Household interventions for preventing domestic lead exposure in children

Knowledge, Attitudes, Practices, and Prevention Barriers Related to Childhood Lead Poisoning Among Nepali-Speaking Bhutanese Parents in Northeast Ohio, United States

The study objectives were: (i) to develop and administer a survey to assess childhood lead poisoning (CLP) knowledge, attitudes, practices and prevention barriers (KAP-B) among the Nepali-Speaking Bhutanese (NSB) community in Northeast Ohio; and (ii) to examine the association between socio-demographic characteristics of NSB parents and their understanding of CLP as measured by the constructs of knowledge and attitudes. A Nepali language KAP-B questionnaire was developed and 200 NSB parents with at least one child ≤ 7 years of age from the Akron Metropolitan Area, Ohio were interviewed. NSB parents demonstrated a low level of knowledge about CLP prevention measures. While 82% lived in pre-1978 houses, only 27.5% perceived their house/neighborhood to be potentially lead contaminated. Only 33% of the parents reported understanding lead-related information provided by their child's healthcare provider. Low-level CLP awareness among NSB community emphasizes a need for culturally tailored and linguistically appropriate community-level CLP educational intervention programs in this vulnerable community.

Estimating the Effects of Soil Remediation on Children's Blood Lead near a Former Lead Smelter in Omaha, Nebraska, USA

BACKGROUND

Lead exposures from legacy sources threaten children's health. Soil in Omaha, Nebraska, was contaminated by emissions from a lead smelter and refinery. The U.S. Environmental Protection Agency excavated and replaced contaminated soil at the Omaha Lead Superfund Site between 1999 and 2016.

OBJECTIVES

The goal of this study was to assess the association of soil lead level (SLL) and soil remediation status with blood lead levels (BLLs) in children living near or on the site.

METHODS

We linked information on SLL at residential properties with children's BLLs and assigned remediation status to children's BLL measurements based on whether their measurements occurred during residence at remediated or unremediated properties. We examined the association of SLL and remediation status with elevated BLL (EBLL). We distinguished the roles of temporal trend and the intervention with time-by-intervention-status interaction contrasts. All analyses estimated odds ratios (ORs) with a generalized estimating equations approach to ensure robustness under the complex correlations among BLL measurements. All analyses controlled for relevant covariates including children's characteristics.

RESULTS

EBLL (>5μg/dL) was associated with both residential SLL [e.g., OR=2.00; 95% confidence interval (CI): 1.83, 2.19; >400-800 vs. ≤200 ppm] and neighborhood SLL [e.g., OR=1.85 (95% CI: 1.62, 2.11; >400-800 vs. ≤200 ppm)] before remediation but only with neighborhood SLL after remediation. The odds of EBLL were higher before remediation [OR 1.52 (95% CI: 1.34, 1.72)]. Similarly, EBLL was positively associated with preremediation status in our interaction analysis [interaction OR=1.18 (95%CI: 1.02, 1.37)].

DISCUSSION

Residential and neighborhood SLLs were important predictors of EBLLs in children residing near or on this Superfund site. Neighborhood SLL remained a strong predictor following remediation. Our data analyses showed the benefit of soil remediation. Results from the interaction analyses should be interpreted cautiously due to imperfect correspondence of remediation times between remediation and comparison groups. https://doi.org/10.1289/EHP8657.

Exploring persistent racial/ethnic disparities in lead exposure among American children aged 1-5 years: results from NHANES 1999-2016

OBJECTIVE

The aim of this study was to determine whether long-standing racial disparities in lead exposure still exists for children age 1-5 years old. We examined if blood lead levels were higher among non-Hispanic Black children and others compared to non-Hispanic White children.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) from 1999-2016 were used. Geometric mean blood lead levels (BLLs) were compared by race/ethnicity using log-transformed simple linear regression. Associations between race and elevated BLL were assessed using weighted Chi-square tests. Log-transformed multiple weighted linear regression was used to assess what factors affected BLLs.

RESULTS

A total of 6772 children were included in this study. In 1999-2000, the geometric mean BLL for non-Hispanic Black children was 3.08 μg/dL, compared to 2.03 μg/dL for non-Hispanic White children (p = 0.01). The difference in geometric mean BLL between non-Hispanic Black children and non-Hispanic White children continued to be statistically significant in later years (all p < 0.05) until 2015-2016 (0.89 μg/dL vs 0.74 μg/dL, p = 0.17). Log-transformed linear regression showed that being non-Hispanic Black and having low family income were independently associated with higher BLL.

CONCLUSION

Although lead exposure in the general population continued to decline for all racial/ethnic groups, non-Hispanic Black children still had higher BLL than non-Hispanic White children. In more recent years, the racial/ethnic gap was lesser but persisted. Racial/ethnic disparity in childhood BLL could be partially explained by socio-economic factors.

