Children’s Health and the Environment 

in North America

A First Report on Available 

Indicators and Measures 

Country Report: United States 

Prepared by the US Environmental Protection Agency 

December 2005 
2 

Table of Contents 

Executive Summary...................................................................................3

1 Introduction.......................................................................................5

1.1 Context Indicators........................................................................... 9

2 Asthma and Respiratory Disease..................................................15

2.1 Outdoor Air Pollution.................................................................... 15

2.2 Indoor Air Pollution....................................................................... 24

2.3 Asthma ........................................................................................... 29

3 Lead and Other Chemicals, Including Pesticides........................35

3.1 Blood Lead Levels......................................................................... 35

3.2 Lead in the Home .......................................................................... 43

3.3 Industrial Releases of Lead.......................................................... 45

3.4 Industrial Releases of Selected Chemicals ................................ 48

3.5 Pesticides....................................................................................... 53

4 Waterborne Diseases .....................................................................57

4.1 Drinking Water............................................................................... 57

4.2 Sanitation ....................................................................................... 62

4.3 Waterborne Diseases.................................................................... 62

5 Opportunities for Improvement.....................................................66

5.1 Indicators Related to Asthma and Respiratory Disease ........... 66

5.2 Indicators Related to the Effects of Lead and Chemicals, 

Including Pesticides...................................................................... 66

5.3 Indicators Related to Waterborne Diseases ............................... 67

6 References ......................................................................................68

Appendix 1 US Metadata for the Indicators ...................................74

Appendix 2 Indicators Steering Group – United States ................92
3 

Executive Summary 

Children’s Health and the Environment in North America: A First Report on Available Indicators and 

Measures is the United States’ contribution to the development of children’s environmental health 

indicators for North America. Children’s environmental health indicators provide quantitative information 

that can improve understanding of children’s health and the environment. The aim is to increase 

awareness of the relationship between environmental issues and children’s health and to provide a 

means of measuring trends, assist in assessing the effectiveness of interventions and policy, and help 

identify priorities for further research and policies. 

Context 

Children under the age of 18 accounted for about 26 percent of the US population, with approximately 72 

million children in 2000. Over the last decade, the overall well-being of America's children has shown 

gains in some areas but has declined in others. The teen birth rate is at a new low, youth are less likely to 

become the victims of violent crimes, and the death rate has declined for children and young teens. 

There has been a small increase in the percentage of low birthweight infants, the percentage of infants 

who die before their first birthday, and the percentage of children who are living in poverty. 

Key Findings for Children’s Environmental Health Indicators 

Asthma and Respiratory Diseases 

Outdoor Air Pollution 

• The highest number of exceedances of National Ambient Air Quality Standards is consistently 

reported for ozone. In 1990, approximately 55 percent of children lived in counties in which the 

eight-hour ozone standard was exceeded on at least one day per year. In 2003, approximately 58 

percent of children lived in such counties. 

• The percentage of children living in counties that exceeded the annual Particulate Matter 2.5 

microns or greater (PM2.5) air quality standard decreased from 30 percent in 1999 to 

approximately 19 percent in 2003. 

• In 1990, about 2 percent of children lived in counties that exceeded the three-month air quality 

standard for airborne lead. In 2003, only one county, with less than 0.1 percent of US children, 

had airborne lead measurements that exceeded the standard for lead. 

Indoor Air Quality 

• The percentage of children ages 6 and under who are regularly exposed to environmental 

tobacco smoke in the home decreased from 27 percent in 1994 to 11 percent in 2003. 

• The percent of children ages 4 to 11 with cotinine in their blood, a marker for exposure to 

environmental tobacco smoke, decreased from 88 percent in 1988–94 to 64 percent in 1999–

2000.. 

Asthma 

• Between 1980 and 1996, the percentage of children with asthma ranged from 3.6 percent to 6.2 

percent, representing an annual increase of 4.3 percent per year during that period. 

• In 2003, about 9 percent of children reported currently having asthma. These include children 

with active asthma symptoms and those whose asthma is well-controlled. 

• In 2003, about 13 percent of children had been diagnosed with asthma at some time in their lives, 

though some of those children may no longer have asthma. 
4 

Effects of Lead and Other Chemicals, Including Pesticides 

Lead 

• The median concentration of lead in the blood of children 5 years old and under dropped from 15 

micrograms per deciliter (μg/dL) in 1976–80 to 1.7 μg/dL in 2001–2002, a decline of 89 percent. 

• The decline in blood lead levels is due largely to the phasing out of lead in gasoline between 

1973 and 1995 and some to the reduction in the number of homes with lead-based paint from 64 

million in 1990 to 38 million in 2000. Some decline also resulted from regulations reducing lead 

levels in drinking water, legislation banning lead from paint, restricting the content of lead in 

solder, faucets, pipes, and plumbing, and elimination or reduction of lead in food and beverage 

containers and ceramic ware, and in products such as toys, mini-blinds, and playground 

equipment. 

• In 1999–2000 the median blood lead level in children ages 1–5 was 2.2 μg/dL. The median blood 

lead level for children living in families with incomes below the poverty level was 2.8 μg/dL and for 

children living in families above the poverty level it was 1.9 μg/dL. 

• In 1999–2000, White non-Hispanic children ages 1–5 had a median blood lead level of about 2 

μg/dL, unchanged from the level in 1992–1994. In 1992–94, Black non-Hispanic children ages 1–

5 had a median blood lead level of 3.9 μg/dL and in 1999–2000 they had a median blood lead 

level of 2.8 μg/dL. In 1992–94, Hispanic children ages 1–5 had a median blood lead level of 2.6 

μg/dL and in 1999–2000 they had a median blood lead level of 2.0 μg/dL. 

• In 1998–2000, 40 percent of houses in the United States had paint that had some lead in it. 

Twenty-five percent of houses in the United States had a significant lead based paint hazard, 

which could be from deteriorating paint, contaminated dust, or contaminated soil outside the 

house. 

Industrial Releases of Chemicals 

• The total industrial facilities reporting releases of the 153 “matched” chemicals decreased over the 

reporting period of 1998 to 2002 as did the total releases which went from 1,450,616 tonnes 

(metric tons) in 1998 to 1,284,757 tonnes in 2002, a decrease of 11 percent. There were 

reductions in releases to on-site air, water and underground injection with on-site land and off-site 

releases reporting the only increase. “Matched chemicals” are from a data set compiled by the CEC in 

which only chemicals that are reported by both Canada NPRI and the US TRI are included.

Pesticides 

• Between 1994 and 2001, the percentage of food samples with detectable organophosphate 

pesticide residues ranged between 19 percent and 29 percent. The highest detection rates were 

observed during 1996 and 1997, while the lowest detection rate was observed in 2001. 

Waterborne Diseases 

Drinking Water 

• The percentage of children served by public water systems that reported exceeding a Maximum 

Contaminant Level (MCL) or violated a treatment standard decreased from 20 percent in 1993 to 

8 percent in 1999. 

• In 1993, approximately 22 percent of children lived in an area served by a public water system 

that had at least one major monitoring and reporting violation. This figure decreased to about 10 

percent in 1999. 

Waterborne Diseases 

• Between 1971 and 2000, there were 751 voluntarily reported waterborne disease outbreaks 

associated with drinking water from individual, non-community systems, and community water 

systems. 
5 

1 Introduction 

Children’s Health and the Environment in North America: A First Report on Available Indicators and 

Measures is the United States’ contribution to the development of children’s environmental health 

indicators for North America. Children’s environmental health indicators provide quantitative information 

that can improve understanding of children’s health and the environment. The aim is to increase 

awareness of the relationship between environmental issues and children’s health and to provide a 

means of measuring trends, assist in assessing the effectiveness of interventions and policy, and help 

identify priorities for further research and policies. 

Environmental contaminants can affect children quite differently than adults, both because children may 

be more highly exposed to contaminants and because they may be more vulnerable to the toxic effects of 

contaminants. Children generally eat more food, drink more water, and breathe more air relative to their 

size than adults do, and consequently may be exposed to relatively higher amounts of contaminants. 

Children’s normal activities, such as putting their hands in their mouths or playing on the ground, can 

result in exposures to contaminants that adults do not face. In addition, environmental contaminants may 

affect children disproportionately because their immune defenses are not fully developed and their 

growing organs are more easily harmed. 

In June 2002, the environment ministers of Canada, Mexico and the United States, members of the 

Council of the Commission for Environmental Cooperation (CEC), agreed to a Cooperative Agenda to 

protect children from environmental risks. The Cooperative Agenda committed the three countries to 

selecting and publishing a core set of indicators of children's health and the environment for North 

America. The core set of indicators were based on the three priority areas that are associated with illness 

and death in North American children identified by the CEC Council: 

 Asthma and Respiratory Diseases 

 Effects of Lead and Other Toxics Substances 

 Water-borne Diseases 

A Steering Group was established from the three countries and it recommended the use of the World 

Health Organization’s (WHO) Multiple Exposure – Multiple Effect (MEME) model (see Figure 1.1) as the 

guiding framework for developing children’s environmental health indicators. The MEME model illustrates 

the complex interactions between the environment and children’s health. The MEME model highlights the 

fact that environmental exposures and health outcomes are based on many links between the 

environment and health and are rarely based on simple, direct relationships. The model illustrates that 

environmental exposures and health outcomes are influenced by social, economic and demographic 

factors (context). These factors are among a number of factors that are known to influence health 

outcomes and are frequently referred to as determinants of health. 
6 

Figure 1.1: The MEME model 

The Steering Committee also recommended that the three countries report a set of initial 12 indicators of 

children’s health and the environment based on the four priority areas identified by the CEC Council 

(Table 1.1). The indicators presented by the US are shown alongside. 

