Childhood lead poisoning is widely recognized as one of the most significant environmental health problems impacting children in the United States (Landrigan et al. 2002), as well as many other countries (WHO 2010; Jacobs 2011). Lead is one of the longest-known, best-understood, and most well-monitored environmental toxins. Most (but not all) children with elevated blood lead levels are exposed to lead through lead hazards in older housing.

More than half a million children in the United States still have blood lead levels above the Centers for Disease Control and Prevention reference value of 5 micrograms per deciliter (or µg/dL) (CDC, 2013). The National Toxicology Program of the National Institutes of Health (NIH) has concluded that there is now sufficient scientific evidence that even below the CDC level, children can experience decreased academic achievement and IQ, and increased incidence of attention-related behaviors and problem behaviors (NTP, 2012).  Population-wide rates of elevated blood lead levels have declined since lead was removed from paint, food cans, gasoline and other sources by federal law in the 1970’s, and since industrial emissions and water lead levels were reduced (Levin et al., 2008), but elevated rates of lead poisoning persist in certain areas and among low-income and minority children, and others who continue to be disproportionately affected (Levin et al., 2008). Therefore, there is increasing interest in the potential of local housing policies to reduce lead hazards.

The federal bans on lead in new paint and gasoline did not eliminate risks from existing lead paint in older homes. To address remaining risks, Title X of the federal 1992 Housing and Community Development Act took several steps to reduce lead hazards in housing.  In 1996, the US Department of Housing and Urban Development (HUD) and the US Environmental Protection Agency (EPA) started requiring disclosure of known lead hazards in all pre-1978 housing.  HUD phased in lead safety requirements for federally assisted housing and established federal grants for housing rehabilitation. By 2000, government-assisted housing had lower levels of lead paint hazards compared to non-assisted low-income housing (Jacobs et al. 2002).  Additionally, as of 2010, the EPA regulates renovation, repair and painting practices in pre-1978 housing.

At the state level, legislatures have adopted a variety of policy approaches. Most rely on secondary prevention: identifying children with elevated blood lead levels through blood lead screening programs and then removing the lead hazards from these children’s environments. Unfortunately, secondary prevention does not protect children from the permanent injuries caused by lead poisoning. Research has clearly established that medical treatment for a child with lead poisoning is necessary but has limited effect. The best solution is to prevent exposure in the first place (Brown and Meehan 2004, 8–9, Lanphear et al. 2005). For this reason, there is interest in the effectiveness of housing-based primary prevention policies—laws that aim to identify and fix lead hazards before children become poisoned. Several states, notably Maryland, Massachusetts, Washington, DC, and Rhode Island, have housing-based primary prevention laws (Brown et al. 2001; Mares 2003; Breysse et al. 2007). However, statewide or local primary prevention laws have not been implemented in most jurisdictions.

Thus, privately-owned pre-1978 housing remains a major source of children’s exposure to lead and resulting elevated blood lead levels. To fill this gap, in recent years a number of innovative local policies have been enacted (Brown, 2005; Korfmacher and Hanley, 2013). Although they differ in terms of target housing, mechanism, and enforcement strategy, these local policy approaches aim to reduce childhood lead poisoning by reducing the prevalence of lead hazards in high-risk housing, and do so by improving maintenance practices and controlling lead hazards. This Knowledge Asset summarizes the rationale underlying local housing policies and their effectiveness.

Lead poisoning remains one of the most critical children’s environmental health hazards in the United States.

Lead poisoning remains a significant environmental health threat, particularly for low-income and minority children in the United States. (Landrigan et al. 2002, Levin et al. 2008, NTP 2012). Lead is one of the longest-known, best-understood, and most well-monitored environmental toxicants. Nationally, lead poisoning rates in the United States have dropped dramatically over the past three decades. While the percentage of children ages 1-5 with blood lead levels greater than 10 micrograms per deciliter (µg/dL) has dropped from 88% (1976-180 NHANES) to 0.8% (2007-2010 NHANES) (CDC,  2013), more than half a million children still have blood lead levels exceeding the CDC reference value.

As research has clearly established, primary prevention, or preventing lead poisoning before it occurs, is the most effective way of combatting lead poisoning. Childhood lead poisoning cannot be treated solely through medical means, and lead can cause long-term health, behavioral, and learning problems (Brown and Meehan 2004, 8–9, Lanphear et al. 2005). Therefore, policy efforts focus on removing lead hazards from children’s environments before they are exposed.

Federal policies banning lead from gasoline (1976) and residential paint (1978) are widely credited for the rapid decline in blood lead levels since that time (Levin et al. 2008). Nonetheless, more than half a million children in the United States still have blood lead levels greater than the CDC reference value of 5 µg/dL (CDC, 2013) and average blood lead levels today are still 100 times higher than in pre-industrial times (Flegal and Smith 1992; Jones et al. 2009; Jacobs et al  2013).

Housing-based hazards remain the primary source of childhood blood lead elevations in the United States.