Household interventions for secondary prevention of domestic lead exposure in children

BACKGROUND

Lead exposure is a serious health hazard, especially for children. It is associated with physical, cognitive and neurobehavioural impairment in children. There are many potential sources of lead in the environment, therefore trials have tested many household interventions to prevent or reduce lead exposure. This is an update of a previously published review.

OBJECTIVES

To assess the effects of household interventions intended to prevent or reduce further lead exposure in children on improvements in cognitive and neurobehavioural development, reductions in blood lead levels and reductions in household dust lead levels.

SEARCH METHODS

In March 2020, we updated our searches of CENTRAL, MEDLINE, Embase, 10 other databases and ClinicalTrials.gov. We also searched Google Scholar, checked the reference lists of relevant studies and contacted experts to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of household educational or environmental interventions, or combinations of interventions to prevent lead exposure in children (from birth to 18 years of age), where investigators reported at least one standardised outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed all eligible studies for inclusion, assessed risk of bias and extracted data. We contacted trialists to obtain missing information. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 17 studies (three new to this update), involving 3282 children: 16 RCTs (involving 3204 children) and one quasi-RCT (involving 78 children). Children in all studies were under six years of age. Fifteen studies took place in urban areas of North America, one in Australia and one in China. Most studies were in areas with low socioeconomic status. Girls and boys were equally represented in those studies reporting this information. The duration of the intervention ranged from three months to 24 months in 15 studies, while two studies performed interventions on a single occasion. Follow-up periods ranged from three months to eight years. Three RCTs were at low risk of bias in all assessed domains. The other 14 studies were at unclear or high risk of bias; for example, we considered two RCTs and one quasi-RCT at high risk of selection bias and six RCTs at high risk of attrition bias. National or international research grants or governments funded 15 studies, while the other two did not report their funding sources. Education interventions versus no intervention None of the included studies in this comparison assessed effects on cognitive or neurobehavioural outcomes, or adverse events. All studies reported data on blood lead level outcomes. Educational interventions showed there was probably no evidence of a difference in reducing blood lead levels (continuous: mean difference (MD) -0.03, 95% confidence interval (CI) -0.13 to 0.07; I² = 0%; 5 studies, 815 participants; moderate-certainty evidence; log-transformed data), or in reducing floor dust levels (MD -0.07, 95% CI -0.37 to 0.24; I² = 0%; 2 studies, 318 participants; moderate-certainty evidence). Environmental interventions versus no intervention Dust control: one study in this comparison reported data on cognitive and neurobehavioural outcomes, and on adverse events in children. The study showed numerically there may be better neurobehavioural outcomes in children of the intervention group. However, differences were small and the CI included both a beneficial and non-beneficial effect of the environmental intervention (e.g. mental development (Bayley Scales of Infant Development-II): MD 0.1, 95% CI -2.1 to 2.4; 1 study, 302 participants; low-certainty evidence). The same study did not observe any adverse events related to the intervention during the eight-year follow-up, but observed two children with adverse events in the control group (1 study, 355 participants; very low-certainty evidence). Meta-analysis also found no evidence of effectiveness on blood lead levels (continuous: MD -0.02, 95% CI -0.09 to 0.06; I² = 0%; 4 studies, 565 participants; moderate-certainty evidence; log-transformed data). We could not pool the data regarding floor dust levels, but studies reported that there may be no evidence of a difference between the groups (very low-certainty evidence). Soil abatement: the two studies assessing this environmental intervention only reported on the outcome of 'blood lead level'. One study showed a small effect on blood lead level reduction, while the other study showed no effect. Therefore, we deem the current evidence insufficient to draw conclusions about the effectiveness of soil abatement (very low-certainty evidence). Combination of educational and environmental interventions versus standard education Studies in this comparison only reported on blood lead levels and dust lead levels. We could not pool the studies in a meta-analysis due to substantial differences between the studies. Since the studies reported inconsistent results, the evidence is currently insufficient to clarify whether a combination of interventions reduces blood lead levels and floor dust levels (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Based on available evidence, household educational interventions and environmental interventions (namely dust control measures) show no evidence of a difference in reducing blood lead levels in children as a population health measure. The evidence of the effects of environmental interventions on cognitive and neurobehavioural outcomes and adverse events is uncertain too. Further trials are required to establish the most effective intervention for reducing or even preventing further lead exposure. Key elements of these trials should include strategies to reduce multiple sources of lead exposure simultaneously using empirical dust clearance levels. It is also necessary for trials to be carried out in low- and middle-income countries and in differing socioeconomic groups in high-income countries.