Table 1.1: Children’s health indicator priority areas identified by the CEC council, the 12 target 

indicators and the US indicators presented in this report 

Asthma and Respiratory Disease

Issue area Current Indicator Purpose of Indicator 

Indicator Used in the 

US Report 

Percentage of children 

living in counties in 

which air quality 

standards were 

exceeded in the United 

States, 1990–2003 

Outdoor Air Pollution Percentage of children 

living in areas where air 

pollution levels exceed 

relevant air quality 

standards 

To provide information 

on children’s potential 

exposures to outdoor air 

pollution, with a focus 

on common air 

contaminants 

Percentage of children’s 

days with good, 

moderate, or unhealthy 

air quality, 1990–1999 

Well-being

Morbidity 

Mortality 

Exposure 

Ambient 

environment 

Community 

Home 

Health outcome

Preventive 

actions 

Remedial 

actions 

Actions

Contexts

Distal 

Proximal 

Less 

severe 

More 

severe 

Social conditions

Economic conditions 

Demographic conditions 

causes or 

is 

associated 

with 

attributable 

to or is 

associated 

with 

Figure 1.1:The MEME model 

The Multiple Exposure-Multiple Effect (MEME) model emphasizes the many-to-many links 

between environment and health. Exposures, in different environmental settings (on the left) 

lead to many different health effects (on the right). Individual health effects (on the right) can 

be traced back to many different exposures (on the left). Both exposures and health 

outcomes—as well as the associations between them—are affected by contextual conditions, 

such as social, economic or demographic factors.Actions can be targeted at either exposures 

or health outcomes (and in the longer term, also, at the underlying contexts).1
7 

Percentage of children 

ages 6 and under 

regularly exposed to 

secondhand smoke in 

US homes, 1994–2003 

Indoor Air Pollution Measure of children 

exposed to 

environmental tobacco 

smoke (Canada, United 

States); measure of 

children exposed to 

emissions from the 

burning of biomass fuels 

(Mexico) 

To provide information 

on children’s potential 

exposures to indoor air 

pollution, with a focus 

on environmental 

tobacco smoke and 

emissions from the 

burning of biomass fuels

Percentage of children 

ages 4-11 with 

detectable blood 

cotinine by race and 

ethnicity, 1988–94 and 

1999–2000 

Percentage of children 

with asthma in the 

United States, 1980–

2003 

Asthma Prevalence of asthma in 

children 

To track asthma in 

children 

Percentage of children 

having an asthma attack 

in the previous 12 

months, by 

race/ethnicity and family 

income, 1997–2000 

Effects of Exposure to Lead and Other Toxic Substances

Issue area Current Indicator Purpose of Indicator 

Indicator Used in the 

US Report 

Concentrations of lead 

in the blood of children 

five and under in the 

United States, 1976–

2002 

Distribution of 

concentrations of lead in 

blood of children ages 

1-5 in the United States, 

1999–2000 

Lead Body Burden Blood lead levels in 

children 

To provide information 

on children’s exposure 

to lead

Median concentrations 

of lead in blood of 

children ages 1-5, by 

race/ethnicity and family 

income, 1999–2000 

Lead in the Home Percentage of children 

living in homes with a 

potential source of lead 

To provide information 

on children’s potential 

exposure to sources of 

lead in the home

Lead in US housing, 

1998–2000 

Industrial Releases of 

Lead

Pollutant release and 

transfer register (PRTR) 

data on industrial 

releases of lead 

To provide information 

on industrial releases of 

lead 

On- and off-site 

industrial releases of 

lead (and its 

compounds) in the 

United States, 1995–

2000
8 

On- and off-site 

industrial releases of 

matched chemicals in 

the United States, 

1998–2002 

On- and off-site 

releases of matched 

chemicals from major 

industrial sources, in the 

United States, 1998–

2002 

Industrial Releases of 

Selected Chemicals

PRTR data on industrial 

releases of 153 

chemicals 

To provide information 

on industrial releases of 

selected chemicals

Total on- and off-site 

releases of matched 

chemicals, by industry 

sector, in the United 

States, 1998–2002 

Pesticides Pesticide residues on 

foods 

To provide information 

on children’s potential 

exposure to pesticides

Percentage of fruits, 

vegetables, and grains 

with detectable residues 

of organophosphate 

pesticides, 1994–2001 

Waterborne Diseases

Issue Area Current Indicator Purpose of Indicator 

Indicator Used in the 

US Report

Percentage of children 

living in areas served by 

public water systems 

that exceeded a 

drinking water standard 

or violated a treatment 

requirement, 1993–

1999 

Drinking Water (a) Percentage of 

children (households) 

without access to 

treated water 

(b) Percentage of 

children living in areas 

served by public water 

systems in violation of 

local standards 

To provide information 

on the percentage of 

children potentially 

exposed to 

contaminants and 

pathogens in drinking 

water 

Percentage of children 

living in areas served by 

public water systems 

with major violations of 

drinking water 

monitoring and reporting 

requirements in the 

United States, 1993–

1999 

Sanitation Percentages of children 

(households) that are 

not served by sanitary 

sewers 

To provide information 

on the percentage of 

children who are 

potentially exposed to 

untreated sewage in 

their immediate 

surroundings

Not provided 
9 

Waterborne Diseases (a) Morbidity: number of 

cases of childhood 

illnesses attributed to 

waterborne diseases 

(Canada, Mexico, 

United States) 

(b) Mortality: number of 

child deaths attributed 

to waterborne diseases 

(Mexico) 

To provide information 

on children who have 

been sick from or have 

died as a result of 

waterborne diseases

Waterborne disease 

outbreaks by year and 

type of water system in 

the United States, 

1971–2000 

1.1 Context Indicators 

The effects of environmental exposures and health outcomes are influenced by social, economic, and 

demographic factors. Socioeconomic factors, such as family income and parental education, can 

influence a child’s health status. For example, children living in poverty are more likely to suffer certain 

health effects and may be less likely to have access to care than are children living in middle- or upperclass homes. In addition, the health status of children can influence a child’s response to environmental 

contaminants. For example, children with existing asthma can be more sensitive to exposure to air 

pollution. This section provides a set of common indicators used by Canada, the United States, and 

Mexico to provide basic information on child well-being and demographics. 

1.1.1 Overview of Population Demographics 

In the United States, 28 percent of its 281 million citizens were 19 years of age or under as of 2000. (See 

Figure 1.2 below and Vol. 1) This is a reduction from the peak at the end of the baby boom in 1964, 

when children comprised 36 percent of the population. Children (defined in this report as under the age of 

18, unless otherwise indicated) are projected to be 24 percent of the population by 2020.2 The current 

child population in the United States is evenly distributed among the age groups 0–4, 5–9, 10–14, and 

15–19. (Table 1.2) 
10 

Figure 1.2: Population Pyramid for the United States, 2000 

Population (millions)

Age

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80+ Male Female 

15 0 10 5 5 10 15

Source: U.S. Census Bureau 

The crude birth rate in the United State fell 16 percent from 16.7 births per 1,000 persons in 1990 to 14.1 

in 2001. During this time, the rate declined in all by 2 years (1998 and 2000). Between 1990 and 1997, 

the rate fell 15 percent accounting for most of the decline. The most striking decline in birth rate has been 

among teenagers of ages 15 to 19, which dropped steadily since 1991 to a record low of 24.7 births per 

1,000 among teenagers of ages 15 to 17 in 2002. The steepest decline has been among Black, nonHispanic adolescents who experienced a decline of more than half between 1991 and 2002 (from 86 to 

41 per 1,000, respectively). The birth rate for older teenagers also declined during this period but the 

decline was more moderate.3

 

Table 1.2: US Child Population by Age Group, 2000 

Age Population (millions) 

0–4 19.2 

5–9 20.2 

10–14 20.6 

15–19 20.3 

Source: US Census Bureau 

http://www.census.gov/cgi-bin/ipc/idbsum?cty=US

*Note that the Census does not provide an age 

breakdown for 18 and under to correspond with this 

report’s definition of children. 

1.1.2 Overview of Child Mortality and Morbidity 

In the United States, infant mortality rates (infants are defined as less than one year old) were 6.9 deaths 

per 1000 live births in 2000, while child mortality for children 1 to 4 years was 0.3 per 1000 in the same 

year. Table 1.3 shows the leading causes of child mortality in the United States for various age groups. 
11 

The leading cause of mortality for children up to one year was congenital malformations, deformations 

and chromosomal abnormalities. After the first year of life, the primary cause of death for US children 1 to 

17 years of age is unintentional injuries (e.g., accidents and poisonings, though homicide/suicide are 

included in addition to injuries for ages 15 to 19). For children 15 to 19 years of age, the leading cause of 

death were injuries including homicide and suicide. Table 1.4 shows the leading causes of 

hospitalizations. The leading cause of hospitalization for ages 1-9 years of age was respiratory disease 

and the leading cause of hospitalization for children 10–14 years of age was mental disorders. Lastly, for 

15 to 19-year-olds, the leading cause of hospitalization in the United States was pregnancy/childbirth. 

