Household lead control education interventions

There is strong evidence that providing education alone for parents about lead exposure pathways does not prevent lead poisoning or reduce children’s blood lead levels (BLLs) (Balza 2024, Cochrane-Nussbaumer-Streit 2020, Armstrong 2014). Temporary dust control measures, usually specialized cleaning efforts, have not been shown to effectively reduce children’s BLLs and in some cases, dusting and cleaning can increase childhood lead exposure by dispersing lead dust, which can be inhaled or ingested when it settles on objects that children touch (Cochrane-Nussbaumer-Streit 2020). Comprehensive, permanent lead abatement programs are needed to reduce lead exposure (Balza 2024, Cochrane-Nussbaumer-Streit 2020).

Lead is often found in paint, dust, pipes, and soil in or around homes built before 1978. Lead paint on windows and doors is particularly hazardous as friction created by the opening and closing motion often releases lead dust (US EPA-Lead). Early recommendations regarding lead control suggested that continually cleaning lead dust could mitigate its negative effects; however, studies suggest such efforts are ineffective (Cochrane-Nussbaumer-Streit 2020, Armstrong 2014) and can significantly increase BLLs, especially for toddlers exhibiting mouthing behaviors (Cochrane-Nussbaumer-Streit 2020).

Education interventions are often secondary prevention efforts implemented after children have elevated BLLs from lead exposure, education interventions may be more helpful as part of comprehensive primary prevention interventions that include policies and funding to remove lead hazards (Balza 2024, Cochrane-Nussbaumer-Streit 2020). Comprehensive lead poisoning prevention policies should address lead exposure risks from all pathways, including lead contaminated dust, soil, water, and air (Zartarian 2017). Education interventions that increase public awareness of lead exposure risks and trust in government communication about lead can increase support for prompt abatement of lead hazards (Goebel 2023).

Household lead control education interventions alone, without support for lead hazard removal, have the potential to increase disparities in lead exposure between children from families of color, with lower incomes, who do not own their homes, and children from white families, with higher incomes, who own their homes, since homeowners have decision-making power and many can afford to remove lead hazards from their homes (Lynch 2020, Bloomberg-Bliss 2016). Education interventions alone are not effective in reducing childhood lead poisoning (Balza 2024, Cochrane-Nussbaumer-Streit 2020), which occurs at higher rates among children of color, from families with lower incomes, living in older homes, and living in urban areas than among their counterparts (Teye 2021, Lynch 2020, White 2015). Education interventions that account for language barriers, varying literacy levels, and challenges faced by different racial or ethnic groups can improve parent knowledge of lead exposure pathways; but are not sufficient by themselves to reduce childhood lead poisoning (Teye 2021, Balza 2024). Experts suggest comprehensive lead poisoning prevention interventions are needed to identify lead exposure risks, offer environmental testing, and take action to abate or contain lead found in paint, soil, and pipes, especially for communities of color that are systematically disadvantaged (Teye 2021).

Lead hazards are a persistent environmental injustice that disproportionately affects children of color, children from families that immigrated to the U.S., children living in urban areas, and children living in areas with lower incomes (Teye 2021, Lynch 2020, White 2015, Balza 2024). Disparities in BLLs between Black children and white children ages 1-5 years old have decreased in recent decades; however, disparities persist, with Black children suffering from higher BLLs and higher lead exposures than white children, even at the highest income and highest education levels (Teye 2021). Black children, especially younger children, also have the highest outlier BLLs; the data show potentially thousands of Black children with BLLs of 40 μg/dL or more and no children from any other racial or ethnic group with BLLs that high (Teye 2021).

Available data suggest that children living in households with higher education levels have lower rates of lead exposure than children living in households with less formal education, and as income levels increase, BLLs among children decrease (Teye 2021). Children from families with lower income levels living in areas with higher risk of lead exposure experience negative brain development and cognitive outcomes more than children from families with higher income levels living in the same higher risk areas (Marshall 2020a). Children from families with lower incomes also have higher risks of nutritional problems, especially iron deficiency, which can increase lead absorption and elevate BLLs (Hauptman 2023).