Spatiotemporal exposome dynamics of soil lead and children's blood lead pre- and ten years post-Hurricane Katrina: Lead and other metals on public and private properties in the city of New Orleans, Louisiana, U.S.A

BACKGROUND

Anthropogenic re-distribution of lead (Pb) principally through its use in gasoline additives and lead-based paints have transformed the urban exposome. This unique study tracks urban-scale soil Pb (SPb) and blood Pb (BPb) responses of children living in public and private communities in New Orleans before and ten years after Hurricane Katrina (29 August 2005).

OBJECTIVES

To compare and evaluate associations of pre- and ten years post-Katrina SPb and children's BPb on public and private residential census tracts in the core and outer areas of New Orleans, and to examine correlations between SPb and nine other soil metals.

METHODS

The Louisiana Healthy Housing and Childhood Lead Poisoning Prevention Program BPb (µg/dL) data from pre- (2000-2005) and post-Katrina (2010-2015) for ≤6-year-old children. Data from public and adjacent private residential census tracts within core and outer areas are stratified from a database that includes 916 and 922 SPb and 13,379 and 4830 BPb results, respectively, from pre- and post-Katrina New Orleans. Statistical analyses utilize Multi-Response Permutation Procedure and Spearman's Rho Correlation.

RESULTS

Pre- to Post-Katrina median SPb decreases in public and private core census tracts were from 285 to 55mg/kg and 710-291mg/kg, respectively. In public and private outer census tracts the median SPb decreased from 109 to 56mg/kg and 88-55mg/kg. Children's BPb percent ≥5µg/dL on public and private core areas pre-Katrina was 63.2% and 67.5%, and declined post-Katrina to 7.6% and 20.2%, respectively. BPb decreases also occurred in outer areas. Soil Pb is strongly correlated with other metals.

CONCLUSIONS

Post-Katrina re-building of public housing plus landscaping amends the exposome and reduces children's BPb. Most importantly, Hurricane Katrina revealed that decreasing the toxicants in the soil exposome is an effective intervention for decreasing children's BPb.

Household interventions for preventing domestic lead exposure in children

BACKGROUND

Lead poisoning is associated with physical, cognitive and neurobehavioural impairment in children, and trials have tested many household interventions to prevent lead exposure. This is an update of the original review, first published in 2008.

OBJECTIVES

To assess the effects of household interventions for preventing or reducing lead exposure in children, as measured by improvements in cognitive and neurobehavioural development, reductions in blood lead levels and reductions in household dust lead levels.

SEARCH METHODS

In May 2016 we searched CENTRAL, Ovid MEDLINE, Embase, nine other databases and two trials registers: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. We also checked the reference lists of relevant studies and contacted experts to find unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of household educational or environmental interventions, or combinations of interventions to prevent lead exposure in children (from birth to 18 years of age), where investigators reported at least one standardised outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed all eligible studies for inclusion, assessed risk of bias and extracted data. We contacted trialists to obtain missing information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 14 studies involving 2643 children: 13 RCTs (involving 2565 children) and one quasi-RCT (involving 78 children). Children in all studies were under six years of age. Thirteen studies took place in urban areas of North America, and one was in Australia. Most studies were in areas with low socioeconomic status. Girls and boys were equally represented in all studies. The duration of the intervention ranged from 3 months to 24 months in 12 studies, while 2 studies performed interventions on a single occasion. Follow-up periods ranged from 6 months to 48 months. Three RCTs were at low risk of bias in all assessed domains. We rated two RCTs and one quasi-RCT as being at high risk of selection bias and six RCTs as being at high risk of attrition bias. For educational interventions, we rated the quality of evidence to be high for continuous blood lead levels and moderate for all other outcomes. For environmental interventions, we assessed the quality of evidence as moderate to low. National or international research grants or governments funded 12 studies, while the other 2 did not report their funding sources.No studies reported on cognitive or neurobehavioural outcomes. No studies reported on adverse events in children. All studies reported blood lead level outcomes.We put studies into subgroups according to their intervention type. We performed meta-analyses of both continuous and dichotomous data for subgroups where appropriate. Educational interventions were not effective in reducing blood lead levels (continuous: mean difference (MD) 0.02, 95% confidence interval (CI) -0.09 to 0.12, I² = 0%; 5 studies; N = 815; high quality evidence (log transformed); dichotomous ≥ 10.0 µg/dL (≥ 0.48 µmol/L): risk ratio (RR) 1.02, 95% CI 0.79 to 1.30; I² = 0%; 4 studies; N = 520; moderate quality evidence; dichotomous ≥ 15.0 µg/dL (≥ 0.72 µmol/L): RR 0.60, 95% CI 0.33 to 1.09; I² = 0%; 4 studies; N = 520; moderate quality evidence). Meta-analysis for the dust control subgroup also found no evidence of effectiveness on blood lead levels (continuous: MD -0.15, 95% CI -0.42 to 0.11; I² = 90%; 3 studies; N = 298; low quality evidence (log transformed); dichotomous ≥ 10.0 µg/dL (≥ 0.48 µmol/L): RR 0.93, 95% CI 0.73 to 1.18; I² = 0; 2 studies; N = 210; moderate quality evidence; dichotomous ≥ 15.0 µg/dL (≥ 0.72 µmol/L): RR 0.86, 95% CI 0.35 to 2.07; I² = 56%; 2 studies; N = 210; low quality evidence). After adjusting the dust control subgroup for clustering in meta-analysis, we found no evidence of effectiveness. We could not pool the studies using soil abatement (removal and replacement) and combination intervention groups in a meta-analysis due to substantial differences between studies, and generalisability or reproducibility of the results from these studies is unknown. Therefore, there is currently insufficient evidence to clarify whether soil abatement or a combination of interventions reduces blood lead levels.