Note that unless otherwise indicated, this report defines “children” as under the age of 18. Table 1.5 

provides additional general indicators of children’s health. 

Table 1.3: Leading Causes of Child Mortality in the United States, by Age Group, 2000 

Age Top Three Causes of Mortality 

0–1 1. Congenital malformations, deformations, and chromosomal abnormalities 

2. Disorders related to short gestation and low birth weight 

3. Sudden Infant Death Syndrome 

1–4 1. Unintentional injuries 

2. Birth defects 

3. Cancer 

5–14 1. Unintentional injuries 

2. Birth defects 

3. Cancer 

15–19 1. Injuries (including homicide/suicide) 

2. Birth defects 

3. Cancer 

Source: 

Ages 0-1: Centers for Disease Control and Prevention, 2002, Infant mortality statistics from the 2000 

period linked birth/infant death data set. National Vital Statistics Reports, 50 (12). 

http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_12.pdf. 

Ages 1-14: Federal Interagency Forum on Child and Family Statistics, America’s Children 2003 

http://www.childstats.gov/ac2003/indicators.asp?IID=126&id=4; 

Adolescents: Federal Interagency Forum on Child and Family Statistics, America’s Children 2003 

http://www.childstats.gov/ac2003/indicators.asp?IID=130&id=4
12 

Table 1.4: Leading Causes of Child Hospitalizations in the United States, by Age Group, 2000 

Age Top Three Causes of Hospitalizations 

1–4 1. Respiratory diseases 

2. Endocrine, nutritional, and metabolic diseases and immunity disorders 

3. Infectious and parasitic diseases 

5–9 1. Respiratory diseases 

2. Diseases of the digestive system 

3. Accidents 

10–14 1. Mental disorders 

2. Diseases of the digestive system 

3. Injury 

15–19 1. Pregnancy/childbirth 

2. Mental disorders 

3. Injury 

Source: Maternal and Child Health Bureau, US Department of Health and Human Services, 2003. 

Child Health USA 2002. http://www.mchirc.net/HTML/CHUSA-02/main_pages/page_30.htm
13 

Table 1.5: General Children’s Health Indicators, 2000 

Rate Source 

Infant Mortality* 6.9 per 1,000 live births 

US Centers for Disease Control and 

Prevention, National Center for Health 

Statistics 

http://www.cdc.gov/nchs/data/hus/tables/20

03/03hus002.pdf

Perinatal Mortality** 6.9 per 1,000 live births 

US Centers for Disease Control and 

Prevention, National Center for Health 

Statistics 

http://www.cdc.gov/nchs/data/hus/tables/20

03/03hus002.pdf

Child Mortality (ages 

1-4 years) 

32 per 100.000 children aged 1-4 

years Federal Interagency Forum on Child and 

Family Statistics, America’s Children 2003

http://www.childstats.gov/ac2003/indicators.

asp?IID=126&id=4

Immunization 

Combined series*** 76% Federal Interagency Forum on Child and 

Family Statistics, America’s Children 2003

http://www.childstats.gov/ac2003/tbl.asp?iid

=123&id=4&indcode=HEALTH4

Measles only 91% Federal Interagency Forum on Child and 

Family Statistics, America’s Children 2003

http://www.childstats.gov/ac2003/tbl.asp?iid

=123&id=4&indcode=HEALTH4

*Infant death is defined as the death of a live-born child before its first birthday. 

** Perinatal death is defined as death around the time of birth, including late fetal death as well as infant 

death within 7 days of birth. 

****Vaccinations in the combined series are 4 doses of a vaccine containing diphtheria and tetanus toxoids 

(either diphtheria, tetanus toxoids, and pertussis vaccine [DTP] or diphtheria and tetanus toxoids vaccine 

[DT]), 3 doses of polio vaccine, 1 dose of a measles-containing vaccine (MCV), and 3 doses of Haemophilus 

influenzae type b (Hib) vaccine. The recommended immunization schedule for children is available at 

http://www.cdc.gov/nip/recs/child-schedule.pdf. 

1.1.3 Socioeconomic Information and Other Determinants of Health 

Socioeconomic factors, such as family income and parental education, are important social determinants 

of child health. In addition, particular racial or ethnic groups can be at higher risk for certain childhood 

diseases. Children who have lower socioeconomic status may also be more exposed to environmental 

pollutants. Similarly, children of different race and ethnic groups may be at higher risk for certain 

environmental hazards. 
14 

In 2000, Non-Hispanic White children made up 60.9 percent of the US child population, Hispanic children 

made up 17.1 percent, Non-Hispanic Black children made up 14.7 percent, Asian and Pacific Islanders 

made up 3.4 percent, and Native American and Alaska Natives made up 1.2 percent.4

In the United States, 21.7 percent of children were born to mothers with less than 12 years of education in 

2000 (Table 1.6).5

 The proportion of children living in absolute poverty (living under nationally defined 

poverty level) in 2000 was 16.1 percent. 

In 2002, the number of children under 18 in poverty was 12.1 million, up from 11.7 million in 2001. 

Children represented a larger share of the people in poverty (35.1 percent), than represented in the 

overall population (one-fourth of total population). In 2002, the poverty rate for related children under 6 

was 18.5 percent, unchanged from 2001.5

As part of the North American Indicators effort, all three countries are reporting on the same 

socioeconomic information, including maternal educational level, the proportion of children living in 

poverty, and the percentage of the population living in urban and rural areas. In addition, racial and ethnic 

information is provided above, since race and ethnicity are important determinants of health. 

Table 1.6: Determinants of Health 

Maternal Educational Level, 

2000 

Proportion of Children Living 

in Poverty, 2000 

Percentage of Population Living 

in Urban/Rural Areas, 2000 

Less than 12 years of 

education: 21.7 percent of live 

births 

At least 16 years of 

education: 24.7 percent of live 

births 

Children living in absolute 

poverty (living under 

nationally defined poverty 

level): 16.1% of total population 

under age 18. 

Children living in relative 

poverty (families in the 

lowest income quintile):

22.6%. 

Urban: 79% 

Rural: 21% 

Source: Centers for Disease 

Control and Prevention, 

National Center for Health 

Statistics, National Vital 

Statistics System, Birth Files. 

http://www.cdc.gov/nchs/data/h

us/tables/2003/03hus010.pdf

Source: US Census Bureau 

Absolute poverty: 

http://ferret.bls.census.gov/mac

ro/032001/pov/new25_003.htm

Relative poverty: 

Calculated from Census data. 

Source: US Census Bureau 

http://factfinder.census.gov/servlet/

DTTable?ds_name=D&geo_id=D&

mt_name=DEC_2000_SF1_U_P00

2&_lang=en

Additional indicators on child well-being that relate to health, economic, and social measures where 

children live can be found in America’s Children in Brief: Key National Indicators of Well-Being, 2004, 

which provides a useful context on the health of America’s children.2
15 

2 Asthma and Respiratory Disease 

2.1 Outdoor Air Pollution 

Common (Criteria) Air Pollutants 

Air pollution contributes to a wide variety of adverse health effects. Six of the most common air 

pollutants—carbon monoxide, lead, ground-level ozone, particulate matter, nitrogen dioxide, and sulfur 

dioxide—are known as “criteria” pollutants because the US EPA uses health-based criteria as the basis 

for setting permissible levels of these pollutants in the atmosphere. 

EPA periodically conducts comprehensive reviews of the scientific literature on health effects associated 

with exposure to the criteria air pollutants. The resulting “criteria documents” critically assess the scientific 

literature and serve as the basis for making regulatory decisions about whether to retain or revise the 

National Ambient Air Quality Standards (NAAQS) that specify the allowable concentrations of each of 

these pollutants in the air. The standards are set at a level that protects public health with an adequate 

margin of safety. However, the standards are not “risk free.” Even in areas that meet the standards, there 

may be days when unusually sensitive individuals, including children, experience health effects related to 

air pollution. This is especially the case for pollutants such as ozone and particulate matter that do not 

have discernible thresholds below which health effects are absent. 

Some of the standards are designed to protect the public from adverse health effects that can occur after 

being exposed for a short time, such as one hour or one day. Other standards are designed to protect 

people from health effects that can occur after being exposed for a much longer time, such as a year. For 

example, current standards for carbon monoxide are for short-term periods of one hour and eight hours. 

By contrast, the current standard for nitrogen dioxide is for one year. Some pollutants have both shortterm and long-term standards. 

