Targeting Coordinated Federal Efforts to Address Persistent Hazardous Exposures to Lead

The Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA), the US Food and Drug Administration (FDA), the US Department of Housing and Urban Development (HUD), and other federal agencies are committed to primary and secondary prevention of lead exposure and its adverse health outcomes. Updated national standards, guidance, and coordinated policies combined with abatement, enforcement, remediation, infrastructure replacement, and other lead exposure prevention projects will further reduce the presence of lead in the diets of children and their families and in the places where they live, work, learn, and play. This includes providing resources to support cleanup or removal of remaining lead exposure hazards; identifying the most vulnerable US locations to focus prevention and mitigation efforts through coordinated lead-mapping efforts; targeting blood lead surveillance, education, outreach, and training to the most vulnerable locations; and updating national standards and guidance based on the best available science. We describe how agencies are coordinating their efforts.

From the 1970s to the 2020s blood lead levels (BLLs) measured in children¹ have fallen steadily as actions taken by different federal agencies reduced or removed lead from motor vehicle gasoline, paint, water, air, food containers, and other sources.² One indicator of the success of lead mitigation efforts is the CDC’s reduction of the blood lead reference value from 5.0 to 3.5 micrograms per deciliter in October 2021.³ The blood lead reference value is a population-based measurement of the 97.5th percentile of BLLs of US children aged 1 to 5 years. This reduction reflects the decline in BLLs among the US children most exposed to lead.

Despite this progress, lead exposure in children remains a significant public health concern. More than half a million children aged 1 to 5 years in the United States have detectable BLLs.⁴ Racial disparities in childhood BLLs persist, with higher BLLs observed in non-Hispanic Black children than in non-Hispanic White children from 1999 to 2016.^4–6 Elimination of lead exposure, the most preventable environmental hazard facing young children, can potentially generate $84 to $269 billion in long-term savings per birth cohort.^7,8 Eliminating lead from children’s environments is the subject of policy and agency initiatives, and responses to petitions, public comment, public reports,⁸ and responses to court orders. Federal agencies also implement actions responding to reviews of their lead safety programs by Congress’s General Accountability Office and their Office of Inspector General.

During Lead Poisoning Prevention Week in October 2021, department leaders from the President’s Task Force on Environmental Health Risks and Safety Risks to Children met and affirmed their commitment to the 2018 federal action plan to eliminate lead poisoning.⁹ Shortly thereafter, the presidential administration issued its Lead Pipe and Paint Action Plan,¹⁰ describing a broad set of initiatives to reduce exposure in disadvantaged communities and government-assisted homes. It includes more than 15 major actions by federal agencies that are part of the President’s Task Force Lead Subcommittee.¹¹

Figure 1 highlights the federal partnerships necessary to act on lead, given the complex set of laws and rules regulating lead. For example, the Lead Pipe and Paint Action Plan includes a partnership among the EPA, the US Department of Education, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) to prioritize funding and develop data and coordinated guidance to reduce the risk of lead exposure in the nation’s schools and childcare facilities. Other broad partnerships include those needed to address lead in soil and to provide worker protection and prevent take-home lead exposure. Similarly, lead in aviation fuel is addressed by the EPA and the Federal Aviation Administration (FAA), and BLL testing is handled largely by multiple offices in the HHS together with state and local public health and clinical practitioners. The CDC,^12,13 the EPA,¹⁴ the FDA,¹⁵ and HUD¹⁶ have each put forward strategic plans or initiatives that recognize the importance of working across federal agencies to address lead exposure, especially in communities with environmental justice concerns.

FIGURE 1—

Federal Partnerships Necessary to Act on Lead Exposure to Protect Public Health

Note. ACF = Administration for Children and Families; ATSDR = Agency for Toxic Substances and Disease Registry; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare & Medicaid Services; CPSC = Consumer Product Safety Commission; DOI = Department of the Interior; DOL/OSHA = Department of Labor/Occupational Safety and Health Administration; ED = Department of Education; EPA = Environmental Protection Agency; FAA = Federal Aviation Administration; FDA = Food and Drug Administration; HHS = Department of Health and Human Services; HRSA = Health Resources and Services Administration; HUD = Department of Housing and Urban Development; NCEH = National Center for Environmental Health; NIOSH = National Institute for Occupational Safety and Health; PEHSU = Pediatric Environmental Health Specialty Unit; USDA = US Department of Agriculture.

