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Childhood lead poisoning prevention in the United States was marked by a largely failed medical approach from 1971 to 1990; an emergent (but small) healthy housing primary prevention strategy from 1991 to 2015; and implementation of large-scale proven interventions since then.Childhood Lead Poisoning PreventionHealthy Housing.Historic and recent health and housing data from the National Health and Nutrition Examination Survey (NHANES) and the American Healthy Homes Survey (AHHS) were retrieved to analyze trends and associated policy gaps.Approximately 590 000 US children aged 1 through 5 years had elevated blood lead levels of 3.5 μg/dL and greater in 2016, and 4.3 million children resided in homes with lead paint in 2019. Despite large improvements, racial and other disparities remain stubbornly and statistically significant. The NHANES and the AHHS require larger sample sizes. The Centers for Disease Control and Prevention has not published children's blood lead surveillance and NHANES data in several years; the Department of Housing and Urban Development (HUD) has no analogous housing surveillance system; and the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA) have not updated training, Superfund, and occupational standards in decades.The nation has been without a plan and an associated budget for more than 2 decades. Congress has not reformed the nation's main lead poisoning prevention laws in more than 30 years. Such reforms include stopping US companies from producing new residential lead paint in other countries; enabling the disclosure law to identify all residential lead hazards; closing loopholes in federally assisted housing regulations and mortgage insurance standards; harnessing tax policy to help homeowners mitigate lead hazards; streamlining training requirements; increasing the size of health and housing surveys and surveillance systems; and updating housing codes, medical guidance, dust lead standards, training, Superfund, and worker exposure limits. Congress and the president should reauthorize a cabinet-level task force (dormant since 2010) to develop a new strategic plan with an interagency budget to implement it. These reforms will scale and optimize markets, subsidies, enforcement, and other proven interventions to end ineffective, costly, harmful, and irrational cost shifting that threatens children, workers, and affordable housing. International Lead Poisoning Prevention Week in October 2022 presents an opportunity to initiate long-overdue reforms in the United States.

Introduction: Prevalence surveys conducted in geographically small areas such as towns, zip codes, neighborhoods or census tracts are a valuable tool for estimating the extent to which environmental risks contribute to children’s blood lead levels (BLLs). Population-based, cross-sectional small area prevalence surveys assessing BLLs can be used to establish a baseline lead exposure prevalence for a specific geographic region. Materials and Methods: The required statistical methods, biological and environmental sampling, supportive data, and fieldwork considerations necessary for public health organizations to rapidly conduct child blood lead prevalence surveys at low cost using small area, cluster sampling methodology are described. Results: Comprehensive small area prevalence surveys include partner identification, background data collection, review of the assessment area, resource availability determinations, sample size calculations, obtaining the consent of survey participants, survey administration, blood lead analysis, environmental sampling, educational outreach, follow-up and referral, data entry/analysis, and report production. Discussion: Survey results can be used to estimate the geographic distribution of elevated BLLs and to investigate inequitable lead exposures and risk factors of interest. Conclusions: Public health officials who wish to assess child and household-level blood lead data can quickly apply the data collection methodologies using this standardized protocol here to target resources and obtain assistance with these complex procedures. The standardized methods allow for comparisons across geographic areas and over time.

In 2017, Puerto Rico sustained extensive damage from Hurricane Maria, increasing the risk of fires and carbon monoxide (CO) poisonings. Using a population-based, in-person survey of households with children less than 6 years old in Puerto Rico, we collected data in 2010 concerning the presence of smoke alarms and CO alarms in these households. We generated national estimates by extrapolating the number of households in each stratum using data from the 2010 Census. We determined which household characteristics predicted the presence of these alarms. Of 355 households analyzed, 31% had functional smoke alarms, or an estimated 109,773 households territory wide. The presence of smoke alarms was associated with living in multifamily housing and no child in the household receiving government medical insurance. Public housing or publicly subsidized housing, as compared to owner-occupied housing and unsubsidized rental housing, was associated with having a functional smoke alarm in households with children aged less than 6 years. Based on only six houses having CO alarms, we estimated only 7685 (2%) households had CO alarms. The low prevalence of functional smoke or CO alarms 7 years before Hurricane Maria is unfortunate and should be remedied by ensuring that such alarms are widely installed in current rebuilding activities.

INTRODUCTION Several urban neighborhoods in Philadelphia, Pennsylvania, have a history of soil, household lead paint, and potential lead-emitting industry contamination. OBJECTIVES To (1) describe blood lead levels (BLLs) in target neighborhoods, (2) identify risk factors and sources of lead exposure, (3) describe household environmental lead levels, and (4) compare results with existing data. METHODS A simple, random, cross-sectional sampling strategy was used to enroll children 8 years or younger living in selected Philadelphia neighborhoods with a history of lead-emitting industry during July 2014. Geometric mean of child BLLs and prevalence of BLLs of 5 μg/dL or more were calculated. Linear and logistic regression analyses were used to ascertain risk factors for elevated BLLs. RESULTS Among 104 children tested for blood lead, 13 (12.4%; 95% confidence interval [CI], 7.5-20.2) had BLLs of 5 μg/dL or more. The geometric mean BLL was 2.0 μg/dL (95% CI, 1.7-2.3 μg/dL). Higher geometric mean BLLs were significantly associated with front door entryway dust lead content, residence built prior to 1900, and a child currently or ever receiving Medicaid. Seventy-one percent of households exceeded the screening level for soil, 25% had an elevated front door floor dust lead level, 28% had an elevated child play area floor dust lead level, and 14% had an elevated interior window dust lead level. Children in households with 2 to 3 elevated environmental lead samples were more likely to have BLLs of 5 μg/dL or more. A spatial relationship between household proximity to historic lead-emitting facilities and child BLL was not identified. CONCLUSION Entryway floor dust lead levels were strongly associated with blood lead levels in participants. Results underscore the importance to make housing lead safe by addressing all lead hazards in and around the home. Reduction of child lead exposure is crucial, and continued blood lead surveillance, testing, and inspection of homes of children with BLLs of 5 μg/dL or more to identify and control lead sources are recommended. Pediatric health care providers can be especially vigilant screening Medicaid-eligible/enrolled children and children living in very old housing.