Ground-level Ozone 

Short-term (also known as “acute”) exposure to ground-level ozone can cause a variety of respiratory 

health effects, including inflammation of the lung, reduced lung function, and respiratory symptoms such 

as cough, chest pain, and shortness of breath. It also can decrease the capacity to perform exercise.6

Exposure to ambient concentrations of ozone also has been associated with the exacerbation of asthma, 

bronchitis, and respiratory effects serious enough to require emergency room visits and hospital admissions.6

 Some evidence suggests that high ozone concentrations may contribute to increased mortality.6

Health effects associated with long-term (also known as “chronic”) exposure to ozone are not as well 

established and documented as health effects associated with short-term exposure, but long-term 

exposures also are of concern. In 1996, EPA’s criteria document for ozone concluded that there was 

insufficient evidence to determine whether health effects resulted directly from long-term exposure, 

although the evidence suggested that long-term ozone exposure, along with other environmental factors, 

could be responsible for health effects.6

 Since 1996, a few studies suggest that long-term exposure to 

ozone is associated with decreases in lung function in humans,7

 increased prevalence of asthma,8

increased development of asthma in children who exercise outdoors,9

 and exacerbation of existing 

asthma.10

Particulate Matter 

Particulate matter has been found to cause increased risk of mortality (death), hospital admissions and 

emergency room visits for heart and lung diseases, respiratory effects including incidence of asthma and 

other respiratory symptoms such as bronchitis, and decreases in lung function.11 Such health effects have 

been associated with both short-term and long-term exposure to particulate matter. Children and adults 
16 

with asthma are considered to be among the groups more sensitive to respiratory effects.11-15 Studies also 

have confirmed that chronic exposure to particulate matter is associated with mortality in adults16-18 and 

suggest that it may be associated with mortality in infants.11,19 In addition, while there is limited evidence 

on the potential risks from particulate matter on other important child health outcomes, such as low 

birthweight and preterm birth, this has been identified as an emerging area of concern.11 

Prior to 1997, the National Ambient Air Quality Standard for particulate matter was based on particulate 

matter measuring 10 microns or less (PM10). In 1997, the standard was revised based on scientific 

evidence to address the health risks from particulate matter measuring 2.5 microns or less (PM2.5). 

Lead 

Lead accumulates in bones, blood, and soft tissues of the body. Exposure to lead can affect development 

of the central nervous system in young children, resulting in neurobehavioral effects such as reduced 

intelligence and cognitive development.20-22 Studies also have found that childhood exposure to lead 

contributes to attention-deficit/hyperactivity disorder23 and hyperactivity and distractibility;24-26 increases 

the likelihood of dropping out of high school, having a reading disability, lower vocabulary, and lower 

class standing in high school;27 and increases the risk for antisocial and delinquent behavior.28

Sulfur Dioxide 

Sulfur dioxide poses particular concerns for those with asthma, who are considered to be especially 

susceptible to its effects.29 Short-term exposures of asthmatic individuals to elevated levels of sulfur 

dioxide while exercising at a moderate level may result in breathing difficulties accompanied by symptoms 

such as wheezing, chest tightness, or shortness of breath. Effects that have been associated with longerterm exposures to high concentrations of sulfur dioxide, in conjunction with high levels of particulate 

matter include respiratory illness, alterations in the lung’s defenses, and aggravation of existing 

cardiovascular diseases. 

Carbon Monoxide 

Exposure to carbon monoxide reduces the capacity of the blood to carry oxygen, thereby decreasing the 

supply of oxygen to tissues and organs such as the heart. Short-term exposure can cause effects such as 

reduced time to onset of angina pain, neurobehavioral effects, and a reduction in exercise performance.30

Long-term exposure has not been studied adequately in humans to draw conclusions regarding possible 

chronic effects, though a recent study reported an association between long-term exposure to carbon 

monoxide and other traffic-related pollutants and respiratory symptoms in children.31

Nitrogen Dioxide 

Exposure to nitrogen dioxide has been associated with a variety of health effects.32 Effects include 

decreased lung function,31,33,34 increased respiratory symptoms or illness,12,31,35-37 and increased 

symptoms in children with asthma.38 Nitrogen dioxide also is a major contributor to the formation of 

ground-level ozone.6
17 

Percentage of Children Living In Counties in Which Air Quality Standards Were Exceeded in the 

United States 

This indicator uses EPA air quality data from counties with monitors across the United States. One use of 

the monitors is to inform the public about their air quality through the Air Quality Index and National 

Ambient Air Quality Standards. The indicator simply shows whether the level of any standard was 

exceeded at any time during a year. The indicator shows the percentage of children living in counties with 

any such exceedances. These children may be exposed to poor daily air quality at some point during a 

year. The measure includes air quality data for ozone, particulate matter, lead, and carbon monoxide 

(nitrogen dioxide and sulfur dioxide had essentially no exceedances). 

This measure does not differentiate between counties in which the indicators are exceeded frequently or 

by a large margin, and counties in which indicators are exceeded only rarely or by a small margin. It 

should be noted that this measure is slightly different from the air quality standard used by EPA to identify 

areas that must develop plans to lower air pollution levels. For ozone, the standard for developing further 

plans is based on the day with the 4th highest 8-hour average ozone concentration. 

Figure 2.1: Percentage of Children Living In Counties in Which Air Quality 

Standards Were Exceeded in the United States, 1990–2003 

Ground-level ozone

Lead

PM10

PM2.5

CO

0%

10%

20%

30%

40%

50%

60%

70%

1990 1992 1994 1996 1998 2000 2002

Years

Percent (%)

Source: US Environmental Protection Agency, Office of Air and Radiation, Aerometric Information Retrieval System
18 

Key Observations 

• The highest number of exceedances is consistently reported for ground-level ozone. In 1990, 

approximately 55 percent of children lived in counties in which the eight-hour ozone standard was 

exceeded on at least one day per year. In 2003, approximately 58 percent of children lived in 

such counties. 

• In 2000, approximately 30 percent of children lived in counties that exceeded the annual PM2.5 

standard. In 2003, approximately 19 percent of children lived in such counties. The standard for 

particulate matter was revised in 1997 to include PM2.5. The standard is intended to protect 

against both short-term and long-term health effects. 

• In 1990, approximately 13 percent of children lived in counties in which the carbon monoxide 

standard was exceeded. In 2003, approximately 1 percent of children lived in such counties. 

• From 1990 to 2001, the percentage of children living in counties that exceeded the one-day 

standard for PM10 fluctuated, but was as high as 14 percent in 1990 and 1991, and 11 percent in 

1999. The percentage remained around 6 to 9 percent during 2000–2003. 

• In 1990, about 2 percent of children lived in counties that exceeded the three-month standard for 

lead. In 2003, only one county, with less than 0.1% of children, had airborne lead measurements 

that exceeded the standard for lead. 

• Few exceedances of the sulfur dioxide and nitrogen dioxide standards have occurred since 1993. 

Consequently, they were not included on the graph. 

Data Table 2.1: Percentage of Children Living in Countries in Which Air Quality Standards were 

Exceeded in the United States, 1990–2003 

1990-1995

 1990 1991 1992 1993 1994 1995

Ozone 54.9% 53.4% 53.3% 53.4% 57.8% 58.0% 

PM10 14.0% 12.8% 13.8% 7.3% 6.8% 11.8% 

Carbon monoxide 12.7% 11.9% 8.0% 6.4% 11.3% 8.3% 

Lead 2.2% 8.0% 1.8% 2.1% 1.7% 1.7% 

Sulfur dioxide 0% 0% 0% 0% 0% 0% 

Nitrogen dioxide 3.7% 3.7% 0% 0% 0% 0% 

Any standard* 58.7% 58.1% 55.8% 55.2% 58.8% 59.8% 

1996–2001 

 1996 1997 1998 1999 2000 2001

Ozone 56.1% 54.0% 61.5% 62.0% 59.6% 59.8% 

PM10 3.6% 6.0% 5.0% 11.3% 5.8% 5.9% 

PM2.5 29.2% 25.4% 

Carbon monoxide 7.8% 5.8% 5.3% 5.7% 0.7% 0.7% 

Lead 1.6% 1.7% 1.6% 0.7% 1.0% 1.0% 

Sulfur dioxide 0% 0% 0% 0% 0% 0% 

Nitrogen dioxide 0% 0% 0% 0% 0% 0% 

Any standard* 56.9% 55.2% 62.5% 64.8% 64.1% 63.1% 

2002–2003 2002 2003 

Ozone 59.8% 58.1% 

PM10 9.5% 7.6% 
19 

PM2.5 21.4% 19.3% 

Carbon monoxide 4.1% 1.0% 

Lead 0.1% 0.0% 

Sulfur dioxide 0% 0% 

Nitrogen dioxide 0% 0% 

Any standard* 61.2% 60.0% 

*Does not include the PM2.5 standard 

SOURCE: US Environmental Protection Agency, Office of Air and Radiation, Aerometric Information Retrieval 

System 

Limitations 

This indicator does not differentiate between counties in which the indicators are exceeded frequently or 

by a large margin, and counties in which indicators are exceeded only rarely or by a small margin. It 

should be noted that this measure is slightly different from the air quality standard used by EPA to identify 

areas that must develop plans to lower air pollution levels. For ozone, the standard for developing further 

plans is based on the day with the 4th highest 8-hour average ozone concentration. The standards are 

set at a level that protects public health with an adequate margin of safety. However, the standards are 

not “risk free.” Even in areas that meet the standards, there may be days when unusually sensitive 

individuals, including children, experience health effects related to air pollution. This is especially the case 

for pollutants such as ozone and particulate matter that do not have discernible thresholds below which 

health effects are absent. 

