Children with Elevated Blood Lead Levels Related to Home Renovation, Repair, and Painting Activities --- New York State, 2006--2007

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Although blood lead levels (BLLs) >10 µg/dL are associated with adverse behavioral and developmental outcomes, and environmental and medical interventions are recommended at >20 µg/dL, no level is considered safe (1,2). A 1997 analysis conducted by the New York State Department of Health (NYSDOH) indicated that home renovation, repair, and painting (RRP) activities were important sources of lead exposure among children with BLLs >20 µg/dL in New York state (excluding New York City) during 1993--1994 (3). Subsequently, local health departments in New York state began to routinely collect information about RRP activities when investigating children's home environments for lead sources. This report updates the 1997 analysis with data from environmental investigations conducted during 2006--2007 in New York state (excluding New York City) for 972 children with BLLs >20 µg/dL. RRP activities were identified as the probable source of lead exposure in 139 (14%) of the 972 children. Resident owners or tenants performed 66% of the RRP work, which often included sanding and scraping (42%), removal of painted materials or structures (29%), and other activities (29%) that can release particles of lead-based paint. RRP activities continued to be an important source of lead exposure during 2006--2007. Children living in housing built before 1978 (when lead-based paint was banned from residential use) that are undergoing RRP activities should be considered at high risk for elevated BLLs, and appropriate precautions should be taken to prevent exposure.

Since 1993, New York state regulations* have required BLL testing for all children at ages 1 and 2 years. In 2007, 83% of children were tested at least once before age 3 years, but only 41% were tested at ages 1 and 2 years (NYSDOH, unpublished data, 2008). Regulations also require laboratories to report all BLLs to NYSDOH, which then provides results to respective local health departments. For all children reported with BLLs >20 µg/dL, local health departments are required to conduct environmental investigations to determine potential sources of exposure and recommend actions to reduce or eliminate exposures following CDC guidelines (1,2). Investigations include questioning about any activities that might have disturbed lead-based paint, including RRP activities, inspection of the home and household items for evidence of cracked or peeling paint, and water testing. If available, paint chips are tested for lead.

During 2006--2007, local health departments conducted environmental investigations for all 972 children reported in New York state with BLLs >20 µg/dL. In January 2008, NYSDOH abstracted data from local health department records to identify investigations in which RRP activities were determined to be the most likely source of lead exposure and in which no other source of exposure was identified. RRP activities were considered the most likely source if an activity occurred that might have generated dust or paint chips that could have been inhaled or ingested. Lead-based paint that was intact and in good condition was not considered a source of exposure. For each case, abstracted data included 1) child's age, 2) blood test date, 3) BLL, 4) address and approximate age of dwelling, 5) activities that might have disturbed paint, and 6) identity of person who performed the RRP work.

The results indicated that, during 2006--2007, the elevated BLLs of 139 (14%) of the 972 children with BLLs >20 µg/dL were related to RRP activities (Table). Among the 139 children, 63 (45%) had BLLs of 20--24 µg/dL, 24 (17%) had BLLs of 25--29 µg/dL, and 52 (38%) had BLLs e30 µg/dL. Most of the children (71%) were aged 1--2 years, and 25% were aged 3--5 years. The 139 children resided in 131 homes; eight homes had two children per home, and all other homes had only one child. All but one of the homes were built before 1978. Of 131 homes in which environmental investigations were conducted, 56 (43%) were identified as urban, 36 (28%) as suburban, and 39 (30%) as rural.

Reported by: EM Franko, DrPH, JM Palome, New York State Dept of Health. MJ Brown, ScD, CM Kennedy, DrPH, Lead Poisoning Prevention Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; LV Moore, PhD, EIS Officer, CDC.

Editorial Note:

In the United States, median BLLs in children aged <5 years have declined 89% from 1976--1980 to 2003--2004 (4). This decline is largely a result of the phase-out of leaded gasoline and efforts by federal, state, and local agencies to limit lead paint hazards in housing. The latter has resulted in a decline in housing units with lead paint hazards from 64 million to 38 million during 1990--2000 (4). The decline in the prevalence of elevated BLLs over time has been most pronounced among children belonging to high-risk groups, especially non-Hispanic black children (5). However, an estimated 250,000 children remain at risk for exposure to harmful lead levels in the United States (4). Children living in housing undergoing RRP and built before 1978, when lead-based paint was banned from residential use, and particularly those built before 1950, when concentrations of lead in paint were higher (6), are now at high risk for elevated BLLs. This is of particular concern in New York state, where both the number (3,309,770) and proportion (43%) of housing units built before 1950 are greater than in any other state (7).

The assessment described in this report showed that RRP activities were an important source of lead exposure among children with BLLs >20 µg/dL during 2006--2007 in New York state. Of 972 children investigated for BLLs >20 µg/dL during 2006--2007, 139 (14%) were traceable to RRP. Among the 131 homes linked to RRP-related lead exposures, all but one were built before 1978. Young children in homes built before 1978 are known to be a high-risk group for lead exposure (5), and these findings indicate RRP activities are an important source of lead exposure in this group.

NYSDOH used methods identical to ones used for this analysis to assess the role of RRP in elevated BLLs during 1993--1994, except that the majority of 2006--2007 records were electronic. During 1993--1994, the total number of children reported with BLLs >20 µg/dL related to RRP was 320, and these children made up 7% of all children detected with BLLs >20 µg/dL, compared with 139 children and 14% of such cases during 2006--2007. Thus, although the absolute number of RRP-related cases dropped substantially between the two periods, the relative burden of these cases on the state's lead screening and treatment efforts increased.

The increase in the relative burden of RRP-related cases might signal a shift in populations at risk for lead exposure in New York state. Additional analyses and follow-up studies are needed to better characterize this possible shift.

The findings in this study are subject to at least two limitations. First, any incomplete reporting of children with BLLs >20 µg/dL by laboratories might result in an underestimation of the number of children exposed to lead. Second, RRP activities also might be an important lead exposure source among children with lower BLLs (<20 µg/dL) who were not included in this study. Although not required by regulation, several local health departments conducted environmental investigations for children with BLLs <20 µg/dL during 2006--2007. Children identified with BLLs <20 µg/dL were similar in characteristics to those in this analyses, and RRP activities were the most probable source of lead exposure for 71 (40%) of 178 children (NYSDOH, unpublished data, 2008).

Contractors performed a small percentage (6.5%) of RRP work related to elevated BLLs in New York state during 2006--2007. Resident owners or tenants performed 66% of this work. To help prevent lead contamination when contractors perform RRP projects, the U.S. Environmental Protection Agency issued regulations in March 2008 that will require all renovators in the United States that work on certain types of housing or child-occupied facilities to be certified and follow specific work practices as of April 2010 (8). To address the risk from RRP by owners and do-it-yourselfers, more public outreach and education is needed to raise awareness of potential lead-exposure hazards from RRP and to ensure protective measures that safely contain dust and paint chips. In New York, state and local health departments have implemented education programs on RRP activities and lead-safe work practices for contractors and do-it-yourselfers.^†

Persons who remove lead-based paint should follow recommendations of the U.S. Department of Housing and Urban Development and the U.S. Environmental Protection Agency to protect children from lead exposure (9,10). These recommendations include 1) relocate occupants during paint removal, and exclude children and pregnant women from the work area; 2) isolate work areas from other areas of the house; 3) avoid practices that create lead dust or fumes; 4) perform a full cleanup after work is completed; and 5) consider monitoring BLLs in persons who live or work in the dwelling.

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