In most areas with high rates of lead poisoning, the primary sources of exposure for children are lead in deteriorated house paint, household dust, and bare contaminated soil (Lanphear et al., 1998; Levin et al. 2008). Non-housing sources, including ethnic products (such as traditional folk medicines, imported candies and cosmetics), consumer products, and water may be sources of lead exposure for up to 30% of children (Levin et al. 2008). A full list of products can be found at on the CDC website. In some areas, unsafe renovations in pre-1978 housing may account for a significant proportion of elevated blood lead levels (Franko et al. 2009; Spanier et al. 2013). Housing-based hazards have been reduced by federal policies and by replacement of older housing with new construction over time (Jacobs and Nevin 2006). Nonetheless, as of 2000 it was estimated that 24 million housing units in the United States contained lead hazards (Jacobs et al. 2002). Housing-based hazards remain the primary source of lead exposure contributing to approximately 530,000 US children ages 1-5 with elevated blood lead levels greater than 5 µg/dL (CDC, 2013).

Privately owned, low income, pre-1978 rental housing that is not subject to federal housing standards is most likely to have lead hazards.

The federal policies banning lead from gasoline (1976) and residential paint (1978) did not eliminate risks from existing lead paint in older homes. The federal government has since implemented additional measures to reduce risks. Between 1999 and 2002, the US Department of Housing and Urban Development (HUD) phased in lead safety requirements for federally-owned and -assisted housing (24 C.F.R. Part 35, Subparts B through R). By 2000, government-assisted housing was safer than non-assisted low-income housing (Jacobs et al. 2002). Further, federal grants for rehabilitating pre-1978 housing require lead hazard controls. 

However, non-federally assisted rental housing built before 1978 is not regulated by most federal and state lead laws. Low-income rental housing may not be properly maintained and therefore may pose the greatest risk to children. Past studies comparing lead safety have found low income rental units to be most likely to contain lead hazards (Lanphear et al., 1998). In addition, low-income owner-occupants of pre-1978 homes may not have sufficient resources to maintain lead-safe homes.

Low-income neighborhoods with high concentrations of pre-1978 rental housing continue to have higher rates of children with elevated blood lead levels.

Both observational and modeling studies show that childhood lead poisoning is geographically concentrated in areas with high numbers of children living in housing likely to contain lead hazards. Geographic analysis of childhood lead poisoning in Chicago, IL, Louisville, KY, Providence, RI, Rochester, NY and elsewhere have identified subareas within each city with dramatically elevated rates of lead poisoning (Boyce, 2002; Providence Plan, 2002; Reyes, et al. 2006; Meyer, 2005; Korfmacher and Kuholski, 2007). Models based on housing, economic, and demographic data can help predict the location of these high-risk areas (Sargent et al. 1997; Lanphear et al. 1998; Haley and Talbot 2004). The geographic concentration of lead poisoning cases suggest that in many cities, it is possible to geographically target lead hazard reduction policies to efficiently prevent the largest number of cases.

Home maintenance standards and renovation, repair, and painting practices determine the extent of lead hazards in pre-1978 housing.

Not all of the 38 million American homes that contain lead paint pose immediate or current lead hazards to children (Jacobs et al. 2002). Lead safety is partly a function of maintenance: intact lead paint is typically not hazardous unless it is disturbed by deterioration, friction, or renovation that releases lead dust into the environment. Conversely, pre-1978 homes with deteriorated paint, dust from friction or impact surfaces (particularly windows, doors, and porches), and bare soil are more likely to expose children to lead. A 2009 review of the evidence found that educational and dust-control (cleaning) interventions alone are not effective in reducing children’s blood lead levels in homes with lead hazards, suggesting that it is necessary to address the sources of household lead through proper maintenance of paint and soil containing lead (Yeoh et al, 2009). Evaluations of the HUD Lead Hazard Control grant programs have assessed the effectiveness of a wide range of lead hazard control interventions (NCHH, 2004; Wilson et al., 2006). Full abatement (removal or permanent encapsulation) of lead paint is effective but can be very expensive. However, less costly “interim control” measures were found to be effective in reducing lead hazards if they are properly maintained over time. Window replacement appears to be particularly effective in reducing lead hazards (Jacobs and Nevin, 2006; Dixon et al. 2012). 

The federal EPA’s Renovation, Repair, and Painting (RRP) rule, which went into effect in April 2010, set training and certification requirements, work practice standards, and enforcement mechanisms for renovations that disturb painted surfaces in most pre-1978 buildings (See 40 C.F.R. §§745.80-92).  In buildings with lead paint, failure to follow lead-safe work practices can easily generate high levels of lead in dust and create hazards where there previously were none. This law provides important protections for occupants by requiring lead-safe work practices and clean-up when paid workers renovate pre-1978 buildings. It does not require removal of lead hazards on an ongoing basis, or clearance testing to prove lead hazards have been cleaned up, unlike the federal rule governing federally assisted housing.

The structure of local housing-based lead laws varies widely.