We describe actions taken nationally by the CDC, the EPA, the FDA, and HUD, the primary agencies on the federal action plan to eliminate lead poisoning,⁹ to develop and enforce updated standards and guidance for dust, soil, paint, water, food, and air. We further discuss actions taken by these agencies locally, including remediation, enforcement, outreach, and education focused on reducing exposure and exposure disparities, working together with state, tribal, and local governments; nongovernmental organizations; and industry stakeholders.

TARGETING LEAD EXPOSURE HOTSPOTS

The federal action plan to eliminate lead poisoning has prioritized mapping lead exposures and exposure disparities to target mitigation efforts.⁹ CDC, HUD, and EPA scientists have been working to improve publicly available maps of lead exposure risk,¹⁷ using spatial modeling and updated statistical models to support the agencies’ related goals: the CDC¹⁸ to enhance BLL surveillance data analyses and focus primary prevention; HUD to focus lead paint mitigation programs; and the EPA to target lead remediation, enforcement, education, and outreach actions (Zartarian et al., p. S658 of this issue).

BLOOD LEAD SURVEILLANCE

In 2021, the CDC’s Childhood Lead Poisoning Prevention Program (CLPPP) funded 62 state and local childhood lead-poisoning prevention programs and enhanced the national Childhood Blood Lead Surveillance System. This effort has expanded blood lead testing and reporting to the largest number of funding recipients to date, linked exposed children to services, and supported targeted primary prevention interventions while improving data quality and reportability.¹⁹ In addition, the CDC’s Lead-Free Communities Initiative is focused on eliminating lead exposure from children’s environments, and using BLL surveillance is an important metric to measure progress.¹² The CDC is also collaborating with the Centers for Medicare & Medicaid Services to bolster the nationwide network of CLPPPs, federal partners, and other stakeholders to increase BLL screening rates among children who receive Medicaid. This collaborative approach is underscored by the EPA and the CDC Agency for Toxic Substances and Disease Registry’s joint funding of the Pediatric Environmental Health Specialty Units, a nationwide network of pediatric health care providers that prevent, diagnose, and educate about children’s environmental health issues.

TARGETING LEAD IN FOOD

The FDA launched Closer to Zero to reduce exposure to lead and other contaminants from foods for babies and young children to as low as feasible. Recognizing that there is no safe level of exposure to these contaminants, Closer to Zero commits to a science-based approach to setting interim reference levels for dietary exposure.¹⁵ For lead, the interim reference level, based on the blood lead reference value, informs the development of action levels for individual foods. Closer to Zero commits to ongoing scientific review that can guide further reductions and adjustments in the interim reference and action levels. The FDA works closely with the USDA to identify opportunities for growers and manufacturers to effect sustainable lead reduction in commodities and other foodstuffs. The FDA works with many other federal agencies, such as the National Institutes of Health, to address research gaps on the interaction of toxicants and nutrients and on the role of nutrition and nutrition status on mitigating the impacts of exposure to lead.

In 2018, the FDA modernized its Total Diet Study, through which the FDA estimates dietary exposure to lead in food, to include population-based sampling of regionally and nationally distributed foods in different regions and seasons.²⁰ Total Diet Study data can be used to identify actions to reduce dietary lead exposure that can have the greatest impact and to help prioritize needed research.

LEAD PAINT, SOIL, AND DUST

Lead exposure is an especial concern for those living in homes and buildings built before 1978 (especially before 1940) where lead-based paint (LBP) is in deteriorating condition or where children are exposed to lead in soil or dust. HUD and the EPA play critical roles in reducing lead exposures from residential paint, dust, and soil.