* Abbreviation: CDC — : Centers for Disease Control and Prevention A core principle of screening is that there should be a direct benefit to the patient. This restriction undervalues the impact that screening could have by not considering the population-level benefits to others, including family members, close contacts of affected individuals, and the broader community. Screening for lead poisoning offers an example of how individual screening has resulted in long-term health improvements for many by identifying and abating lead from the environment. The US Preventive Services Task Force states that the balance of information regarding the benefits and harms of screening for elevated blood lead levels is insufficient to recommend for or against it.1 However, lead screening has been associated with significant overall public health improvement. In this commentary, we identify generalizable lessons about when it might be appropriate to screen even if there may be limited direct benefit to the child being screened. Childhood blood lead testing of asymptomatic children began in the 1970s.2 Initially, most blood lead screening was done through local health departments, maternal and child health programs, and other community-based organizations, with support from the Centers for Disease Control and Prevention (CDC) and other federal agencies. Screening was also recommended to occur within primary care and required for Medicaid-enrolled children at 1 and 2 years or by 6 years if not previously done. Regardless of setting, screening was often inconsistent. As late as 1998, only ∼20% of Medicaid-enrolled children had ever received a blood lead test.3 In addition, many children with elevated blood lead levels did not receive follow-up care.4,5 Specific … Address correspondence to Mary Jean Brown, ScD, RN, 157 Leeder Hill Dr #201, Hamden, CT 06517. E-mail: mbrown{at}hsph.harvard.edu

Centuries of human activities, particularly housing and transportation practices from the late 19(th) century through the 1980’s, dispersed hundreds of millions of tons of lead into our urban areas. The urban lead burden is evident among humans, wild and domesticated animals, and plants. Animal lead exposures closely mirror and often exceed the lead exposure patterns of their human partners. Some examples: Pigeons in New York City neighborhoods mimicked the lead exposures of neighborhood children, with more contaminated areas associated with higher exposures in both species. Also, immediately following the lead in drinking water crisis in Flint MI in 2015, blood lead levels in pet dogs in Flint were 4 times higher than in surrounding towns. And combining lead’s neurotoxicity with urban stress results in well-characterized aggressive behaviors across multiple species. Lead pollution is not distributed evenly across urban areas. Although average US pediatric lead exposures have declined by 90% since the 1970s, there remain well defined neighborhoods where children continue to have toxic lead exposures; animals are poisoned there, too. Those neighborhoods tend to have disproportionate commercial and industrial lead activity; a history of dense traffic; older and deteriorating housing; past and operating landfills, dumps and hazardous waste sites; and often lead contaminated drinking water. The population there tends to be low income and minority. Urban wild and domesticated animals bear that same lead burden. Soil, buildings, dust and even trees constitute huge lead repositories throughout urban areas. Until and unless we begin to address the lead repositories in our cities, the urban lead burden will continue to impose enormous costs distributed disproportionately across the domains of the natural environment. Evidence-based research has shown the efficacy and cost-effectiveness of some US public policies to prevent or reduce these exposures. We end with a series of recommendations to manage lead-safe urban environments.

Background: Lead can adversely affect maternal and child health across a wide range of exposures; developing fetuses and breastfeeding infants may be particularly vulnerable. We describe the distribution of blood lead levels (BLLs) in U.S. women of childbearing age and associations with sociodemographic, reproductive, smoking, and housing characteristics over a 40-y period. Methods: Data from the National Health and Nutrition Examination Survey (NHANES) II, NHANES III Phase I and Phase II, and 1999–2016 continuous NHANES were used to describe the distribution of BLLs (given in micrograms per deciliter; 1μg/dL=0.0483μmol/L) in U.S. women 15–49 years of age between 1976 and 2016. For all women with valid BLLs (n=22,408), geometric mean (GM) BLLs and estimated prevalence of BLLs ≥5μg/dL were calculated overall and by selected demographic characteristics. For NHANES II, estimated prevalence of BLLs ≥10 and ≥20μg/dL were also calculated. Results: The most recent GM BLLs (2007–2010 and 2011–2016, respectively) were 0.81μg/dL [95% confidence interval (CI): 0.79, 0.84] and 0.61μg/dL (95% CI: 0.59, 0.64). In comparison, GM BLLs in earlier periods (1976–1980, 1988–1991, and 1991–1994) were 10.37μg/dL (95% CI: 9.95, 10.79), 1.85μg/dL (95% CI: 1.75, 1.94), and 1.53μg/dL (95% CI: 1.45, 1.60), respectively. In 2011–2016, 0.7% of women of childbearing age had BLLs ≥5μg/dL, and higher BLLs were associated with older age, other race/ethnicity, birthplace outside the United States, four or more live births, exposure to secondhand tobacco smoke, and ever pregnant or not currently pregnant. Discussion: Lead exposure in U.S. women of childbearing age is generally low and has substantially decreased over this 40-y period. However, based on these estimates, there are still at least 500,000 U.S. women being exposed to lead at levels that may harm developing fetuses or breastfeeding infants. Identifying high-risk women who are or intend to become pregnant remains an important public health issue. https://doi.org/10.1289/EHP5925

