CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention 

Recommendations in “Low Level Lead Exposure Harms Children: A Renewed Call of 

Primary Prevention”

BACKGROUND 

In late 2010, the Centers for Disease Control and Prevention’s (CDC) Advisory Committee for 

Childhood Lead Poisoning Prevention (ACCLPP) formed a workgroup to evaluate new 

approaches, terminology, and strategies for defining elevated blood-lead levels (BLLs) among 

children. ACCLPP established the ad hoc Blood Lead Level workgroup on November 10, 2010. 

The charge of this workgroup was to: 

1. Recommend how to best replace the term, ‘level of concern,’ regarding accumulating 

scientific evidence of adverse effects of BLLs at < 10 μg/dL in children. 

2. Consider laboratory capability for measuring BLLs in establishing new guidance on 

childhood BLLs. 

3. Advise ACCLPP on how CDC should communicate advisories to groups affected by 

policy changes concerning: 

a. Interpretation of childhood BLLs and trends in childhood BLLs over time; 

b. Screening and follow-up screening intervals; 

c. Requirements and procedures for notifying parents or guardians concerning BLL 

test results; and,

d. Interventions known to control or eliminate lead exposure. 

June 7, 2012 NOTE: This version of the CDC response has been slightly modified from one 

released on May 13, 2012. This version reflects the verbatim recommendations made by the 

ACCLPP on January 04, 2012 and has been formatted to link each recommendation to its 

response. No other changes were made. 
On November 16–17, 2011, the ACCLPP met and deliberated on the ad hoc workgroup draft 

report. On January 4, 2012, the ACCLPP met and a majority approved the report, including the 

recommendations. 

In brief, the ACCLPP recommendations include: 

Elimination of the use of the term “blood lead level of concern” based on the compelling 

evidence that low BLLs are associated with IQ deficits, attention-related behaviors, and 

poor academic achievement. The absence of an identified BLL without deleterious 

effects, combined with the evidence that these effects appear to be irreversible,

underscores the critical importance of primary prevention. This strategy emphasizes 

preventing lead exposure rather than responding after the exposure has taken place.

ACCLPP recommends specific actions that CDC and other local, state, and federal 

agencies should take to shift priorities to primary prevention and provides guidance to 

respond to BLLs < 10 μg/dL in children. The ACCLPP recommends that CDC 

collaborate with these and other stakeholders, and provide advice and guidance. ACCLPP 

also recommends using a reference value based on the 97.5th percentile of the BLL 

distribution among children 1–5 years old in the United States (currently 5 μg/dL) to 

identify children with elevated BLLs using data generated by the National Health and 

Nutrition Examination Survey (NHANES). Approximately 450,000 children in the 

United States have BLLs higher than this reference value. 

Additional research is needed to develop and evaluate interventions that effectively 

maintain BLLs below the reference value in children. Other research priorities should 

include efforts that better use data from screening programs; develop next-generation,
point-of-care lead analyzers; and improve the understanding of epigenetic mechanisms of 

lead action. 

Herein we describe CDC’s response to each of the ACCLPP recommendations. The proposed 

methods to address recommendations are contingent on the availability of resources. In FY 2012, 

funding for CDC’s Childhood Lead Poisoning Prevention activities was reduced significantly 

from FY 2011. As a result, funding is not available for state and local Childhood Lead 

Poisoning Prevention Programs (CLPPPs). In many instances, these reductions limit CDC’s 

ability to fully implement many of these recommendations in the short term. This draft response 

was prepared by CDC’s National Center for Environmental Health (NCEH).

For the purpose of these responses:

Concur – We agree, and we have the funding, staff, and control over the means to implement the 

recommendation. The response provides potential strategies which are achievable within current 

FY 2012 or proposed FY 2013 resources.

Concur in principle – We agree, but we do not have the funding, staff, or control over the means 

to implement the recommendation. The response highlights strategies that have been shown to be 

effective, however a commitment to implement actions cannot be made due to our lack of control 

over available resources. 