By the late 19^th century, lead’s toxic and harmful effects were known, yet the lead industry and many businesses profited from selling lead for use in paint, pipes, and gasoline. Lead was also part of many consumer goods, including toys and household appliances. By the 1950s, millions of children had been poisoned by lead, either chronically or acutely, and public health officials had documented the irreversible effects of childhood lead poisoning from lead exposures in paint and contaminated water (Bloomberg-Bliss 2016). Powerful leaders of the lead industry avoided responsibility for knowingly selling products containing toxic lead, claiming that lead poisoning was only a problem among individuals and families of color and those living in poverty and falsely suggesting that education about the risks of lead paint was all that was needed (Bloomberg-Bliss 2016).

Formerly redlined neighborhoods are more likely to be communities of color with lower incomes and fewer resources, affected by polluting industries and waste dumping sites, comprised of older and deteriorating houses with lead-based paint, located near lead-polluting industries, and surrounded by heavy traffic with residual effects from leaded gasoline pollution (Teye 2021, Lynch 2020). Children of color experience disproportionate adverse exposures, including to lead, living in racially segregated, formerly redlined neighborhoods. Government disinvestment and the systematic concentration of poverty has increased and exacerbated lead hazards as housing stock deteriorates, lead water service lines degrade, and industry and waste dumping sites further contaminate the air and soil (Hauptman 2023, Howarth 2023, Bravo 2022).

During the 1970s and 1980s, federal regulation began to address lead air pollution after lead’s toxic effects were evident among children from families with higher incomes, not just among children from families of color with lower incomes (Hauptman 2023, Dignam 2019, Bloomberg-Bliss 2016). Legislation reduced the amount of lead in gasoline, and the Clean Air Act Amendments of 1990 banned leaded gasoline for most motor vehicles (Dignam 2019). Lead emissions still come from other sources, including industrial processing and leaded gasoline for some aircraft, racing cars, boats, and trucks (Dignam 2019). As of 2001, roughly 2.7 million people lived in counties that fail to meet U.S. EPA air quality standards for lead emissions, and all of these locations are near industrial sources (Dignam 2019).

The Lead-Based Paint Poisoning Prevention Act in 1971 banned lead paint as of 1978 and identified paint chips as the primary lead hazard in homes. The Residential Lead-Based Paint Hazard Reduction Act of 1992 included lead-contaminated dust and soil in the definition of lead hazards and moved towards prevention of poisoning rather than reaction to poisoning as the national strategy for addressing lead hazards (Dignam 2019, Hauptman 2023). Additional federal legislation addressing lead hazards has removed lead from consumer products, foods, pesticides, pottery and glassware, and food packaging (Dignam 2019).

The Safe Drinking Water Act of 1974 established limits for lead levels in drinking water, but it wasn’t until the 1986 amendment that requirements for lead-free plumbing were included, and those did not take effect until 1988 (Dignam 2019, Hauptman 2023). The Lead and Copper Rule of 1991 identified corrosion of lead pipes and service lines as a major source of lead-contaminated drinking water and encouraged corrosion control and line replacement. Replacement efforts that only partially replace lead pipes can dislodge lead-containing minerals and contaminate drinking water. After serious water contamination events as in Flint, Michigan and Washington, D.C. many cities are attempting to fully replace their lead water service lines; however, private connections to public service lines are typically paid for by homeowners, which may increase disparities in who has access to clean water from lead-free pipes (Dignam 2019).

