclusion criteria. Interior interventions ranged from professional cleaning with spot painting to lead abatement on windows, and enclosure, encapsulation, or removal of other leaded building components. Modeling was used to develop a visual Housing Assessment Tool (HAT), which was then used to predict relative intervention effectiveness for a range of intervention intensities and baseline floor and windowsill dust lead loadings in occupied dwellings. More than 117,000 potential HATs were considered. To be deemed successful, potential HATs were required to meet these criteria: (1) the effect of interior strategy had to differ for HAT ratings of good vs. poor building condition and/or baseline dust lead loadings; (2) the HAT rating had to be a predictor of one year post-intervention loadings; (3) interior intervention strategy had to be a predictor of one-year loadings; (4) higher baseline loadings could not be associated with lower one-year loadings; and (5) neither exterior work nor site/soil work could result in higher predicted one-year loadings for either HAT rating. Of the 1299 HATs that met these criteria, one was selected because it had the most significant differences between strategy intensities when floors and sills were considered together. For the selected HAT, site/soil work was a predictor of one-year loadings for floors (p = 0.009) but not for sills (p = 0.424). Hazard control work on the building exterior was a predictor of both sill and floor one-year loadings (p = 0.004 and p < 0.001, respectively). Regardless of the type of interior intervention strategy, interior work was a predictor of both floor and sill one-year loadings (each p < or = 0.001).

Professionals who identify residential lead-based paint hazards and develop lead hazard control plans are instructed to assess painted friction and impact surfaces in homes as potentially active sources of dust lead, a known exposure vector for young children. However, empirical tests of the importance of these surfaces had not been conducted. Using data collected as part of a 1998 three-community study of the Housing and Urban Development Lead Risk Assessment protocols, this article explores how much rubbing or binding on friction and impact surfaces on windows and doors influence dust lead levels on windowsills and floors, while taking into account paint condition on these surfaces and other sources of lead. The analyses included windowsill dust wipe samples from 611 rooms in 182 homes and 782 floor dust wipe samples collected in 209 rooms from 104 homes. The study found that when the paint on windows is intact but the window is rubbing or binding, the dust lead levels on the windowsills are significantly higher than on windows with intact paint without rubbing or binding, after controlling for other lead sources. Windowsill dust lead on a window with intact lead-based paint at 1 mg/cm(2) and no rubbing/binding would be 27% lower than on a window with nonintact paint, rubbing/binding surfaces, or both of these conditions. An independent effect of rubbing/binding of doors on floor dust lead loadings was not observed. These findings support federal regulations calling for lead risk assessors to check the friction/impact surfaces at windows when dust lead samples taken below them are elevated, but these analyses did not offer support for taking extra observations of friction/impact surfaces around doors.

A 1994 Maryland law prescribes a lead-based paint risk reduction standard for pre-1950, privately owned rental housing. This standard, applied at each tenancy change, can be met by sampling to verify that dust lead loadings are within acceptable limits or by performing specific lead hazard reduction treatments, followed by an independent visual inspection without dust sampling. We evaluated the ability of visual inspection to predict treatment completion and dust lead loadings. Fifty-two Baltimore housing units were enrolled and received the law-specified treatments. Before treatment, study risk assessors conducted visual assessments and dust lead wipe sampling in each unit. After treatment, Maryland-certified visual inspectors conducted the law's required visual inspection, followed by the study risk assessors, who performed a separate visual assessment and collected dust wipe samples. One year later, study risk assessors performed another visual assessment and dust wipe sampling (n=34). Dust lead loadings declined significantly immediately after prescribed lead treatments were implemented. Fifty-three percent, 20%, and 47% of units had at least one sample that exceeded 1995 EPA/HUD floor, window sill and window trough clearance guidance of 100, 500 and 800 microg/ft2, respectively. Overall, 73% of units had one or more immediate post-intervention single surface sample results exceeding the 1995 clearance values that were in effect at the time of the study. One-year post-intervention loadings remained significantly below pre-intervention levels for floors but not window sills or troughs. Visual assessments alone, without dust lead testing, did not ensure that prescribed treatments were completed or that dust lead loadings were below clearance values.