Nonconcur – We disagree with the recommendations and provide the reasons for the 

disagreement.
CDC concurred or concurred in principle with all of the recommendations approved by the 

ACCLPP.
RECOMMENDATIONS

I. Recommendation: Based on the scientific evidence, the ACCLPP recommends that the term,

“level of concern”, be eliminated from all future agency policies, guidance documents, and 

other CDC publications, and that current recommendations based on the “level of concern” 

be updated according to the recommendations contained in this report.

Concur

Specific Means to Address or Implement

a. CDC will emphasize that the best way to end childhood lead poisoning is to prevent, 

control or eliminate lead exposures. Since no safe blood lead level in children has 

been identified, a blood lead “level of concern” cannot be used to define individuals 

in need of intervention.

b. In FY2012, CDC will discontinue using the term ‘level of concern’ in future 

publications and replace it with the reference value and the date of the NHANES that

was used to calculate the reference value. CDC also will make this standard language 

available to operating divisions across CDC and use the cross-clearance procedure to 

ensure that authors adopt this language.

c. Publications on the Web site (www.cdc.gov/nceh/lead) will use the terminology in 

place at the time of their publication. The CDC Lead statement 1975–1991 includes
an asterisked note that “these documents are being kept on this website for historical 

purposes and are no longer in print.” In FY2012, CDC will add the asterisk to the 

2005 statement and the footnote will be edited to include the words “These 

documents refer to various blood-lead thresholds and levels of concern for adverse 

health outcomes in children. This terminology is outdated and readers are referred to 

the ACCLPP recommendations of 2012.” A similar note will be applied to the 

document, “Managing Elevated Blood Lead Levels Among Children” (CDC, 2002)

that states: “This document refers to a blood-lead level of 10 μg/dL as the CDC level 

of concern for adverse health outcomes in children. This terminology is outdated and 

readers are referred to the ACCLPP recommendations of 2012. However, the 2012 

document does not recommend changes to the guidelines for the evaluation and 

treatment of children requiring chelation (BLLs ≥ 45 μg/dL) published here.”

Status: The statement will be placed on www.cdc.gov/nceh/lead no later than two weeks 

following agency clearance. A joint publication summarizing the ACCLPP recommendations 

and CDC’s response will be submitted jointly to the Morbidity Mortality Weekly Review and the 

journal, Pediatrics, no later than May 2012. 

II. Recommendation: CDC should use a childhood BLL reference value based on the 97.5th 

percentile of the population BLL in children ages 1-5 (currently 5 μg/dL) to identify children 

and environments associated with lead-exposure hazards. The reference value should be 

updated by CDC every four years based on the most recent population based blood lead 

surveys among children.
Concur in principle

Specific Means to Address or Implement

In FY12, CDC will:

a. Use the reference value in recommendations that involve follow-up evaluation of 

children after BLL testing.

b. Use the reference value as defined to identify high-risk childhood populations and 

geographic areas most in need of primary prevention.

c. Provide this information, including specific high-risk areas, to a wide variety of 

federal, state, and local government agencies and nongovernment organizations 

interested in lead-poisoning prevention.

In addition, CDC will update the value every 4 years using the two most recent NHANES 

surveys. The updated reference value will be posted at www.cdc.gov/nceh/lead and widely 

distributed through various Web-based LISTSERV sites, pediatric associations, and partners at 

the federal, state, and local level. Updated reference values will be reported in the National 

Report on Human Exposures to Environmental Chemicals and other relevant journals.

Status: CDC’s National Center for Health Statistics (NCHS) will continue to monitor BLLs in 

the United States and make data tapes available on its Web site for public use at 2-year intervals.
CDC publications will use the reference value to provide guidance to clinical health care 

providers and others as these publications are prepared. Broader dissemination through Web

sites, notices to clinical pediatric care providers, and the MMWR will be considered by CDC in 

the future. 

III. Recommendation: CDC should develop and help implement a nationwide primary 

prevention policy to ensure that no children in the U.S. live or spend significant time in 

homes, buildings or other environments with lead-exposure hazards.