Legislation and lead hazard removal has reduced childhood lead exposure, with population level decreases in BLLs since the 1970s (Dignam 2019). As of 2010, 23 states have adopted comprehensive lead prevention laws (Hauptman 2023). Several local and state governments have adopted legislation that requires lead testing for children at age 1 or 2, including Philadelphia and Pittsburgh, as well as Connecticut, Delaware, Maryland, New Jersey, and New York (Howarth 2023). However, roughly half a million children age 1 to 5 still have BLLs at or above 5 μg/dL, when it is known that there is no safe blood lead level and significant disparities in lead exposure by race, ethnicity, and income remain (Dignam 2019, Hauptman 2023). Although a federal program to provide nationwide lead abatement would require allocating significant funds, cost benefit analysis suggests benefits of $17-$221 for every dollar invested in lead paint hazard control due to reduced health care, special education, and crime costs as well as increased lifetime earnings and tax revenue (Gould 2009). Government decisions about what it is worth to save communities and people suffering from lead hazard exposure are value judgments that have been influenced by explicit and implicit bias with disastrous effects for many communities of color (Bloomberg-Bliss 2016). The World Health Organization estimates that lead exposure worldwide accounts for over 1 million deaths annually and over 24 million years of healthy life lost (Balza 2024), and as of January 2024, only 48% of countries have banned lead paint (WHO-Lead paint).

• What lead poisoning prevention interventions exist in your community? Are these interventions comprehensive, with funding to remove lead hazards, or are they providing education only? If only education is being provided, why is that? What funding could be made available to prevent lead poisoning through abatement or removal of lead hazards?
• Are all pathways to lead exposure considered and addressed through preventative lead poisoning efforts in your community? What partnerships or collaborations could support addressing lead hazards in contaminated dust, soil, water, and air? How can your community gather support and coordinate efforts from public agencies, community organizations, grant funders, property owners, the public, and others for comprehensive lead poisoning prevention?
• What neighborhoods in your community have higher lead exposure risks? Who has the decision-making power to prioritize reducing disproportionate lead exposure risks?

* Journal subscription may be required for access.

Armstrong 2014 - Armstrong R, Anderson L, Synnot A, et al. Evaluation of evidence related to exposure to lead. Canberra: National Health and Medical Research Council; 2014.

Arora 2024* - Arora J, Singal A, Jacob J, Garg S, Aeri R. Chapter 4: A systematic review of lead exposure on mental health. In: Kumar N, Jha AK. Lead toxicity mitigation: Sustainable nexus approaches. Cham: Springer International Publishing; 2024:51-71.

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Bravo 2022 - Bravo MA, Zephyr D, Kowal D, Ensor K, Miranda ML. Racial residential segregation shapes the relationship between early childhood lead exposure and fourth-grade standardized test scores. Proceedings of the National Academy of Sciences. 2022;119(34):e2117868119.

CDC-Lead CLPP - Centers for Disease Control and Prevention (CDC), National Center for Environmental Health. Childhood Lead Poisoning Prevention (CLPP) program.

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Goebel 2023 - Goebel M, Wardropper CB. Trust and subjective knowledge influence perceived risk of lead exposure. Risk Analysis. 2023;44(5):1204-1218.

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Hauptman 2023* - Hauptman M, Rogers ML, Scarpaci M, Morin B, Vivier PM. Neighborhood disparities and the burden of lead poisoning. Pediatric Research. 2023;94:826-836.

Howarth 2023* - Howarth MV, Eiser AR. Environmentally mediated health disparities. American Journal of Medicine. 2023;136(6):518-522.

Lynch 2020 - Lynch EE, Meier HCS. The intersectional effect of poverty, home ownership, and racial/ethnic composition on mean childhood blood lead levels in Milwaukee County neighborhoods. PLoS ONE. 2020;15(6):e0234995.

Marshall 2020a* - Marshall AT, Betts S, Kan EC, et al. Association of lead-exposure risk and family income with childhood brain outcomes. Nature Medicine. 2020;26:91-97.

Teye 2021* - Teye SO, Yanosky JD, Cuffee Y, et al. Exploring persistent racial/ethnic disparities in lead exposure among American children aged 1–5 years: Results from NHANES 1999–2016. International Archives of Occupational and Environmental Health. 2021;94:723-730.

US EPA-Lead - U.S. Environmental Protection Agency (U.S. EPA). Lead: Lead poisoning is preventable.

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WHO-Lead paint - World Health Organization (WHO). Legally-binding controls on lead paint.

Zartarian 2017 - Zartarian V, Xue J, Tornero-Velez R, Brown J. Children’s lead exposure: A multimedia modeling analysis to guide public health decision-making. Environmental Health Perspectives. 2017;125(9):097009.