At the national level, the EPA collaborates with HUD on rule makings and guidance on LBP hazards (certain LBP conditions or dust or soil lead concentrations)^21,22 consistent with the May 2021 EPA case decision in the Ninth Circuit Court of Appeals.²³ Under the Toxic Substances Control Act, the EPA has initiated rulemaking to reconsider the dust lead hazard standards and dust lead clearance levels for identifying and addressing dust lead hazards. The EPA coordinates with HUD on these and on guidance for remediating residential soil lead for HUD grantees. To support these updates, HUD and the EPA are using the coupled Stochastic Human Exposure and Dose Simulation–Multimedia (https://bit.ly/3DxN66Y) and Integrated Exposure Uptake and Biokinetic models (https://bit.ly/3eQob45) to develop probabilistic estimates of BLLs resulting from aggregate exposure to lead. Concentrations of lead in drinking water, soil, dust, food, and air, combined with real-world activity pattern diaries, using data from the EPA, HUD, the FDA, and the CDC, are used to estimate children’s BLLs for the US population.²⁴ These modeled BLL estimates are evaluated against measured data from the CDC’s National Health and Nutrition Examination Survey to help agencies make regulatory decisions.

HUD awards lead hazard reduction grants to state and local governments to identify and control LBP hazards in privately owned rental or owner-occupied pre-1978 homes of low-income families, provided the homes are not receiving HUD rental assistance. However, government-assisted pre-1978 homes are covered by HUD’s Lead Safe Housing Rule,²⁵ under which owners must keep them free of LBP hazards. Although the lead hazard reduction grants are not funded sufficiently to address these hazards in all pre-1978 homes of low-income families (funding would have to increase by ∼1000-fold), the grants protect families’ health and bolster the lead hazard evaluation and control industry.

HUD has required grantees to target areas with high percentages of pre-1978 homes, young children, and low-income families. HUD is tightening the third criterion to be high percentages (at least 40%) of disadvantaged census tracts, per Executive Order 14008’s environmental Justice40 Initiative.²⁶ HUD also protects residents’ health by enforcing the HUD–EPA lead disclosure rule, which requires disclosing known LBP and LBP hazards when selling or leasing pre-1978 homes.²⁷ In some significant cases, HUD jointly enforces the rule with the EPA or the Department of Justice. HUD targets landlords with poor safety and health records to abate LBP throughout their whole housing portfolios, not just in units where they violated the rule. The EPA and HUD also provide outreach to homeowners, tenants, and additional stakeholders to help make homes lead safe, including operating its lead safety Web site and lead regulations help desk and tips line.^28–30

Renovation efforts in pre-1978 homes are regulated under the EPA’s Repair, Renovation, and Painting Rule.³¹ The EPA has launched the Enhancing Lead-Safe Work Practices Through Education and Outreach initiative to increase the number of certified renovation firms in communities disproportionately affected by lead exposure, providing training in English and Spanish for contractors to become Repair, Renovation, and Painting Rule certified. This pilot program aims to ensure the health of painting and renovation professionals and residents. In addition, Occupational Safety and Health Administration is considering revising its standards for occupational exposure to lead.³² The EPA also offers interactive webinars to tribal leaders and educational materials to families and communities.^33,34

Residential Contamination Exposures

HUD and the EPA signed a 2017 memorandum of understanding, updated in 2022, to help ensure that residents of HUD-assisted public and multifamily housing located on superfund sites are informed about and protected from potential exposures, including those with lead as a primary contaminant of concern.³⁵ HUD’s fiscal year 2023 budget proposes a pilot program on distressed neighborhoods that contain such homes on and near the sites.

If funded, the program will use the ongoing memorandum of understanding work and include the HHS in developing transformation plans for these communities; the communities will use the three agencies’ funds for catalytic investments to attract private and other public investment for economic initiatives, affordable homes, and social services for residents.

American Healthy Homes Surveys

HUD, the EPA, and the National Institute of Environmental Health Sciences have cosponsored national surveys of LBP and LBP hazards in US homes, most recently the American Healthy Homes Survey II. The survey’s sample included cross-sectional (70% newly stratified randomly selected homes) and longitudinal (30% homes from the similarly selected American Healthy Homes Survey I sample) subsamples; findings were comparable between the two. These surveys demonstrate national progress from 2005–2006 to 2018–2019 in making homes lead safe.³⁶ (Only 9% [5.7 million] of pre-1978 homes were demolished in that time; demolition did not significantly affect LBP or LBP hazard prevalence changes.)