BACKGROUND: Elevated blood lead levels (EBLL, ≥5 µg/dL) are more prevalent among refugee children resettled in the United States than the general US population and contribute to permanent health and neurodevelopmental problems. Therefore, CDC recommends routine screening of refugee children aged 6 months to 16 years upon arrival in the United States, and retesting those aged 6 months

This report provides data concerning childhood blood lead levels (BLLs) in the United States during 2007-2013. These data were collected and compiled from raw data extracts sent by state and local health departments to CDC's Childhood Blood Lead Surveillance (CBLS) system. These raw data extracts have been de-identified and coded into a format specifically for childhood lead reporting. The numbers of children aged

Background. In March 2010, Medecins Sans Frontieres/Doctors Without Borders detected an outbreak of acute lead poisoning in Zamfara State, northwestern Nigeria, linked to low-technology gold ore processing. The outbreak killed more than 400 children ≤5 years of age in the first half of 2010 and has left more than 2,000 children with permanent disabilities. Objectives. The aims of this study were to estimate the statewide prevalence of children ≤5 years old with elevated blood lead levels (BLLs) in gold ore processing and non-ore-processing communities, and to identify factors associated with elevated blood lead levels in children. Methods. A representative, population-based study of ore processing and non-ore-processing villages was conducted throughout Zamfara in 2012. Blood samples from children, outdoor soil samples, indoor dust samples, and survey data on ore processing activities and other lead sources were collected from 383 children ≤5 years old in 383 family compounds across 56 villages. Results. 17.2% of compounds reported that at least one member had processed ore in the preceding 12 months (95% confidence intervals (CI): 9.7, 24.7). The prevalence of BLLs ≥10 μg/dL in children ≤5 years old was 38.2% (95% CI: 26.5, 51.4) in compounds with members who processed ore and 22.3% (95% CI: 17.8, 27.7) in compounds where no one processed ore. Ore processing activities were associated with higher lead concentrations in soil, dust, and blood samples. Other factors associated with elevated BLL were a child's age and sex, breastfeeding, drinking water from a piped tap, and exposure to eye cosmetics. Conclusions. Childhood lead poisoning is widespread in Zamfara State in both ore processing and non-ore-processing settings, although it is more prevalent in ore processing areas. Although most children's BLLs were below the recommended level for chelation therapy, environmental remediation and use of safer ore processing practices are needed to prevent further exposures. Patient consent. Obtained Ethics approval. The study protocol was approved by the US Centers for Disease Control Institutional Review Board-A and the National Health Research Ethics Committee of Nigeria. Competing Interests. The authors declare no competing financial interests.

During April 25, 2014-October 15, 2015, approximately 99,000 residents of Flint, Michigan, were affected by changes in drinking water quality after their water source was switched from the Detroit Water Authority (DWA), sourced from Lake Huron, to the Flint Water System (FWS), sourced from the Flint River.* Because corrosion control was not used at the FWS water treatment plant, the levels of lead in Flint tap water increased over time. Adverse health effects are associated with lead exposure (1). On January 2, 2015, a water advisory was issued because of detection of high levels of trihalomethanes, byproducts of disinfectants.(†)(,)(§) Studies conducted by local and national investigators detected an increase in the prevalence of blood lead levels (BLLs) ≥5 µg/dL (the CDC reference level) among children aged

Despite significant progress made in recent decades in preventing childhood lead poisoning in the United States through the control or elimination of lead sources in the environment, it continues to be an issue in many communities, primarily in low-income communities with a large percentage of deteriorating housing built before the elimination of lead in residential paint. The purpose of this study is to determine whether state laws aimed at preventing childhood lead poisoning are also effective in preventing recurring lead poisoning among children previously poisoned.An evaluation was conducted to determine whether laws in two representative states, Massachusetts and Ohio, have been effective in preventing recurrent lead poisoning among children less than 72 months of age previously poisoned, compared to a representative state (Mississippi) which at the time of the study had yet to develop legislation to prevent childhood lead poisoning.Compared to no legislation, unadjusted estimates showed children less than 72 months old, living in Massachusetts, previously identified as being lead poisoned, were 73% less likely to develop recurrent lead poisoning. However, this statistically significant association did not remain after controlling for other confounding variables. We did not find such a significant association when analyzing data from Ohio.While findings from unadjusted estimates indicated that state lead laws such as those in Massachusetts may be effective at preventing recurrent lead poisoning among young children, small numbers may have attenuated the power to obtain statistical significance during multivariate analysis. Our findings did not provide evidence that state lead laws, such as those in Ohio, were effective in preventing recurrent lead poisoning among young children. Further studies may be needed to confirm these findings.