Additional Indicators 

In this report: 

• Percentage of children’s days with good, moderate, or unhealthy air quality, in the United States, 

1990 – 1999 

• Percentage of children with asthma, in the United States, 1980 – 2003 

• Percentage of children having an asthma attack in the previous 12 months, by race/ethnicity and 

family income, in the United States, 1997–2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Children’s emergency room visits for asthma and other respiratory causes 

 Children’s hospital admissions for asthma and other respiratory causes 

 Percentage of children’s days with good, moderate, or unhealthy air quality 

 Long-term trends in annual average concentrations of criteria pollutants 

 Number of children living in counties with high annual averages of PM10

Opportunities for Improvement 

The indicators could provide additional information to reflect the number, margin, and duration of 

exceedances to help distinguish among exceedances. 

Related Programs/Activities 

Objective 8-01 of Healthy People 2010 aims to reduce the proportion of persons exposed to air that 

exceeds the levels of the US Environmental Protection Agency’s health-based standards for harmful air 

pollutants. 

AIRNow, is a government-backed program and through AIRNow, EPA, the National Oceanic and 

Atmospheric Administration (NOAA), National Air and Space Agency (NASA) Langley Laboratory, 

National Park Services (NPS) Air Resources and Environment Canada, and news media, tribal, state and 

local agencies work together to report conditions for ozone and particle pollution. 

http://www.epa.gov/airnow/
20 

Daily Air Quality 

EPA provides an Air Quality Index (AQI) that represents air quality for specific days and is widely reported 

in newspapers and other media outlets in metropolitan areas. 

The AQI is based on measurements of up to five of the six air quality criteria pollutants (carbon monoxide, 

ground-level ozone, nitrogen dioxide, particulate matter, and sulfur dioxide). Lead is not included in the 

AQI. The specific pollutants considered in the AQI for each metropolitan area depend on which pollutants 

are monitored in that area. Each pollutant concentration is given a value on a scale that is related to the 

air quality standards for that pollutant. An AQI value of 100 for a criteria pollutant generally corresponds to 

the short-term National Ambient Air Quality Standard for that pollutant, and is the level EPA has set to 

protect public health for a single day. Above this level, pollutant-specific health advisories are issued. The 

daily AQI is based on the pollutant with the highest index value on the scale that day. It does not add up 

values for more than one pollutant. Therefore, it does not reflect the possible effects of simultaneous 

exposure to high levels of multiple pollutants. 

EPA has divided the AQI scale into categories. Air quality is considered “good” if the AQI is between 0 and 

50, posing little or no risk. Air quality is considered “moderate” if the AQI is between 51 and 100. Some 

pollutants at this level may present a moderate health concern for a small number of individuals. 

Moreover, such a level may pose health risks if maintained over many days. Air quality is considered 

“unhealthy for sensitive groups” if the AQI is between 101 and 150. Members of sensitive groups such as 

children may experience health effects, but the general population is unlikely to be affected. Air quality is 

considered “unhealthy” if the AQI is between 151 and 200. The general population may begin to 

experience health effects, and members of sensitive groups may experience more serious health effects. 

Figure 2.2 is based on the reported AQI for counties of the United States. (Not all counties have air 

quality monitoring stations.) This indicator was developed by reviewing the air quality designation for each 

day for each county and weighting the daily designations by the number of children living in each county. 

The overall indicator reports the percentage of children’s days of exposure considered to be of good, 

moderate, or unhealthy air quality. 
21 

Figure 2.2: Percentage of Children’s Days with Good, Moderate, or Unhealthy Air 

Quality, in the United States, 1990–1999 

Good

Moderate

Unhealthy

No Monitoring Data

0.0

10.0

20.0

30.0

40.0

50.0

60.0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Years

Percent (%)

Source: US Environmental Protection Agency, Office of Air and Radiation, Aerometric Information Retrieval System

Key Observations 

• The percentage of days that were designated as having “unhealthy” air quality (including days 

that were unhealthy for everyone as well as those that were unhealthy for sensitive groups) 

decreased from 3 percent in 1990 to less than 1 percent in 1999. The percentage of days with 

“moderate” air quality remained around 20 percent between 1990 and 1999, although an upward 

trend is suggested by the fact that the percentage of moderate air quality days was higher in 1999 

than for any other year in this analysis. As the percentage of either unhealthy or good air days 

decreases, the percentage of moderate days would be expected to increase. 

• The coverage of monitoring for this measure, in terms of area and percentage of days monitored, 

was largely unchanged between 1990 and 1999. Approximately 30 percent of children’s days of 

exposure to air pollutants were not monitored. This percentage includes days for which no AQI 

was reported in counties where the AQI is sometimes reported, as well as counties in which the 

AQI is not reported at all. On days that were monitored, in many cases only one or a few 

pollutants were monitored. 
22 

Data Table 2.2: Percentage of Children’s Days with Good, Moderate, or Unhealthy Air Quality 

1990–1995 

Pollution Level 1990 1991 1992 1993 1994 1995 

Good 43.6% 44.2% 47.7% 46.9% 45.7% 47.2%

Moderate 20.6% 21.0% 18.4% 19.2% 20.5% 19.7%

Unhealthy 3.0% 3.0% 2.7% 2.3% 2.3% 2.2%

No Monitoring Data 32.8% 31.8% 31.2% 31.6% 31.5% 30.8% 

1996–1999 

Pollution Level 1996 1997 1998 1999 

Good 48.9% 48.8% 47.1% 46.6% 

Moderate 19.1% 19.0% 20.7% 21.9% 

Unhealthy 1.7% 1.3% 1.3% 0.9% 

No Monitoring Data 30.3% 30.9% 30.9% 30.7% 

Limitations 

Not all counties have air quality monitoring stations. The AQI is based on the single pollutant with the 

highest value for each day; it does not reflect any combined effect of multiple pollutants. It reflects only 

short-term, daily pollution burdens. It does not include lead. The approach is influenced by the frequency 

of measurements. Because the AQI is reported daily, pollutants that are measured daily—such as 

ozone—will appear to have more effect than those that are measured less frequently, such as PM10, 

which typically is measured every six days. Also, the AQI is not well-suited for reporting concentrations of 

nitrogen dioxide, because this pollutant does not have a short-term standard. 

Additional Indicators 

In this report: 

• Percentage of children living in counties in which air quality standards were exceeded in the 

United States, 1990–2003 

• Percentage of children with asthma, in the United States, 1980 – 2003 

• Percentage of children having an asthma attack in the previous 12 months, by race/ethnicity and 

family income, in the United States, 1997–2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Children’s emergency room visits for asthma and other respiratory causes 

 Children’s hospital admissions for asthma and other respiratory causes 

 Percentage of children’s days with good, moderate, or unhealthy air quality 

 Long-term trends in annual average concentrations of criteria pollutants 

 Number of children living in counties with high annual averages of PM10

 

Opportunities for Improvement 

More frequent measurement of PM2.5 and other pollutants to include in the Air Quality Index may more 

accurately reflect air quality. The combination of multiple pollutants as part of an overall air quality index 

might better replicate the health impacts of high pollution days and provide more useful information on 

potential air quality hazards to sensitive populations. In addition, consideration of the potential for health 

risks from long-term exposures to pollutants could be incorporated into an indicator as well as expansion 

of monitor locations to additional counties across the US to better reflect child population exposure. 

Related Programs/Activities 

Objective 8-01 of Healthy People 2010 aims to reduce the proportion of persons exposed to air that 

exceeds the levels of the US Environmental Protection Agency’s health-based standards for harmful air 

pollutants. 
23 

AIRNow, is a government-backed program and through AIRNow, EPA, the National Oceanic and 

Atmospheric Administration (NOAA), National Air and Space Agency (NASA) Langley Laboratory, 

National Park Services (NPS) Air Resources and Environment Canada, and news media, tribal, state and 

local agencies work together to report conditions for ozone and particle pollution. 

http://www.epa.gov/airnow/
24 

2.2 Indoor Air Pollution 

Children can be exposed to a number of air pollutants that come from sources inside homes, schools, 

and other buildings. Indoor sources include combustion sources such as gas stoves, fireplaces, and 

cigarettes; building materials such as treated wood and paints, furnishings, carpet, and fabrics; and 

consumer products such as sprays, pesticides, window cleaners, and laundry soap. Indoor air pollutants 

also can come from outside, as air pollution penetrates indoors. Information on the toxic effects of air pollutants from indoor sources indicates that they could pose health risks to children.39,40

 

Children who are exposed to environmental tobacco smoke, also known as secondhand smoke, are at 

increased risk for a number of adverse health effects, including lower respiratory tract infections, 

bronchitis, pneumonia, fluid in the middle ear, asthma symptoms, and sudden infant death syndrome 

(SIDS).41-46 Exposure to environmental tobacco smoke also may be a risk factor contributing to the 

development of new cases of asthma.46-48 Young children appear to be more susceptible to the effects of 

environmental tobacco smoke than older children are.40,46

 

Smoking in the home is an important source of exposure because young children spend most of their 

time at home and indoors. The measure for environmental tobacco smoke shows the percentage of 

homes with children ages 6 and under in which someone smokes regularly. Most often the smoker in the 

home is a parent. 