Concur in Principle

Specific Means to Address or Implement

CDC recognizes the value of primary prevention. As feasible, CDC will develop strategies and 

guidelines for primary prevention. Implementation of primary-prevention programs is not 

currently practicable.

Status: CDC may examine the possibilities of working with the U.S. Department of Housing and 

Urban Development (HUD), the Health Resources and Services Administration (HRSA), state 

and local governments, and philanthropic organizations to identify opportunities for 

collaboration on primary prevention in the future.

IV. Recommendation: Clinicians should be a reliable source of information on lead hazards 

and take the primary role in educating families about preventing lead exposures. This includes 
recommending environmental assessments PRIOR to blood lead screening of children at risk 

for lead exposure.

Concur in Principle

Specific Means to Address or Implement

Although this recommendation is directed to clinicians, CDC may play a supportive role in 

enhancing the recommendation by working with providers to provide educational material. Some 

currently available resources can be used to update CDC/ATSDR documents to reflect the 

primacy of clinical health care providers in educating families about preventing lead exposure.

For example, revisions to the ATSDR Lead Toxicity Case Study (available at 

http://www.atsdr.cdc.gov/csem/csem.html) are scheduled for 2012, and these changes can be 

incorporated.

Status: Full implementation contingent on funding

V. Recommendation: Clinicians should monitor the health status of all children with a 

confirmed BLL ≥5 μg/dL for subsequent increase or decrease in BLL until all recommended 

environmental investigations and mitigation strategies are complete, and should notify the 

family of all affected children of BLL test results in a timely and appropriate manner. 

Concur in Principle

Specific Means to Address or Implement
Although this recommendation is directed to clinicians, CDC may play a supportive role in 

enhancing the recommendation by working with clinical care providers and professional 

organizations to achieve this goal. Ensuring that children with BLLs > 5 μg/dL can be retested is 

feasible within the current resources because these tests are covered by Medicaid and many 

private health care insurance providers. As discussed earlier, some provider training will be 

conducted.

Status: Full implementation contingent on funding

VI. Recommendation: Clinicians should ensure that BLL values at or above the reference 

value are reported to local and state health and/or housing departments if no mandatory 

reporting exists and collaborate with these agencies in providing the appropriate services and 

resources to children and their families.

Concur in Principle

Specific Means to Address or Implement

Although this recommendation is directed to clinicians, CDC may play a supportive role in 

enhancing the recommendation through CDC’s continued work with testing laboratories, pointof-care instrument manufacturers, and clinical health care providers to ensure the availability of 

high-caliber laboratory services. In addition, most of the state CLPPPs funded by CDC have 

mandatory reporting laws in place, and those that do not are required to implement such laws 

during this year of funding.
Status: Full implementation contingent on funding

VII. Recommendation: Educate families, service providers, advocates, and public officials on 

primary prevention of lead exposure in homes and other child-occupied facilities, so that lead 

hazards are eliminated before children are exposed.

Concur in Principle

Specific Means to Address or Implement

In FY12, CDC will provide available educational materials through its Web site, and seek the 

assistance of partner agencies and organizations to implement this recommendation. In FY 

2012, funding is not available for state and local CLPPPs.

Status: Implementation contingent on funding

VIII. Recommendation: CDC should encourage local, state, and other federal agencies to: (a) 

facilitate data-sharing between health and housing agencies, (b) develop and enforce 

preventive lead-safe housing standards for rental and owner-occupied housing, (c) identify 

financing for lead hazard remediation, and (d) provide families with the information needed to 

protect their children from hazards in the home.

Concur in Principle (a.-c.)