Context Limited data exist about blood lead levels (BLLs) and potential exposures among children living in Puerto Rico. The Puerto Rico Department of Health has no formal blood lead surveillance program. Objectives We assessed the prevalence of elevated BLLs (≥5 micrograms of lead per deciliter of blood), evaluated household environmental lead levels, and risk factors for BLL among children younger than 6 years of age living in Puerto Rico in 2010. Methods We used a population-based, cross-sectional sampling strategy to enroll an island-representative sample of Puerto Rican children younger than 6 years. We estimated the island-wide weighted prevalence of elevated BLLs and conducted bivariable and multivariable linear regression analyses to ascertain risk factors for elevated BLLs. Results The analytic data set included 355 households and 439 children younger than 6 years throughout Puerto Rico. The weighted geometric mean BLL of children younger than 6 years was 1.57 μg/dL (95% confidence interval [CI], 1.27-1.88). The weighted prevalence of children younger than 6 years with BLLs of 5 μg/dL or more was 3.18% (95% CI, 0.93-5.43) and for BLLs of 10 μg/dL or more was 0.50% (95% CI, 0-1.31). Higher mean BLLs were significantly associated with data collection during the summer months, a lead-related activity or hobby of anyone in the residence, and maternal education of less than 12 years. Few environmental lead hazards were identified. Conclusions The prevalence of elevated BLLs among Puerto Rican children younger than 6 years is comparable with the most recent (2007-2010) US national estimate (BLLs ≥5 μg/dL = 2.6% [95% CI = 1.6-4.0]). Our findings suggest that targeted screening of specific higher-risk groups of children younger than 6 years can replace island-wide or insurance-specific policies of mandatory blood lead testing in Puerto Rico.

CONTEXT: During the past 45 years, exposure to lead has declined dramatically in the United States. This sustained decline is measured by blood and environmental lead levels and achieved through control of lead sources, emission reductions, federal regulations, and applied public health efforts. OBJECTIVE: Explore regulatory factors that contributed to the decrease in exposure to lead among the US population since 1970. DESIGN/SETTING: We present historical information about the control of lead sources and the reduction of emissions through regulatory and selected applied public health efforts, which have contributed to decreases in lead exposure in the United States. Sources of lead exposure, exposure pathways, blood lead measurements, and special populations at risk are described. RESULTS: From 1976-1980 to 2015-2016, the geometric mean blood lead level (BLL) of the US population aged 1 to 74 years dropped from 12.8 to 0.82 μg/dL, a decline of 93.6%. Yet, an estimated 500 000 children aged 1 to 5 years have BLLs at or above the blood lead reference value of 5 μg/dL established by the Centers for Disease Control and Prevention. Low levels of exposure can lead to adverse health effects. There is no safe level of lead exposure, and child BLLs less than 10 μg/dL are known to adversely affect IQ and behavior. When the exposure source is known, approximately 95% of BLLs of 25 μg/dL or higher are work-related among US adults. Despite much progress in reducing exposure to lead in the United States, there are challenges to eliminating exposure. CONCLUSIONS: There are future challenges, particularly from the inequitable distribution of lead hazards among some communities. Maintaining federal, state, and local capacity to identify and respond to populations at high risk can help eliminate lead exposure as a public health problem. The results of this review show that the use of strong evidence-based programs and practices, as well as regulatory authority, can help control or eliminate lead hazards before children and adults are exposed.

The purpose of this article is to consider alternate uses of the blood lead reference value for children. There are two possible approaches. Historically the reference value has been used to guide clinical and public interventions for individual children. As the distribution of blood lead levels in the population has been lowered over time, the blood lead level at which interventions are recommended has also been reduced. The use of a reference value of 3.5 μg/dL, based on the 98 percentile of blood lead levels for children in 2011–2014 National Health and Nutrition Examination Survey is under review. For several reasons, adopting the new reference value to guide clinical and public health management puts practitioners in an untenable position. First, the changes in the brain caused by lead are significant and persistent. However, these adverse impacts are subtle and although clearly identified at the population level, not predictive for individual children. In addition, the recommended interventions have not been shown to reduce blood lead levels once they are elevated. Finally, clinical laboratory and office-based blood lead testing devices are not required to quantify blood lead levels

Background. Lead exposure is linked to intellectual disability and anemia in children. The United States Centers for Disease Control and Prevention (CDC) recommends biomonitoring of blood lead levels (BLLs) in children with BLL ≥5 μg/dL and chelation therapy for those with BLL ≥45 μg/dL.Objectives. This study aimed to determine blood and environmental lead levels and risk factors associated with elevated BLL among children from Owino Uhuru and Bangladesh settlements in Mombasa County, Kenya.Methods. The present study is a population-based, cross-sectional study of children aged 12–59 months randomly selected from households in two neighboring settlements, Owino Uhuru, which has a lead smelter, and Bangladesh settlement (no smelter). Structured questionnaires were administered to parents and 1–3 ml venous blood drawn from each child was tested for lead using a LeadCare ® II portable analyzer. Environmental samples collected from half of the sampled households were tested for lead using graphite furnace atomic absorption spectroscopy.Results: We enrolled 130 children, 65 from each settlement. Fifty-nine (45%) were males and the median age was 39 months (interquartile range (IQR): 30–52 months). BLLs ranged from 1 μg/dL to 31 μg/dL, with 45 (69%) children from Owino Uhuru and 18 (28%) children from Bangladesh settlement with BLLs >5 μg/dL. For Owino Uhuru, the geometric mean BLL in children was 7.4 μg/dL (geometric standard deviation (GSD); 1.9) compared to 3.7 μg/dL (GSD: 1.9) in Bangladesh settlement (pConclusions. Children in Owino Uhuru had significantly higher BLLs compared with children in Bangladesh settlement. Interventions to diminish continued exposure to lead in the settlement should be undertaken. Continued monitoring of levels in children with detectable levels can evaluate whether interventions to reduce exposure are effective.Participant Consent. ObtainedEthics Approval. Scientific approval for the study was obtained from the Ministry of Health, lead poisoning technical working group. Since this investigation was considered a public health response of immediate concern, expedited ethical approval was obtained from the Kenya Medical Research Institute and further approval from the Mombasa County Department of Health Services. The investigation was considered a non-research public health response activity by the CDC.Competing Interests. The authors declare no competing financial interests.