This measure is a surrogate for the exposure of children to tobacco smoke. The data come from national 

surveys and are available for 1994, 1998, and 2003. 
25 

Figure 2.3: Percentage of Children Aged 6 and Under Regularly Exposed to 

Secondhand Smoke in US Homes, 1994–2003 

0

5

10

15

20

25

30

1992 1994 1996 1998 2000 2002 2004

Years

Percent (%)

Source: Data for 1994 and 1998: National Health Interview Survey. National Center for Health Statistics, Centers for 

Disease Control and Prevention. Data for 2003: National Survey on Environmental Management of Asthma and 

Children’s Exposure to Tobacco Smoke. United States Environmental Protection Agency Indoor Environments 

Division. 

Key Observations 

• The percentage of children ages 6 and under who are regularly exposed to secondhand smoke in 

the home decreased from 27 percent in 1994 to 11 percent in 2003. 

Data Table 2.3: Percentage of Children Aged 6 and Under Regularly Exposed to Secondhand 

Smoke in US homes, 1994–2003 

1994 1998 2003 

27% 20% 11% 

SOURCE: 1994 and 1998: Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health Interview Survey. 2003: US EPA, Indoor Environments Division, National 

Survey on Environmental Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke. 

Limitations: 

The data used for this indicator are gathered only periodically to assess progress toward Healthy People 

2010 goals, and are not available on an annual basis. 
26 

Additional Indicators 

In this report: 

• Percentage of children aged 4-11 with detectable levels of blood cotinine by race and ethnicity, in 

the United States, 1988–94 and 1999–2000 

• Percentage of children with asthma, in the United States, 1980 – 2003 

• Percentage of children having an asthma attack in the previous 12 months, by race/ethnicity and 

family income, in the United States, 1997–2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Percentage of homes with children under 7 where someone smokes regularly 

 Concentrations of cotinine in blood of children 

 Children’s emergency room visits for asthma and other respiratory causes 

 Children’s hospital admissions for asthma and other respiratory causes 

Opportunities for Improvement 

For indoor air quality in general, the most important improvement would be to add data about sources of 

other indoor air pollutants, such as consumer products, gas stoves, and furnishings, for both homes and 

schools. 

For the indicator on the percentage of children ages 6 and under regularly exposed to secondhand smoke 

in the home, a possible improvement would be more regular reporting, such as annual or biannual 

instead of periodic reporting. 

Related Programs/Activities 

Objective 27-9 of the federal Healthy People 2010 initiative is to reduce the proportion of children who are 

regularly exposed to tobacco smoke at home. 

EPA’s Smoke-Free Homes initiative provides public education on the topic: 

http://www.epa.gov/smokefree 
27 

Cotinine in the Blood of Children 

Cotinine is a breakdown product of nicotine in blood. Measurements of cotinine in blood serum are a 

marker for exposure to environmental tobacco smoke in the previous 1 to 2 days.49 Children can be 

exposed to ETS in their homes or in places where people are allowed to smoke, such as some 

restaurants. This measure presents cotinine levels for non-tobacco-users only. Children who smoke were 

excluded from these statistics. 

Figure 2.4: Percentage of Children Aged 4-11 with Detectable Levels of Blood 

Cotinine by Race and Ethnicity, in the United States, 1988–94 and 1999–2000 1988-1994 1988-1994 1988-1994 1988-1994 1999-2000 1999-2000 1999-2000 1999-2000

0

10

20

30

40

50

60

70

80

90

100

Total White, NonHispanicBlack, NonHispanicMexican-American

Percent (%)

Source: National Health and Nutrition Examination Survey. National Center for Health Statistics, Centers for Disease 

Control and Prevention. 

Key Observations 

• The percentage of children ages 4-11 exposed to environmental tobacco smoke, as indicated by 

detection of cotinine in their blood, decreased between 1988–94 and 1999–2000. Overall, 64 

percent of children ages 4 to 11 had cotinine in their blood in 1999–2000, down from 88 percent 

in 1988–94. 

• In 1999–2000, 86 percent of Black, non-Hispanic children ages 4 to 11 had cotinine in their blood 

compared with 63 percent of White, non-Hispanic children and 49 percent of Mexican American 

children. 

• Despite the overall decrease, in 1999–2000 the median levels of cotinine in children ages 3–11 

and 12-19 were more than twice as high as those of adults. (Data not shown; see the Centers for 
28 

Disease Control and Prevention, 2003, Second National Report on Human Exposure to 

Environmental Chemicals, http://www.cdc.gov/exposurereport/.) 

Data Table 2.4: Percentage of Children aged 4–11 with Detectable Levels of Blood Cotinine by 

Race and Ethnicity in the United States, 1988–94 and 1999–2000 

Race/Ethnicity and 

Cotinine Level 1988–94 1999–2000

Total 

Any detectable cotinine 87.7% 64.4% 

White, non-Hispanic 

Any detectable cotinine 86.4% 62.7% 

Black, non-Hispanic 

Any detectable cotinine 94.5% 85.6% 

Mexican American 

Any detectable cotinine 83.8% 48.6% 

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and 

Nutrition Examination Survey 

Limitations: 

Cotinine remains in the body for only a discrete period of time, and thus is only a short-term indicator of 

exposure to secondhand smoke. This indicator cannot isolate or differentiate home exposure from other 

sources (e.g., from a daily child care provider) without an additional interview screening component. 

In addition, NHANES only tested children ages 4 and older during the periods shown in this indicator. No 

results are available for ages 0-3, when children are most vulnerable to adverse respiratory health 

consequences. NHANES recently began testing children down to age 3, and future indicators will include 

these data. 

Additional Indicators 

In this report: 

• Percentage of children aged 6 and under regularly exposed to secondhand smoke in US homes, 

1994 – 2003 

• Percentage of children with asthma, in the United States, 1980 – 2003 

• Percentage of children having an asthma attack in the previous 12 months, by race/ethnicity and 

family income, in the United States, 1997–2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Percentage of homes with children under 7 where someone smokes regularly 

 Concentrations of cotinine in blood of children 

 Children’s emergency room visits for asthma and other respiratory causes 

 Children’s hospital admissions for asthma and other respiratory causes 

Opportunities for Improvement 

This indicator could be improved by finding a consistent and reliable method to measure exposure levels 

in infants and toddlers (ages 0–3). 
29 

Related Programs/Activities 

Objective 27-9 of the federal Healthy People 2010 initiative is to reduce the proportion of children who are 

regularly exposed to tobacco smoke at home. 

EPA’s Smoke-Free Homes initiative provides public education on the topic: 

http://www.epa.gov/smokefree

2.3 Asthma 

Asthma is a disease of the lungs that can cause wheezing, difficulty in breathing, and chest pain. It is the 

most common chronic disease among children and is costly in both human and monetary terms.40

Asthma is one of the leading causes of school absenteeism – 14 million school days are missed each 

year. In 1998, the cost of asthma to the US economy was 11.3 billion.50

Asthma varies greatly in severity. Some children who have been diagnosed with asthma may not 

experience any serious respiratory effects. Other children may have mild symptoms or may respond well 

to management of their asthma, typically through use of medication. Some children with asthma may 

suffer serious attacks that greatly limit their activities, result in visits to emergency rooms or hospitals, or, 

in rare cases, cause death. 

Asthma among children is increasing in the United States. Researchers do not understand completely 

why children develop asthma. The tendency to develop asthma can be inherited, but genetic factors 

alone are unlikely to explain the significant increases that have occurred in the last 20 years.40 

Research on environmental factors that exacerbate or may contribute to causing asthma has focused on 

environmental agents found outdoors and indoors. The Institute of Medicine concluded that exposure to 

dust mites causes asthma in susceptible children.15 Cockroaches and tobacco smoke are likely to cause 

asthma in young children.40 Other studies have evaluated the role of indoor air pollutants such as nitrogen 

dioxide, pesticides, plasticizers, and volatile organic pollutants. Some of these pollutants may play a role 

in asthma.40 One recent study suggests that chronic exposure to ozone may be associated with the 

development of asthma in children who exercise outside,9

 and two other studies suggest that chronic 

exposure to particulate matter may affect lung function and growth.51,52

Environmental factors may increase the severity or frequency of asthma attacks in children who have the 

disease. Children with asthma are particularly sensitive to outdoor air pollutants, including ozone, 

particulate matter, and sulfur dioxide.11,29,31,38,53-61 These pollutants can exacerbate asthma, leading to 

difficulty in breathing, an increased use of medication, visits to doctors’ offices, trips to emergency rooms, 

and admissions to the hospital. In addition, one study reported a relationship between exposure to 

hazardous air pollutants and increases in chronic respiratory symptoms that are characteristic of 

asthma.62 

Data from the National Health Interview Survey were used to estimate the prevalence of childhood 

asthma. For 1980 to 1996, the percentage of children reported to have asthma in the preceding 12 

months is shown. In 1997, the survey’s method for measuring childhood asthma changed. For 1997 to 

2001, the measure shows the percentage of children who had ever been told by a doctor or health 

professional that they have asthma, as well as the percentage of children who were ever diagnosed with 

asthma and who had an asthma attack in the preceding 12 months. Some children may have asthma 

when they are young and outgrow it as they get older, or their asthma may be well controlled through 

medication and by avoiding triggers of asthma attacks. In such cases, children may have asthma but may 

not have experienced any attacks in a long time. In 2001, the survey’s method was changed to add an 

additional question to measure the percentage of children who currently have asthma. 
30 

Figure 2.5: Percentage of Children with Asthma, in the United States, 1980–2003 

Asthma attack in 

the last 12 

months (%)

Currently have 

asthma (%)

Ever had asthma 

(%)

0

2

4

6

8

10

12

14

1980 1982 1984 1986 1988 1990 1992 1994 1996 1997 1999 2001 2003

Years

Percent (%)

Had asthma in the last 

12 months (%)

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview 

Survey. 