The objective of this study is to provide guidance on where to collect dust lead wipe samples in homes to best characterize the risk of a resident child having a blood lead level at or above the CDC level of concern (10 microg/dl). In 1998, the Milwaukee Health Department enrolled 72 children living in pre-1950 buildings: 34 had elevated (i.e., > or = 10 microg/dl) blood lead levels (EBL); and 38 had non-elevated blood lead levels (non-EBL). This study explored dust lead sampling locations by examining loading differences between homes where children with EBL and non-EBL lived. Floor, windowsill, and window trough samples were collected in the living room, kitchen, bathroom, and child's bedroom and play area. Floor samples were collected at four locations: room entry; center of the room; under a window; and against the wall opposite the window (perimeter). Geometric mean floor dust lead levels were generally two to three times higher in homes of EBL children than homes of non-EBL children. Sampling the floor at the room entry or center is preferable to sampling under the window or from the perimeter of the room. When the central floor average was used, the room combinations that had the greatest differences between homes of EBL children and non-EBL children all included a sample from the child's bedroom and excluded the bathroom. When the entry floor average was used, the greatest differences also excluded bathrooms, but otherwise included a mix of all of the other rooms. Window samples did not distinguish where children with EBLs versus non-EBLs resided. This paper is based on Milwaukee alone, so generalizing results to other locations should be done with caution.

The US Department of Housing and Urban Development (HUD) undertook an evaluation of its Lead Hazard Control Grant Program between 1994 and 1999. The Evaluation is the largest study ever done on the effectiveness of lead hazard controls implemented in residential dwellings. The Evaluation had several major objectives: determining the effectiveness of various lead hazard controls in reducing residential dust lead levels and children's blood lead levels, establishing the costs of doing lead hazard control work and factors that influence those costs, determining the rate of clearance testing failures and their causes, and identifying possible negative effects of lead hazard control work on children's blood lead levels. This paper reports the overall research design and data collection methods of the Evaluation. The large number of dwelling units enrolled in the Evaluation was possible only by the innovative partnership among HUD, the Evaluators, and the grantees. HUD and the Evaluators relied on the grantees for essentially all of the data collection. The 14 participating HUD Lead Hazard Control Grantees were responsible for implementing the lead hazard control programs in their communities and collecting the study data. This paper describes the methods for recruiting and enrolling dwellings and families, collecting environmental and housing data, interviewing participating families, and collecting data on lead hazard control work performed and its costs. The paper also describes the basic quality control and quality assurance procedures used. The principal outcome measures were lead in dust collected using wipes from floors, window sills, and window troughs and lead in blood collected from children who were 6 years old or younger at enrollment. Data collection was conducted before intervention, immediately postintervention, and 6 and 12 months postintervention. For a subset of dwellings undergoing an extended follow-up data were also collected at 24 and 36 months postintervention. This paper provides the context for subsequent reports that will describe such findings as the influence of lead hazard control work on serial dust lead levels, the influence of lead hazard control work on serial blood lead levels in children, the nature and costs of the lead hazard control work done at the dwellings, and the experience of the grantees in meeting clearance testing requirements.

This study is an examination of the effect of lead hazard control strategies on children's blood lead levels immediately after an intervention was conducted as part of the US Department of Housing and Urban Development's Lead-Based Paint Hazard Control Grant Program. Fourteen state and local government grantees participated in the evaluation. The findings indicated an overall average reduction in the blood lead levels of 869 children soon after the implementation of lead hazard controls. However, 9.3% of these children (n = 81) had blood lead increases of 5 microg/dL or more. Data routinely collected as part of the evaluation, as well as additional information supplied by the individual programs, were used to determine potential reasons for these observed increases in blood lead. A logistic regression analysis indicated that three principal factors were associated with the blood lead increases: the number of exterior deteriorations present in the child's home (prior to intervention), the educational level of the female parent or guardian of the child, and the child's age. The statistical analysis did not find evidence that children living in households that either did not relocate or relocated for less than the full work period were significantly more likely to have a blood lead increase equal to or greater than 5 microg/dL than children living in households that fully relocated. Statistical analyses also did not reveal any single interior strategy to be more or less likely than others to be associated with a blood lead increase of 5 microg/dL or more.