In 2017, the American Academy of Pediatrics Council on Environmental Health clarified the use of terminology related to testing children’s blood lead levels in an erratum to its June 2016 Policy Statement, “Prevention of Childhood Lead Toxicity.”1 Although we applaud this effort to develop consistent terminology, we offer the following cautions for consideration. First, all but 5 states have regulatory language that defines health care providers’ obligations in terms of blood lead testing or screening in children

Objective.The World Health Organization (WHO) reports that nonsmokers experience disease and death due to secondhand smoke (SHS) exposure in the home. We estimated the total excess burden and costs to society due to SHS exposure in U.S. public housing.Methods.We quantified the public health burden for outcomes causally related to SHS exposure for nationally representative never-smoking residents in U.S. public housing using ( 1) WHO-recommended health outcomes and methodology, (2) publicly available and other large databases, and ( 3) published estimates of morbidity and mortality rates. We used published estimates of direct medical and nonmedical care costs and the value of productivity losses to estimate SHS-related societal costs for disease and death. We estimated the public health and economic burden for two serum cotinine limits of detection (LODs): 0.05 nanograms per milliliter (ng/mL) and 0.015 ng/mL.Results.In 2011, an estimated 37,791 never-smoking child and adult U.S. public housing residents experienced illness and death due to SHS exposure at home based on an LOD=0.05 ng/mL (50,967 residents at LOD=0.015 ng/mL). Costs incurred by society for these illnesses and deaths totaled $183 million (LOD=0.05 ng/mL) and $267 million (LOD=0.015 ng/mL) annually. Of the total costs, direct costs (medical and nonmedical) accounted for $128 million and $176 million for LOD=0.05 ng/mL and LOD=0.015 ng/mL, respectively. Medical care accounted for the majority of direct costs—$110 million at LOD=0.05 ng/mL and $153 million at LOD=0.015 ng/mL. Adverse respiratory health outcomes accounted for approximately one-half (56% at LOD=0.05 ng/mL and 52% at LOD=0.015 ng/mL) of total societal costs.Conclusion.Implementing smoke-free policies in all U.S. public housing could save lives and decrease SHS-related morbidity and mortality in never-smoking residents, resulting in annual societal savings of $183 million at LOD=0.05 ng/mL and $267 million at LOD=0.015 ng/mL.

This report provides data concerning childhood blood lead levels (BLLs) in the United States during 2009-2014. These data were collected and compiled from raw data extracts sent by state and local health departments to CDC's Childhood Blood Lead Surveillance (CBLS) system. These raw data extracts have been de-identified and coded into a format specifically for childhood blood lead reporting. The numbers of children aged

Background: In 2010, Médecins Sans Frontières discovered a lead poisoning outbreak linked to artisanal gold processing in northwestern Nigeria. The outbreak has killed approximately 400 young children and affected thousands more. Objectives: Our aim was to undertake an interdisciplinary geological- and health-science assessment to clarify lead sources and exposure pathways, identify additional toxicants of concern and populations at risk, and examine potential for similar lead poisoning globally. Methods: We applied diverse analytical methods to ore samples, soil and sweep samples from villages and family compounds, and plant foodstuff samples. Results: Natural weathering of lead-rich gold ores before mining formed abundant, highly gastric-bioaccessible lead carbonates. The same fingerprint of lead minerals found in all sample types confirms that ore processing caused extreme contamination, with up to 185,000 ppm lead in soils/sweep samples and up to 145 ppm lead in plant foodstuffs. Incidental ingestion of soils via hand-to-mouth transmission and of dusts cleared from the respiratory tract is the dominant exposure pathway. Consumption of water and foodstuffs contaminated by the processing is likely lesser, but these are still significant exposure pathways. Although young children suffered the most immediate and severe consequences, results indicate that older children, adult workers, pregnant women, and breastfed infants are also at risk for lead poisoning. Mercury, arsenic, manganese, antimony, and crystalline silica exposures pose additional health threats. Conclusions: Results inform ongoing efforts in Nigeria to assess lead contamination and poisoning, treat victims, mitigate exposures, and remediate contamination. Ore deposit geology, pre-mining weathering, and burgeoning artisanal mining may combine to cause similar lead poisoning disasters elsewhere globally.

Objective To examine the association between refugee status and elevated blood lead levels (EBLLs) among children living in two U.S. cities and to assess the effect of the Centers for Disease Control and Prevention recommendations for BLL testing of newly emigrated refugee children for EBLLs. Design and Sample A longitudinal study was conducted of 1,007 refugee children and 953 nonrefugee children living, when blood testing occurred, in the same buildings in Manchester, New Hampshire and Providence, Rhode Island. Measures Surveillance and blood lead data were collected from both sites, including demographic information, BLLs, sample type, refugee status, and age of housing. Results Refugee children living in Manchester were statistically significantly more likely to have an EBLL compared with nonrefugee children even after controlling for potential confounders. We did not find this association in Providence. Compared with before enactment, the mean time of refugee children to fall below 10 μg/dL was significantly shorter after the recommendations to test newly emigrated children were enacted. Conclusions Refugee children living in Manchester were significantly more likely to have an EBLL compared with nonrefugee children. And among refugee children, we found a statistically significant difference in the mean days to BLL decline