The goal of most local lead laws is to influence property owners’ maintenance decisions in ways that reduce lead hazards in high-risk housing. Most local lead laws focus on rental housing because municipalities have a greater ability to regulate maintenance of rental housing than owner-occupied homes. Korfmacher and Hanley (2013) identified nearly 20 local housing-based lead laws enacted since 2000. Several of these were actually secondary prevention policies (policies guiding environmental investigations in response to a child with elevated blood lead). The remainder varied greatly in scope, approach (mandatory or voluntary), target housing (all pre-1978 housing, rentals, homes with children, geographic area), inspection type, and repair standards. Several added lead to existing inspection systems; yet others created new private inspection mechanisms. Implementation resources and enforcement systems also varied widely.

The impacts of local lead laws are affected by factors including the local housing market, community awareness, and relevant state statutory and case law.

Many contextual factors affect the extent to which rental properties are maintained free of lead hazards (Korfmacher and Hanley 2013). State and federal laws shape the legal environment in which local policies operate; if they change, the effectiveness of the local policy may be affected. Owners’ property management practices are shaped by many factors. The local housing market determines whether investments in maintenance, renovations, or repairs can be recouped through rent. The availability of grants and loans may also subsidize property maintenance decisions. In communities with high levels of awareness of lead hazards, there may be stronger incentives to comply with local policies. Educating property owners about new policies and requirements may be more effective in cities with well-organized housing groups. In addition, sufficiency of government agencies’ resources to enforce the law or risk of legal liability for lead hazards may increase compliance.

Specialized legal enforcement approaches (e.g. “lead courts”) may increase the effectiveness of existing state or local laws.

Many states have laws either recommending or requiring certain children to have their blood tested for lead. When children are identified with elevated blood lead above a certain level, public health officials inspect their homes to identify lead hazards and order their remediation. In several cities in which compliance with these orders was low, specialized “lead courts” or enforcement efforts have been found to be effective in improving compliance. Since 2002, Philadelphia has had a special court focused on increasing compliance with health department-ordered lead hazard remediation (Campbell et al. (1) 2013; Campbell et al. (2) 2013).  Although such systems are based on “secondary prevention” (assessing and addressing lead hazards after a child is identified with elevated blood lead levels), they may serve a “primary prevention” function as well by preventing additional children from being exposed to those same lead hazards in the future (Brown, 2002).

Research on the impacts of local lead laws is limited, but suggests that local lead laws have the potential to significantly reduce housing-based lead hazards.

Of the many recently enacted local lead laws, systematic evaluation data is not yet available for any of them except Rochester, NY (Korfmacher et al 2012). Even in this case, it is not possible to conclusively attribute the observed decline in number of cases of elevated blood lead levels (EBLL) to this law alone (Kennedy et al 2014). Other factors, including changes in the housing market, demolition of high-risk housing, community education, and public health programs have also contributed to this trend. Furthermore, lead is a multi-media toxin, so changes in housing alone are unlikely to fully explain trends in population blood lead levels. Initial evaluation of the Rochester law, however, suggests that effectiveness of such systems depends on resources for implementation, enforcement/quality control, and education of community members, landlords, and housing interest groups (Korfmacher and Hanley, 2013; Korfmacher et al 2012).

References

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Local housing-based lead laws are one of many approaches to reducing childhood lead poisoning, including federal laws, enforcement efforts, ongoing local lead hazard control and grant programs, education, and the monitoring of blood lead levels. Although the evidence is limited, existing research suggests that local laws aimed at reducing lead hazards in housing have the potential to significantly reduce childhood lead poisoning.

To the extent that most local lead laws are targeted at housing with a high concentration of low income and minority children, these laws are likely to reduce the disproportionate burden of lead poisoning on these communities. The effectiveness of these laws depends on local factors, including existing housing inspection systems, government agency resources, community engagement, state-specific case and statutory law, and the local housing market.

Although it is not possible to identify a single ‘model law’ that is likely to be effective in all jurisdictions, Korfmacher and Hanley (2013) suggest a series of issues that should be considered in designing a locally-appropriate housing-based lead law:

• Distribution of lead hazards in housing: To what extent are lead hazards dispersed throughout the city versus clustered in neighborhoods that can be geographically targeted for implementation?  What is the appropriate target housing?

• Lead screening and childhood lead poisoning rates: What percentage of high-risk children receive blood lead tests?  How many have elevated blood lead levels?  Do the data suggest targeting a certain area or population?

• Public awareness:  Do residents, landlords, and community leaders understand the connection between lead poisoning and health, educational, and social outcomes?

• Economy/housing market:  Is the housing market strong enough to support new maintenance requirements?  Are there any financial assistance programs available to subsidize needed repairs?

• State statutory law environment: Does the locality have the authority to implement a local lead law? Does state law have provisions that can serve as a framework for local action?

• Case law: What are the relevant court rulings and settlements related to lead hazards, duty to maintain properties, inspections, and landlord liability?

• Implementation resources: What is the local government’s capacity for implementation and enforcement?  Can other government or community groups support implementation?

Many municipalities are considering developing local laws to target the continued problems of childhood lead poisoning in their communities. In order to continue to learn from experience and inform the development of effective approaches in the future, it is essential to monitor and evaluate the impacts of these varied local lead law innovations over time.