In 2018?2019, as compared to 2005?2006, fewer homes of families in poverty had LBP and, similarly, LBP hazards, and fewer homes of Black Americans had LBP hazards. Fewer homes had soil lead, floor dust lead, and window sill dust lead hazards. Fewer government-assisted homes had LBP hazards than did non–government-assisted homes of low-income families, supporting the effectiveness of ongoing government monitoring of the lead safety conditions of the government-assisted homes. There were, however, more homes with deteriorated LBP, reflecting the aging of the pre-1978 homes and highlighting the importance of ongoing monitoring and maintenance.

TARGETING LEAD IN DRINKING WATER

The Lead Pipe and Paint Action Plan includes actions to make rapid progress toward replacing all lead pipes in the next decade and more equitably protecting public health. The EPA intends to propose improvements to the drinking water regulation under the Lead and Copper Rule Improvements rule that will result in replacing all lead service lines as quickly as is feasible.³⁷ The EPA is also allocating $15 billion under the Bipartisan Infrastructure Law for lead service line replacements to states, tribes and territories. HUD and the Department of the Interior are committed to replacing lead water service lines in their government-assisted homes whenever water main feeder lines are being replaced. And the USDA is committed to replacing lead service lines to all homes connected to a USDA-funded lead remediation project when easements exist.¹⁰

An example of government at all levels reducing lead exposure is the federal partnership with the West Virginia Department of Health and Human Resources Bureau for Public Health (WVBPH), the Harrison–Clarksburg Health Department, and the Clarksburg Water System. The WVBPH identified lead in drinking water during environmental home evaluations of children with elevated BLLs and asked the EPA to assist in identifying lead service lines and reducing lead exposure from drinking water. The EPA asked the CDC Agency for Toxic Substances and Disease Registry to support further assessment of lead exposures, including increasing childhood BLL testing. Ultimately, the CDC Agency for Toxic Substances and Disease Registry, the EPA, HUD, the WVBPH, and the local health department initiated a comprehensive site-specific response plan, incorporating community environmental and BLL data, short- and long-term goals, and detailed activity tracking.

The intergovernmental collaborative is conducting outreach events, focus groups, and health professional education in Clarksburg. This includes special events and free blood lead screening at the local health department. In addition, the local water system has partnered with EPA scientists to pilot water sampling approaches to identify lead service lines without excavation. This case highlights the value of a whole-of-government approach in developing and implementing a timely site-specific comprehensive response plan to address lead exposures.

LEADED AVIATION FUEL

The EPA has been petitioned to address exposure from leaded aviation fuel.³⁸ Piston engine aircraft that operate on leaded fuel are the largest remaining source of leaded air emissions associated with increased BLLs in children.^39–41 The petitions ask the EPA to make an endangerment finding under the Clean Air Act for leaded aviation fuel; the EPA plans to propose a finding in 2022 for public review and comment and any final endangerment finding in 2023.

If the EPA were to make an affirmative finding, it would then propose regulatory standards for lead emissions from aircraft engines. The finding also would trigger the FAA’s statutory mandate to prescribe aircraft fuel composition standards. The FAA and industry announced an initiative to transition to lead-free aviation fuels for piston engine aircraft by the end of 2030.

CONCLUSIONS

The CDC, the EPA, the FDA, HUD, and additional federal agencies are committed to primary and secondary prevention of lead exposure and its adverse health outcomes. The combination of legal actions, an increased national emphasis on addressing long-lasting issues of environmental exposure and health disparities, and an updated blood lead reference value is fueling a more rapid iterative cycle of lead regulation and actions. The EPA is revisiting its dust lead and drinking water lead standards within two years of updating them and working with the FAA to update aviation fuel standards. HUD is enhancing its lead hazard reduction programs’ risk focus and collaborating with the EPA to update dust, soil, and paint lead standards. The CDC and associated offices throughout the HHS are working to achieve health equity and increase blood lead surveillance. And the FDA will regularly update action levels in food.

These actions will provide the regulatory basis to further reduce the presence of lead in the diets of children and their families, and lead sources in the places where they live, work, learn, and play. Federal programs, tools, and resources will also assist public health, clinical, and housing professionals to focus screening and mitigation efforts on the populations at greatest risk of exposure and develop lead exposure reduction plans responsive to local conditions using local data. These national and local actions will collectively reduce or eliminate lead exposure from children’s environments and advance health equity and environmental justice.