Results of the analyses of occupational and environmental samples are frequently reported as "less than a specified value," a practice followed by many analytical laboratories. A left-censored distribution occurs when analytical laboratories do not report results that fall below their limits of detection or quantification. Approximately 37% of the household interior dust lead loadings collected in a large-scale, multisite, longitudinal study of lead-based paint hazard controls were reported to be below the "method detection limit." These unreported values are unusable in any statistical analysis of the data and must be replaced by a valid dust lead loading estimate, a process called data imputation. This investigation tested how well data imputed using a newly formulated procedure for estimating the data below the method detection limit were correlated with dust lead loadings reported by the participating laboratories after special request. These results were also compared with those obtained by imputing the minimum detectable level by the square root of 2. Imputation of the low lead loadings was accomplished by substituting the value associated with the median percentile below each laboratory's method detection limit. A correlation of r = 0.50 was calculated between the predicted and reported dust lead loadings, with only slight bias (2.9%) in the predicted values. An alternative imputation procedure that used the predicted value from structural equation models fit to the noncensored dust lead loadings performed about as well, although the predictions had to be "centered" to correspond to the censored data. An estimator that combined both of these imputation procedures only slightly improved the correlation between the predicted and laboratory values (r = 0.51). These results support the use of the new procedure rather than the commonly used imputed values of the method detection limit divided by 2 or by the square root of 2. Imputing values based on either of these common approaches may result in much more biased predictions for the censored data; in the case of these data, the dust lead loadings were overestimated by 348%. The results also suggest that analytical laboratories should provide a numerical result for all analyzed samples, with a "flag" of those values below their detection limit, since these results may be more accurate than any imputed value, particularly those provided by the commonly used method of dividing the minimum detection limit by the square root of 2., (Copyright 2004 JOEH, LLC)

To aid in understanding the contribution of exterior dust/soil lead to postintervention interior dust lead, a subset of housing from the HUD Lead-Based Paint Hazard Control Grant Program Evaluation was selected for study. Housing from 12 state and local governments was included. Exterior entry and street dust samples were obtained by a vacuum method, and soil samples were building perimeter core composites. Interior dust wipe lead data (microg/ft(2)) and paint lead data (mg/cm(2)) were also available for each of the dwelling units and included in the modeling. Results from 541 dwelling units revealed a wide range of exterior dust and soil lead levels, within and between grantees. Minimum and maximum geometric mean lead levels, by grantee, were 126 and 14400 microg/ft(2) for exterior entry dust; 325 and 4610 microg/ft(2) for street dust; and, for soil concentration, 383 and 2640 ppm. Geometric mean exterior entry dust lead concentration (1641 ppm) was almost four times as high as street dust lead concentration (431 ppm), suggesting that lead dust near housing was often a source of street dust lead. Geometric mean exterior entry dust lead loading was more than four times as high as window trough dust lead loading and more than an order of magnitude higher than interior entry dust lead loading. Statistical modeling revealed pathways from exterior entry dust lead loading to loadings on interior entryway floors, other interior floors, and windowsills. Paint lead was found to influence exterior entry dust lead. Results of this study show that housing where soil lead hazard control activities had been performed had lower postintervention exterior entry, interior entry floor, windowsills, and other floor dust loading levels. Soil was not present for almost half the buildings. Statistical analysis revealed that exterior strategy influenced soil lead concentration, and soil lead concentration influenced street dust lead loading. This study represents one of the few where an impact of soil treatments on dust lead levels within the housing has been documented and may represent the first where an impact on exterior entry dust lead has been found. The inclusion of measures to mitigate the role of exterior sources in lead hazard control programs needs consideration.

Data from an evaluation of the HUD Lead Hazard Control Grant Program were used to evaluate the prevalence and location of teeth marks on painted surfaces in residential housing. The results of these analyses will be useful in the development of more effective pediatric lead poisoning prevention programs. These programs have historically placed considerable emphasis on surfaces accessible to children for mouthing activities. This study analyzes the largest set of data ever assembled on the prevalence of teeth marks in housing. Data from 308,851 observations in 3,454 housing units were analyzed to determine the prevalence of teeth mark observations per surface, dwelling unit, and building component, and by housing age, inspector, and grantee. An average of 4.0 teeth marks per 10,000 surfaces with paint-lead greater than or equal to 1.0 mg/cm2 were observed. For surfaces with less than 1.0 mg/cm2 lead the rate was 1.5 teeth marks/10,000 surfaces. The number of teeth marks per 10,000 surfaces increased with age of housing for surfaces with 1.0 mg/cm2 or higher lead but not for surfaces with less than 1.0 mg/cm2 lead. Teeth mark observation rates were 36 times higher for windowsills than for other components and ranged up to 11 per 10,000 surfaces and 9 dwellings per 100 dwelling units for 2 grantees with the highest rates. Blood lead levels in children exhibiting moderate to high mouthing behavior were higher than in children without such behavior, especially in housing where teeth marks were observed. Special priority should be given to windowsills when making decisions on lead hazard control for "accessible," "chewable," or "mouthable" surfaces.