Background: During May–June 2010, a childhood lead poisoning outbreak related to gold ore processing was confirmed in two villages in Zamfara State, Nigeria. During June–September of that year, villages with suspected or confirmed childhood lead poisoning continued to be identified in Zamfara State. Objectives: We investigated the extent of childhood lead poisoning [≥ 1 child with a blood lead level (BLL) ≥ 10 µg/dL] and lead contamination (≥ 1 soil/dust sample with a lead level > 400 parts per million) among villages in Zamfara State and identified villages that should be prioritized for urgent interventions. Methods: We used chain-referral sampling to identify villages of interest, defined as villages suspected of participation in gold ore processing during the previous 12 months. We interviewed villagers, determined BLLs among children < 5 years of age, and analyzed soil/dust from public areas and homes for lead. Results: We identified 131 villages of interest and visited 74 (56%) villages in three local government areas. Fifty-four (77%) of 70 villages that completed the survey reported gold ore processing. Ore-processing villages were more likely to have ≥ 1 child < 5 years of age with lead poisoning (68% vs. 50%, p = 0.17) or death following convulsions (74% vs. 44%, p = 0.02). Soil/dust contamination and BLL ≥ 45 µg/dL were identified in ore-processing villages only [50% (p < 0.001) and 15% (p = 0.22), respectively]. The odds of childhood lead poisoning or lead contamination was 3.5 times as high in ore-processing villages than the other villages (95% confidence interval: 1.1, 11.3). Conclusion: Childhood lead poisoning and lead contamination were widespread in surveyed areas, particularly among villages that had processed ore recently. Urgent interventions are required to reduce lead exposure, morbidity, and mortality in affected communities.

BACKGROUND: Elevated blood lead levels lead to permanent neurocognitive sequelae in children. Resettled refugee children in the United States are considered at high risk for elevated blood lead levels, but the prevalence of and risk factors for elevated blood lead levels before resettlement have not been described. METHODS: Blood samples from children aged 6 months to 14 years from refugee camps in Thailand were tested for lead and hemoglobin. Sixty-seven children with elevated blood lead levels (venous ≥10 µg/dL) or undetectable (capillary RESULTS: Of 642 children, 33 (5.1%) had elevated blood lead levels. Children aged CONCLUSIONS: The prevalence of elevated blood lead levels among tested US-bound Burmese refugee children was higher than the current US prevalence, and was especially high among children

Objectives. We examined the relationship between self-reported inadequate residential natural light and risk for depression or falls among adults aged 18 years or older. Methods. Generalized estimating equations were used to calculate the odds of depression or falls in participants with self-reported inadequate natural residential light vs. those reporting adequate light ( n=6,017) using data from the World Health Organizations Large Analysis and Review of European Housing and Health Survey, a large cross-sectional study of housing and health in representative populations from eight European cities. Results. Participants reporting inadequate natural light in their dwellings were 1.4 times (95% confidence interval [CI] 1.2,1.7) as likely to report depression and 1.5 times (95% CI 1.2, 1.9) as likely to report a fall compared with those satisfied with their dwellings light. After adjustment for major confounders, the likelihood of depression changed slightly, while the likelihood of a fall increased to 2.5 (95% CI 1.5, 4.2). Conclusion. Self-reported inadequate light in housing is independently associated with depression and falls. Increasing light in housing, a relatively inexpensive intervention, may improve two distinct health conditions.

Objective: Evaluate the effect of changes in the water disinfection process, and presence of lead service lines (LSLs), on children’s blood lead levels (BLLs) in Washington, DC. Methods: Three cross-sectional analyses examined the relationship of LSL and changes in water disinfectant with BLLs in children o 6 years of age. The study population was derived from the DC Childhood Lead Poisoning Prevention Program blood lead surveillance system of children who were tested and whose blood lead test results were reported to the DC Health Department. The Washington, DC Water and Sewer Authority (WASA) provided information on LSLs. The final study population consisted of 63,854 children with validated addresses. Results: Controlling for age of housing, LSL was an independent risk factor for BLLs Z10 mg/dL, and Z 5 mg/dL even during time periods when water levels met the US Environmental Protection Agency (EPA) action level of 15 parts per billion (ppb). When chloramine alone was used to disinfect water, the risk for BLL in the highest quartile among children in homes with LSL was greater than when either chlorine or chloramine with orthophosphate was used. For children tested after LSLs in their houses were replaced, those with partially replaced LSL were 4 3 times as likely to have BLLs Z10 mg/dL versus children who never had LSLs. Conclusions: LSLs were a risk factor for elevated BLLs even when WASA met the EPA water action level. Changes in water disinfection can enhance the effect of LSLs and increase lead exposure. Partially replacing LSLs may not decrease the risk of elevated BLLs associated with LSL exposure. & 2010 Published by Elsevier Inc.

Subject matter experts systematically reviewed evidence on the effectiveness of specific housing interventions in improving health. The panelists reviewed housing interventions associated with exposure to biological and chemical agents, structural injury hazards, and community-level interventions. Intervention studies were grouped together according to recommendations in the Guide to Community Preventive Services, which identifies similarities in the type of intervention, its delivery and setting, and the target population. Review panelists found that 11 interventions had sufficient evidence of effectiveness, 15 required more field evaluation, 19 needed formative research, and 7 either had no evidence of effectiveness or were ineffective. Although many housing conditions are associated with adverse health outcomes, sufficient evidence now shows that specific housing interventions can improve certain health outcomes. The results of these evidence reviews can inform a robust agenda for widespread implementation and further research. This article highlights the project's research methods and summary findings, and its companion articles detail the evidence reviews for specific housing interventions.