Specific Means to Address or Implement
a. In FY12, CDC will continue to recommend that health and housing agencies share 

data that can be used to identify geographic areas where lead-exposure risk is high. In 

the future, CDC can explore strategies to facilitate data sharing between health and 

housing agencies. If funds for CLPPPs become available, CDC will require data 

sharing between CLPPPs and housing agencies in all CLPPP grant programs.

b. CDC has developed guidelines for lead-safe housing and in FY2012 will encourage 

local, state, and federal agencies to enforce these standards.

c. HUD Lead Hazard Control Program provides approximately $100 million annually 

and is the most easily identifiable and largest source of federal funding for leadhazard remediation. Many CLPPPs help property owners complete the HUD 

application process, help to identify alternative funding sources, and negotiate with 

local banks. In FY 2012, however, funding is not available for state and local 

CLPPPs.

Concur (d.)

Specific Means to Address or Implement

d. These materials currently exist and are distributed through a wide variety of 

networks. Future development of new materials could be considered by CDC in the 

future.

Status: Implementation contingent on funding
IX. Recommendation: Elected officials and the leaders of health, housing, and code

enforcement agencies can help protect the children in their jurisdictions from lead exposure in 

their homes through many activities. CDC should work with officials to ensure adoption of a 

suite of preventive policies.

Concur in Principle 

Specific Means to Address or Implement

In the future, CDC could consider educating state and local elected officials about the 

importance of primary prevention and evidenced-based strategies at a national level. In FY 2012, 

funding is not available for state and local CLPPPs.

Status: Full implementation contingent on funding

X. Recommendation: CDC should (a) emphasize the importance of environmental assessments 

to identify and mitigate lead hazards before children demonstrate BLLs at or higher than the 

reference value and (b) adopt prevention strategies to reduce environmental lead exposures in 

soil, dust, paint, and water before children are exposed.

Concur (a.)

Specific Means to Address or Implement
a. For more than 20 years CDC has emphasized the importance of environmental 

assessment and mitigation of lead hazards before children are exposed (before their 

BLLs are at or higher than the reference value) through policies, cooperative 

agreements, interagency agreements, and publications. CDC will continue these 

efforts.

Status: Ongoing

Concur in Principle (b.)

Specific Means to Address or Implement

b. In FY12 and FY13, CDC will work with federal agencies that may also be affected by 

these recommendations including, but not limited to, HUD and the Environmental 

Protection Agency (EPA). The goal of the summit will be to develop primary 

prevention strategies. In FY 2012, funding is not available for state and local 

CLPPPs. 

Status: Full implementation contingent on funding

XI. Recommendation:

If lead hazards trigger a response in any unit in a multi-family housing complex, the same 

response action should be applied to all similar untested units in the housing complex, unless 

a risk assessment demonstrates that no lead hazards are present in the other units.
(Note: During editing of this document, the wording of this recommendation was changed in the CDC 

response to the ACCLPP recommendations. On May 23, 2012 this error was corrected and the wording is 

now the same as that in the original ACCLPP recommendations.)

Concur in Principle

Specific Means to Address or Implement

CDC concurs with the evidence that a building that houses one child with lead poisoning is an 

indication that other children in that building are likely at risk. In the future, CDC may explore 

implementing recommendations for increased inspections. 

Status: Implementation contingent on funding

XII. Recommendation: CDC should encourage additional research directed towards 

developing interventions capable of maintaining children’s BLLs lower than the reference 

value.

Concur in Principle

Specific Means to Address or Implement

CDC will work with the National Institute of Environmental Health Sciences (NIEHS) and 

academic partners to encourage research. This research will be designed to develop and evaluate 

effective, broadly useful interventions that are effective in the complex lead-exposure situations 
that are commonly encountered. In the future, CDC may explore strategies to support additional 

research.

Status: NIEHS is working with other partners to foster collaboration on developing a research 

agenda that will address the spirit of the recommendation. In the future, CDC may explore 

strategies to support additional research.

XIII. Recommendation: Additional research priorities should include improve the use of data 

from screening programs, develop next generation point-of-care lead analyzers, and improve 

the understanding of epigenetic mechanisms of lead action.

Concur

Specific Means to Address or Implement

As funding permits, CDC will work with NIEHS, academic partners, and laboratory instrument 

manufacturers to encourage research in these important areas.

Status: There is ongoing interaction with NIEHS and others to foster collaboration on developing 

a research agenda.