This study evaluates the effectiveness of lead hazard control methods used in the Lead Hazard Control (LHC) grant program of U.S. Department of Housing and Urban Development. The LHC Program awards funds to local jurisdictions to address lead hazards in privately owned, low-income dwellings. Grantees in 14 cities, states, or counties collected environmental data in over 2600-treated dwellings making this the largest study of residential lead hazard control ever undertaken. Grantees employed a range of treatments, the most common being replacement of windows and repair of deteriorated lead-based paint. In this paper, dust lead loading levels and blood lead levels of children (6 months-6 years, if present) were observed at four periods of time (preintervention, immediate, and 6- and 12-months postintervention) in 1212 dwellings. Dust lead loading levels were also observed in a subset of these dwellings at 24- and 36-months postintervention. The geometric mean floor and window dust lead loadings declined at least 50 and 88% (P<0.0001), respectively, immediately postintervention. Three years later, floor dust lead loadings remained at or below the immediate postintervention levels. Window dust lead loadings had moderate increases, but remained substantially reduced from preintervention levels and below clearance standards. At 1 year after intervention, geometric mean age-adjusted blood lead levels had declined from 11.0 to 8.2 microg/dL, a 26% decline (P<0.0001). The LHC Program interventions produced blood lead declines similar to or greater than the percentage changes reported in earlier 1-year lead intervention studies., (Copyright 2001 Academic Press.)

In 1992, the U.S. Congress passed the Residential Lead-Based Paint Hazard Reduction Act, which requires the promulgation of health-based dust lead and soil lead standards for residential dwellings to prevent undue lead exposure in children. Unfortunately, the levels of lead in house dust and soil that are associated with elevated blood lead levels among U.S. children remain poorly defined. This pooled analysis was done to estimate the contributions of lead-contaminated house dust and soil to children's blood lead levels. The results of this pooled analysis, the most comprehensive existing epidemiologic analysis of childhood lead exposure, confirm that lead-contaminated house dust is the major source of lead exposure for children. These analyses further demonstrate that a strong relationship between interior dust lead loading and children's blood lead levels persists at dust lead levels considerably below the U.S. Department of Housing and Urban Development's current postabatement standards and the Environmental Protection Agency's guidance levels. Finally, these analyses demonstrate that a child's age, race, mouthing behaviors, and study-site specific factors influence the predicted blood lead level at a given level of exposure. These data can be used to estimate the potential health impact of alternative health-based lead standards for residential sources of lead exposure.

Lead-contaminated water, soil, and paint have been recognized as potential sources of children's lead exposure for decades, but their contributions to lead intake among urban children remain poorly defined. This analysis was undertaken to estimate the relationship of environmental lead exposures to lead intake among a random sample of urban children, adjusted for exposure to lead-contaminated house dust. Analyses of 183 urban children enrolled in a random sample, cross sectional study were conducted. Children's blood and multiple measures of household dust, water, soil, and paint were analyzed for lead, and interviews were conducted to ascertain risk factors for childhood lead exposure. Environmental sources of lead, including house-dust, soil lead, and water lead, were independently associated with children's blood lead levels. In contrast, paint lead levels did not have a significant effect on blood lead levels after adjusting for other environmental exposures. An increase in water lead concentration from background levels to 0.015 mg/L, the current EPA water lead standard, was associated with an increase of 13.7% in the percentage of children estimated to have a blood lead concentration exceeding 10 micrograms/dL; increasing soil lead concentration from background to 400 micrograms/g was estimated to produce an increase of 11.6% in the percentage of children estimated to have a blood lead level exceeding 10 micrograms/dL, and increasing dust lead loading from background to 200 micrograms/ft2 is estimated to produce an increase of 23.3% in the percentage of children estimated to have a blood lead level exceeding 10 micrograms/dL. These data support the promulgation of health-based standards for lead-contaminated dust and soil and the progressive lowering of standards for lead-contaminated water as the definition of undue lead exposure has been modified.