Objectives Surveillance blood lead screening of refugee children resettled in Manchester, NH, in 2004 revealed that 39 (42%) of 92 children had elevated levels (⩾10 μg/dL) after resettlement. Furthermore, 27/92 children (29%) had nonelevated screening blood lead levels on arrival (BLL1) but had elevated follow-up blood lead levels 3–6 months after settlement (BLL2). The main objective was to identify risk factors for increasing lead levels among refugee children after resettlement in Manchester in 2004. Patients and methods We conducted a cohort study, with completion of household interviews and home assessments for refugee families who had resettled in 2004 in Manchester, NH. Blood lead level (BLL) data were abstracted from the New Hampshire (NH) Childhood Lead Poisoning Prevention Program. To assess acute and chronic malnutrition among refugees, we used anthropometric data from International Organization of Migration documents to calculate nutritional indices. Results and discussion Of the 93 African refugee children in 42 families who participated, 60 (65%) had been born in a refugee camp. Median age was 5.5 years at the time of BLL2 measurement. Thirty-six (39%) of the refugee children had BLL2⩾10 μg/dL. Liberians and those born in refugee camps had higher geometric mean BLL2 than those not Liberian or not born in camps. Younger children and children with nutritional wasting before immigrating to the United States had a greater increase in geometric mean from BLL1 to BLL2, compared to older children and those without nutritional wasting. Follow-up blood lead testing of refugee children, particularly those resettled in areas with older housing stock, as in Manchester, is important for identifying lead exposure occurring after resettlement. Increased attention to improve nutritional status of children in refugee camps and after arrival in the United States and awareness of children who were born in refugee camps should be incorporated into lead-poisoning prevention strategies.

Objective We reviewed the sources of lead in the environments of U.S. children, contributions to children’s blood lead levels, source elimination and control efforts, and existing federal authorities. Our context is the U.S. public health goal to eliminate pediatric elevated blood lead levels (EBLs) by 2010. Data sources National, state, and local exposure assessments over the past half century have identified risk factors for EBLs among U.S. children, including age, race, income, age and location of housing, parental occupation, and season. Data extraction and synthesis Recent national policies have greatly reduced lead exposure among U.S. children, but even very low exposure levels compromise children’s later intellectual development and lifetime achievement. No threshold for these effects has been demonstrated. Although lead paint and dust may still account for up to 70% of EBLs in U.S. children, the U.S. Centers for Disease Control and Prevention estimates that ≥30% of current EBLs do not have an immediate lead paint source, and numerous studies indicate that lead exposures result from multiple sources. EBLs and even deaths have been associated with inadequately controlled sources including ethnic remedies and goods, consumer products, and food-related items such as ceramics. Lead in public drinking water and in older urban centers remain exposure sources in many areas. Conclusions Achieving the 2010 goal requires maintaining current efforts, especially programs addressing lead paint, while developing interventions that prevent exposure before children are poisoned. It also requires active collaboration across all levels of government to identify and control all potential sources of lead exposure, as well as primary prevention.

Lead is a common environmental contaminant. Lead exposure is a preventable risk that exists in all areas of the United States. In children, lead is associated with impaired cognitive, motor, behavioral, and physical abilities. In 1991, the Centers for Disease Control and Prevention defined the blood lead level that should prompt public health actions as 10 μg/dL. Concurrently, the Centers for Disease Control and Prevention also recognized that a blood lead level of 10 μg/dL did not define a threshold for the harmful effects of lead. Research conducted since 1991 has strengthened the evidence that children's physical and mental development can be affected at blood lead levels of

Lead poisoning remains an important, yet entirely preventable, disease among children worldwide. Children's blood lead levels (BLLs) have been declining in the United States; however, nearly half a million children have BLLsor = 10 microg/ dl, the level targeted for elimination by 2010. Attainment of this national goal will require translating knowledge into public health practice. The Centers for Disease Control and Prevention (CDC) funds state and local health departments to develop comprehensive prevention programs and surveillance. The Jefferson County, Kentucky Program, which includes Louisville, adopted CDC's recommendation for targeting lead testing to children at highest risk and used knowledge of risk factors for lead poisoning to develop prevention strategies. Blood lead testing was targeted to Louisville neighborhoods at high risk, i.e., those characterized by housing built before 1950 and valued$50,000, which are known risk factors for BLLsor = 10 microg/dl among children. We evaluated the impact of these and other interventions. Testing of children aged 9-24 months who were born in high risk housing increased from 64.5% to 73.7% (p-value0.001) among the 1996 and 2000 birth cohorts. Among the 1996 and 2000 birth cohorts, there was no significant change in testing of children born in low risk housing, i.e., built after 1950 and valued ator = $50,000 (37.0-37.5%; p-value = 0.649). This report demonstrates that applying scientific knowledge to public health practice and using surveillance and other data to evaluate practice effectively increased testing of children at high risk for lead poisoning, increased lead-safe housing, and empowered communities to protect their children from lead exposure.

Cultural and environmental factors can cause lead poisoning in the pregnant patient. The data regarding the reproductive risks associated with chelation during human pregnancy are sparse. Assessment of the exposure setting, including anticipatory counseling for each pregnant woman, would help assure the ideal outcome of no added lead intake.

Objectives. We conducted an ecologic analysis to determine whether housing characteristics mediate the associations between concentration of poverty and pediatric injury and between concentration of racial minorities and pediatric injury and whether the association between housing conditions and pediatric injury is independent of other risks. Methods. We created a hierarchical data set by linking individual-level data for pediatric injury with census data. Effect sizes were estimated with a Poisson model. Results. After adjustment for owner occupancy and the percentage of housing built before 1950, the association between concentration of poverty and pediatric injury was attenuated. For concentration of racial minorities, only percentage of owner occupancy had some mediating effect. In hierarchical models, housing characteristics remained independent and significant predictors of pediatric injury. Conclusions. The association between community characteristics and pediatric injury is partially mediated by housing conditions. Risk of pediatric injury associated with housing conditions is independent of other risks.