Note: The survey questions for asthma changed in 1997; data before 1997 cannot be directly compared to data in 

1997 or later.

Key Observations 

• Between 1980 and 1995, the percentage of children with asthma (as measured by “children with 

asthma in past twelve months”) doubled, from 3.6 percent in 1980 to 7.5 percent in 1995. A 

decrease in the percentage of children occurred between 1995 and 1996, but it is difficult to 

interpret single-year changes. 

• In 2003, about 9 percent of children were reported to currently have asthma. These include 

children with active asthma symptoms and those whose asthma is well-controlled. 

• In 2003, about 13 percent of children had been diagnosed with asthma at some time in their lives, 

though some of those children may no longer have asthma. 

• Prior to 1997, the percentage of children with asthma was measured by asking parents if a child 

in their family had asthma during the previous 12 months. In 1997–2001, a parent was asked if 

his or her child had ever been diagnosed with asthma by a health professional. If the parent 

answered yes, then he or she was asked if the child had an asthma attack or episode in the last 

12 months. The percentage of children with an asthma attack in the last 12 months measures the 

population with incomplete control of asthma. For 1997–2000, available data do not distinguish 

between those children who may no longer have active asthma and those whose asthma is well 

controlled.
31 

• Approximately 6 percent of all children had one or more asthma attacks in the previous twelve 

months. These children have ongoing asthma symptoms that could put them at risk for poorer 

outcomes, including hospitalizations and death. About two-thirds of children who currently have 

asthma have on-going asthma symptoms (2001–2003). 

• Emergency room visits for asthma and other respiratory causes were 369 per 10,000 children in 

1992 and 379 per 10,000 children in 1999. Hospital admissions for asthma and other respiratory 

causes were 55 per 10,000 children in 1980 and 66 per 10,000 children in 1999. 

Data Table 2.5: Percentage of Children with Asthma in the United States, 1980–2003 

1980–1985

 1980 1981 1982 1983 1984 1985

Percentage of children with asthma in the past 12 months 3.6% 3.7% 4.1% 4.5% 4.3% 4.8%

1986–1991 

 1986 1987 1988 1989 1990 1991

Percentage of children with asthma in the past 12 months 5.1% 5.3% 5.0% 6.1% 5.8% 6.4%

1992–1996 

 1992 1993 1994 1995 1996 1997

Percentage of children with asthma in the past 12 months 6.3% 7.2% 6.9% 7.5% 6.2% 

1997–2001*

 1997 1998 1999 2000 2001 

Children ever diagnosed with asthma and having an asthma 

attack in the past 12 months 5.4% 5.3% 5.3% 5.5% 5.7% 

Children ever diagnosed with asthma 11.4% 12.1% 10.8% 12.3% 12.6% 

Children who currently have asthma 8.7% 

2002–2003 

2002 2003

Children ever diagnosed with asthma and having an asthma 

attack in the past 12 months 5.8% 5.5% 

Children ever diagnosed with asthma 12.2% 12.5% 

Children who currently have asthma 8.2% 8.5% 

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health 

Interview Survey 

Note: *The survey questions for asthma changed in 1997; data before 1997 cannot be directly compared to data in 

1997 and later. 
32 

Figure 2.6: Percentage of Children Having an Asthma Attack in the Previous 12 

Months, by Race/Ethnicity and Family Income, in the United States, 1997–2000 

0% 2% 4% 6% 8% 10%

Hispanic

White

nonHispanic

All

Races/

Ethnicities

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

100-200% of Poverty Level

> 200% of Poverty Level

< Poverty Level

Black

nonHispanic

All Incomes

All Incomes

All Incomes

All Incomes

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview 

Survey 

Key Observations 

• The percentage of children with asthma differs by race/ethnicity and family income. In 1997–

2000, more than 8 percent of Black non-Hispanic children living in families with incomes below 

the poverty level had an asthma attack in the previous 12 months. Approximately 6 percent of 

White non-Hispanic children and 5 percent of Hispanic children living in families with incomes 

below the poverty level had an asthma attack in the previous 12 months. 

• More than 6 percent of children living in families with incomes below the poverty level had an 

asthma attack in the previous 12 months. About 5 percent of children living in families with 

incomes at the poverty level and higher had an asthma attack in the previous 12 months. 
33 

Data Table 2.6: Percentage of Children Having an Asthma Attack in the Previous 12 months, by 

Race/Ethnicity and Family Income in the United States, 1997–2000. 

All Incomes < Poverty 

Level

100–200% of 

Poverty Level

> 200% of 

Poverty Level

Unknown 

Income

All 

races/ethnicities 5.4% 6.4% 5.5% 5.3% 4.9% 

White nonHispanic 5.2% 6.1% 5.5% 5.1% 4.7% 

Black nonHispanic 7.2% 8.5% 7.2% 6.3% 6.5% 

Hispanic 4.6% 5.0% 3.9% 5.2% 4.3% 

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health 

Interview Survey 

Limitations 

It is difficult to obtain an accurate measurement of how many children have asthma, because asthma is a 

complex disease that can be difficult to differentiate from other wheezing disorders, especially in children 

under the age of 6 years. 

Additional Indicators 

In this report: 

• Percentage of children living in counties in which air quality standards were exceeded, in the 

United States, 1990–2003 

• Percentage of children’s days with good, moderate, or unhealthy air quality 

• Percentage of children aged 6 and under regularly exposed to secondhand smoke in US homes, 

1994 – 2003 

• Percentage of children ages 4–11 with detectable blood cotinine by race and ethnicity, 1988–94 

and 1999–2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Children’s emergency room visits for asthma and other respiratory causes 

 Children’s hospital admissions for asthma and other respiratory causes 

 Percentage of homes with children under 7 where someone smokes regularly 

 Concentrations of cotinine in blood of children 

 Long-term trends in annual average concentrations of criteria pollutants 

 Number of children living in counties with high annual averages of PM10 

 Percentage of children living in counties in which air quality standards were exceeded 

 Percentage of children’s days with good, moderate, or unhealthy air quality 

Opportunities for Improvement 

Continuing refinements in the National Health Interview Survey questions may help reduce any false selfreporting of asthma. The questions now ask whether a health professional has diagnosed a child with 

asthma. Additional research could be conducted to document the role of environmental factors in the 

prevalence of asthma. 

Related Programs/Activities 

Objective 1-9 of Healthy People 2010 aims to reduce hospitalization rates for three ambulatory-caresensitive conditions—pediatric asthma, uncontrolled diabetes, and immunization-preventable pneumonia 

and influenza. Objective 24-1 is to reduce asthma deaths, Objective 24-2 is to reduce hospitalizations for 

asthma, Objective 24-3 is to reduce hospital emergency department visits for asthma, and Objective 24-5 

is to reduce the number of school or work days missed by people with asthma due to asthma. 
34 

The US National Institutes of Health coordinates the National Asthma Education and Prevention Program 

to address the growing problem of asthma in the United States. http://www.nhlbi.nih.gov/about/naepp/

EPA’s Indoor Environments Division has launched a national public education and prevention program to 

raise awareness of indoor asthma triggers. http://www.epa.gov/iaq/asthma/iedasthmaprog.html
35 

3 Lead and Other Chemicals, Including Pesticides 

Lead, along with other chemicals, can be important environmental hazards for young children both inside 

and outside their homes. 