AUTHORS' CONCLUSIONS

Based on current knowledge, household educational interventions are ineffective in reducing blood lead levels in children as a population health measure. Dust control interventions may lead to little or no difference in blood lead levels (the quality of evidence was moderate to low, meaning that future research is likely to change these results). There is currently insufficient evidence to draw conclusions about the effectiveness of soil abatement or combination interventions. No study reported on cognitive or neurobehavioural outcomes or adverse events. These patient-relevant outcomes would have been of great interest to draw conclusions for practice.Further trials are required to establish the most effective intervention for preventing lead exposure. Key elements of these trials should include strategies to reduce multiple sources of lead exposure simultaneously using empirical dust clearance levels. It is also necessary for trials to be carried out in low- and middle-income countries and in differing socioeconomic groups in high-income countries.

Spatiotemporal dynamic transformations of soil lead and children's blood lead ten years after Hurricane Katrina: New grounds for primary prevention

BACKGROUND

The contribution of lead contaminated soil to blood lead, especially as it is a large reservoir of lead dust, has been underestimated relative to lead-based paint. On 29 August 2005 Hurricane Katrina flooded and disrupted habitation in New Orleans. Soil and blood lead were mapped prior to Katrina. This unique study addresses soil and blood lead conditions pre- and ten years post-Katrina and considers the effectiveness of low lead soil for lead exposure intervention.

OBJECTIVES

Comparison of soil and blood lead levels pre- and ten years post-Katrina to evaluate and assess the impact of flooding on soil and blood lead at the scale of the city of New Orleans.

METHODS

Post-Katrina soil and blood lead data were stratified by the same census tracts (n=176) as pre-Katrina data. This unique city scale data-set includes soil lead (n=3314 and 3320, pre- vs. post-Katrina), blood lead (n=39,620 and 17,739, pre- vs. post-Katrina), distance, and changes in percent pre-1940 housing. Statistical analysis entailed permutation procedures and Fisher's Exact Tests.

RESULTS

Pre- vs. ten years post-Katrina soil lead median decreased from 280 mg/kg to 132 mg/kg, median blood lead decreased from 5μg/dL to 1.8μg/dL, respectively. Percent pre-1940 housing did not change significantly (P-value=0.674). Soil and blood lead decrease with distance from the center of New Orleans. Except for age-of-housing results, P-values were extremely small (<10(-12)).

CONCLUSIONS

Ten years after Katrina, profound changes in soil lead and children's blood lead occurred in New Orleans. Decreasing the lead on soil surfaces reduces children's interaction with lead dust, thus underscoring soil as a major of source of exposure.

Misled about lead: an assessment of online public health education material from Australia's lead mining and smelting towns

BACKGROUND

This study assesses the accuracy and comprehensiveness of online public health education materials from the three Australian cities with active lead mines and or smelters: Broken Hill, Mount Isa and Port Pirie.

METHODS

Qualitative content analysis of online Australian material with comparison to international best practice where possible.

RESULTS

All materials provided incomplete information about the health effects of lead and pathways of exposure compared to best practice materials. Inconsistent strategies to reduce exposure to lead were identified among the Australian cities, and some evidence-based best practices were not included. The materials normalised environmental lead and neglected to identify that there is no safe level of lead, or that primary prevention is the best strategy for protecting children's health.

CONCLUSIONS

Health education materials need to clearly state health risks from lead across developmental stages and for sensitive populations, integrate a primary prevention perspective, and provide comprehensive evidence-based recommendations for reducing lead exposure in and around the home. Families who rely on information provided by these online public education materials are likely to be inadequately informed about the importance of protecting their children from exposure to lead and strategies for doing so.

Evaluating the effectiveness of state specific lead-based paint hazard risk reduction laws in preventing recurring incidences of lead poisoning in children

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.