This paper describes the characteristics of HIV-related hospitalizations in Illinois and compares these to nationally available data. We used HIV-related hospitalization data abstracted from an administrative dataset maintained by state mandate. Overall, HIV-related hospitalizations decreased in Illinois between 1996 and 2000. The proportion of hospitalizations for infants also decreased. However, trend analyses indicated that both the proportion of hospitalizations involving females and the mean age of hospitalized patients increased while the proportion of hospitalizations ending in mortality and the average charge per hospitalization decreased during the observation period. Small area analyses found significant regional variations in the proportion of hospitalizations ending in in-hospital mortality, costs of a hospitalization and rate of decline in the percent of hospitalization over time. Compared to national data, HIV-related hospitalizations in Illinois were more expensive, less likely to end in mortality and less likely to involve females. These results indicate that evaluation of data at several geographic levels can provide healthcare policy makers with essential information at each level of analysis.

Background. Lead poisoning remains an important, yet entirely preventable disease among young children. This article compares the costs and benefits of strict versus limited enforcement of lead poisoning prevention housing policies in preventing additional cases of childhood blood lead elevation. Methods. The author conducted decision analysis using population-based data that compared recurrence of childhood lead exposure in 2 urban areas with different enforcement capacity, and cost data from a federal project and from medical and public health literature. Results. Strict enforcement prevented additional cases, resulting in $45,360 savings from decreased medical and education costs and increased productivity for protected children. The model was robust to changing estimates of followup, housing repairs, relocation, and increases in lead levels over baseline. No cost savings were realized by strict enforcement if the probability of recurrence in limited units was 44% lower than estimated, or if fewer children were identified in limited versus strict enforcement units. If the discount rate for future productivity losses was ≥7.5%, strict enforcement did not lower costs. Conclusion. This analysis suggests that strict enforcement of housing policies to prevent childhood blood lead elevation results in decreased societal costs due to the avoidance of future medical and special education and to increased productivity of resident children.

Background: Children younger than 72 months are most at risk of environmental exposure to lead from ingestion through normal mouthing behavior. Young children are more vulnerable to lead poisoning than adults because lead is absorbed more readily in a child’s gastrointestinal tract. Our focus in this study was to determine the extent to which state mandated lead laws have helped decrease the number of new cases of elevated blood-lead levels (EBLL) in homes where an index case had been identified. Methods: A cross-sectional study was conducted to compare 682 residential addresses, identified between 2000 and 2009, in two states with and one state without laws to prevent childhood lead poisoning among children younger than 72 months, to determine whether the laws were effective in preventing subsequent cases of lead poisoning detected in residential addresses after the identification of an index case. In this study, childhood lead poisoning was defined as the blood lead level (BLL) that would have triggered an environmental investigation in the residence. The two states with lead laws, Massachusetts (MA) and Ohio (OH), had trigger levels of ≥25 μg/dL and ≥15 μg/dL respectively. In Mississippi (MS), the state without legislation, the trigger level was ≥15 μg/dL. Results: The two states with lead laws, MA and OH, were 79% less likely than the one without legislation, MS, to have residential addresses with subsequent lead poisoning cases among children younger than 72 months, adjusted OR = 0.21, 95% CI (0.08-0.54). Conclusions: For the three states studied, the evidence suggests that lead laws such as those studied herein effectively reduced primary exposure to lead among young children living in residential addresses that may have had lead contaminants.

OBJECTIVE: This study uses screening and hospitalization data to describe the prevalence of childhood lead poisoning in Chicago and the rest of the state of Illinois. METHODS: The authors used aggregate data published by the Illinois Department of Public Health on blood lead testing of children ages 0-6 years and data on lead-related hospital admissions of children ages 0-6 years, drawn from an administrative dataset compiled as part of a state initiative. RESULTS: No clear time trends in the percentage of children with elevated blood lead levels (defined as >15 micrograms per deciliter [microg/dL] or >45 microg/dL) were evident in either Chicago or the rest of Illinois. The proportions of children with elevated blood lead levels in Chicago and in the rest of Illinois did not decline at the dramatic rate seen in the US as a whole during the 1990s. Over a five-year period, in-hospital charges of $7.7 million were generated for the care of lead-poisoned children ages 6-16 in Chicago alone. CONCLUSION: Surveillance data, analyzed at the appropriate geographic level, can be used to focus resources on high-risk areas and to evaluate prevention efforts.

Investigators developed and evaluated a dilution method for the LeadCare II analyzer (LCII) for blood lead levels >65 μg/dL, the analyzer’s maximum reporting value. Venous blood samples from lead-poisoned children were initially analyzed in the field using the dilution method. Split samples were analyzed at the US Centers for Disease Control and Prevention (CDC) laboratory using both the dilution method and inductively coupled plasma-mass spectrometry (ICP-MS). The concordance correlation coefficient of CDC LCII vs. ICP-MS values (N = 211) was 0.976 (95 % confidence interval (CI) 0.970–0.981); of Field LCII vs. ICP-MS (N = 68) was 0.910 (95% CI 0.861–0.942), and CDC LCII vs. Field LCII (N = 53) was 0.721 (95% CI 0.565–0.827). Sixty percent of CDC and 54% of Field LCII values were within ±10% of the ICP-MS value. Results from the dilution method approximated ICP-MS values and were useful for field-based decision-making. Specific recommendations for additional evaluation are provided.