3.1 Blood Lead Levels 

Lead is a serious environmental health hazard for young children. A child’s brain and nervous system are 

vulnerable to adverse impacts from lead because they go through a long developmental process 

beginning shortly after conception and continuing through adolescence.63,64 Studies have found that lead 

can damage children’s developing brain and nervous system. Lead contributes to learning problems such 

as reduced intelligence and cognitive development.20-22 Childhood exposure to lead contributes to 

attention-deficit/hyperactivity disorder23 and hyperactivity and distractibility;24-26 increases the likelihood of 

dropping out of high school, having a reading disability, lower vocabulary, and lower class standing in 

high school;27 and increases the risk for antisocial and delinquent behavior.28 A blood lead level of 10 

micrograms per deciliter (μg/dL) or greater is considered elevated,65,66 but there is no demonstrated safe 

concentration of lead in blood.67 Adverse health effects can occur at lower concentrations.21,22,68

In the past, ambient concentrations of lead from leaded gasoline were a major contributor to blood lead 

levels in children.68 Today, elevated blood lead levels are due mostly to ingestion of contaminated dust, 

paint and soil.65 Soil and dust that are contaminated with lead are important sources of exposure because 

children play outside, and very small children frequently put their hands in their mouths.69,70 Deterioration 

of lead-based paint can generate contaminated dust and soil, and past emissions of lead in gasoline that 

subsequently were deposited in the soil also contribute to lead-contaminated soil and house dust.69-71 As 

of 1998–2000, lead-based paint was present in 40 percent of US homes.72 Sixteen percent of homes had 

dust lead hazards, and 7 percent of homes had soil lead hazards.72 Some small fraction of children also 

are exposed through direct ingestion of lead-containing paint chips and lead contaminated non-food 

items, as commonly found among children with pica.73,74 

Although the concentration of lead in blood is an important indicator of risk, it reflects only current 

exposures. Lead also accumulates in bone and teeth. Recent research suggests that concentrations of 

lead in bone may be more related to adverse health outcomes in children than are concentrations in 

blood, as this would reflect exposure over a longer timeframe .75 This finding suggests that concentrations 

in bone may better reflect the net burden of exposure. However, methods for measuring lead in bone are 

more time-consuming and expensive than those for measuring lead in blood, and nationally 

representative data are not available. 
36 

Figure 3.1: Concentration of Lead in the Blood of Children Five and Under, in the 

United States, 1976–2002 

50th percentile

90th percentile

0

5

10

15

20

25

30

1976-

1980

1988-

1991

1992-

1994

1999-

2000

2001-

2002

Years

Blood lead concentrations (μg/dL)

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens and Illness. www.epa.gov/envirohealth/children

Data: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition 

Examination Survey 

Note: 10 μg of blood has been identified by CDC as elevated, which indicated need for intervention. There is no 

demonstrated safe concentration of lead in blood. Adverse effects may occur at lower concentrations. 

Key Observations 

• The median concentration of lead in the blood of children 5 years old and under dropped from 15 

micrograms per deciliter (μg/dL) in 1976-1980 to 1.7 μg/dL in 2001–2002, a decline of 89 percent. 

• The concentration of lead in blood at the 90th percentile in children 5 years old and under 

dropped from 25 μg/dL in 1976-1980 to 4.2 μg/dL in 2001–2002. This means that 10 percent of 

children had blood lead levels above 4.2 μg/dL and 90 percent had blood lead levels below 4.2 

μg/dL. 

• The decline in blood lead levels is due largely to the phasing out of lead in gasoline between 

1973 and 1995 76 and some to the reduction in the number of homes with lead-based paint from 

64 million in 1990 to 38 million in 2000.72 Some decline also was a result of EPA regulations 

reducing lead levels in drinking water, as well as legislation banning lead from paint and 

restricting the content of lead in solder, faucets, pipes, and plumbing. Lead also has been 

eliminated or reduced in food and beverage containers and ceramic ware, and in products such 

as toys, mini-blinds, and playground equipment. 
37 

Data Table 3.1: Concentration of Lead in the Blood of Children Five and Under in the United 

States, 1976–2002 

Blood lead concentrations (μg/dL)

1976–80 1988–91 1992–94 1999–2000 2001–2002 

50th percentile 15.0 3.5 2.6 2.2 1.7 

90th percentile 25.0 9.4 7.1 4.8 4.2 

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens and Illness. www.epa.gov/envirohealth/children

Data: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition 

Examination Survey

Figure 3.2: Distribution of Concentrations of Lead in Blood of Children Aged One 

to Five, in the United States, 1999–2000 

0%

5%

10%

15%

20%

25%

30%

35%

40%

< 1 1-2 2-3 3-4 4-5 5-6 6-7 > 7

Blood lead concentrations (μg/dL)

Percentage (%) of Children

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens and Illness. www.epa.gov/envirohealth/children. 

Key Observations 

• Based on the 1999–2000 survey, 2.2 percent of US children aged 1-5 years have a blood lead 

level greater than or equal to 10 μg/dL. In the 1976–1980 survey, 88.2 percent of children had a 

blood lead level above or equal to 10 μg/dL. 

• In the 1999–2000 survey, 434,000 US children aged 1-5 years were estimated to have a blood 

lead level of 10 μg/dL or more. The most current estimate of the number of children in the US 
38 

with an elevated blood lead level is 310,000 for the period 1999-2002 (data not shown). This 

contrasts with the 1976-1980 survey, the comparable estimate was 13,500,000 children. 

Data Table 3.2: Distribution of Concentrations of Lead in Blood of Children Aged 1 to 5 in the 

United States, 1999–2000 

Blood lead concentrations (μg/dL)

< 1 1-2 2-3 3-4 4-5 5-6 6-7 > 7

10% 36% 24% 14% 6% 3% 2% 5% 

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and 

Nutrition Examination Survey 

Figure 3.3: Median Concentrations of Lead in Blood of Children Aged One to Five, 

by Race/Ethnicity and Family Income, in the United States, 1999–2000 

All Incomes

All Incomes

All Incomes

All Incomes

< Poverty Level

< Poverty Level

< Poverty Level

< Poverty Level

> 200% of Poverty Level

> 200% of Poverty Level

> 200% of Poverty Level

> 200% of Poverty Level

0 0.5 1 1.5 2 2.5 3 3.5 4

Median concentrations of lead in blood (μg/dL)

Hispanic

Black Non-Hispanic

White Non-Hispanic

All Races/Ethnicities

100-200% of Poverty Level

100-200% of Poverty Level

100-200% of Poverty Level

100-200% of Poverty Level

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens and Illness. www.epa.gov/envirohealth/children. 

Key Observations 

• In 1999–2000 the median blood lead level in children ages 1–5 was 2.2 μg/dL. The median blood 

lead level for children living in families with incomes below the poverty level was 2.8 μg/dL and for 

children living in families above the poverty level it was 1.9 μg/dL. 

• In 1999–2000, White non-Hispanic children ages 1-5 had a median blood lead level of about 2 

μg/dL, unchanged from the level in 1992–94. 
39 

• In 1992–94, Black non-Hispanic children ages 1-5 had a median blood lead level of 3.9 μg/dL and 

in 1999–2000 they had a median blood lead level of 2.8 μg/dL. 

• In 1992–94, Hispanic children ages 1–5 had a median blood lead level of 2.6 μg/dL and in 1999–

2000 they had a median blood lead level of 2.0 μg/dL. 

Data Table 3.3: Median Concentrations of Lead in Blood of Children aged 1 to 5, by Race/Ethnicity 

and Family Income, 1999–2000 

 Blood lead concentrations (μg/dL)

 All 

Incomes

< Poverty 

Level

100–200% of 

Poverty Level

> 200% of Poverty 

Level

Unknown 

Income

All 

Races/Ethnicities 2.2 2.8 1.9 1.9 2.9 

White nonHispanic 2.1 2.8 1.7 2.0 3.2 

Black non-Hispanic 2.8 3.6 2.6 2.2 2.7 

Hispanic 2.0 2.4 1.7 1.6 2.3 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and 

Nutrition Examination Survey 

Limitations 

The percentage of children with blood lead levels greater than 10 μg/dL is influenced by the proportion of 

nonresponses within each category. Families with incomes below the poverty level had a lower response 

rate than families with incomes at or above the poverty level. The percentages are thus the best 

estimates available, but may be biased by the variation of nonresponses by family income. These data 

only represent national averages. They do not adequately represent very high exposures that could occur 

because of local sources, such as high concentrations of housing with deteriorated lead paint. 

Additional Indicators 

In this report: 

• Lead in US housing, 1998–2000 

• Lead-based paint and year of housing unit construction 

• On- and off-site releases of lead (and its compounds) in the United States, 1995–2000 from 

industrial facilities 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Concentrations of lead in blood of children ages 5 and under 

 Median concentrations of lead in blood of children ages 1–5, by race/ethnicity and family income 

 Distribution of concentrations of lead in blood of children ages 1–5 

 Children reported to have mental retardation, by race/ethnicity and family income 

 Percentage of California public elementary schools with lead paint and some deterioration of 

paint 

 Percentage of California public elementary schools with lead in soils 

 Percentage of California public elementary schools with lead in drinking water 

Opportunities for Improvement 

Enhanced monitoring at the state level could improve the availability of geographically specified data and 

could provide more information about existence of higher end exposures. 
40 

Related Programs/Activities 

The US Department of Health and Human Services’ Healthy People 2010 initiative has set a national goal 

of eliminating blood lead levels equal to or greater than 10 μg/dL among children aged 1–5 years by 

2010. 

The US Department of Housing and Urban Development (HUD) and EPA also are implementing targeted 

strategies to prevent lead exposure through addressing lead hazards in the nation’s public and private 

housing stock, certifying building professions in safe lead paint management and in providing education 

and outreach to homebuyers, tenants and the general public regarding lead hazards and their 

management. See http://www.epa.gov/lead/index.html and http://www.hud.gov/offices/lead/index.cfm. 

The National Lead Information Center at http://www.epa.gov/opptintr/lead/nlic.htm provides public 

information and outreach on the risks of lead exposure. 

EPA also operates a Lead Awareness Program, at http://www.epa.gov/opptintr/lead/, which works to raise 

awareness of lead in paint, dust, and soil. 
41 

CASE STUDY 

Blood Lead Levels in Response to Restrictions on Lead in Gasoline and other Products 

The decline in blood lead levels is due largely to the phasing out of lead in gasoline between 1973 and 

1995 76 and some to the reduction in the number of homes with lead-based paint from 64 million in 1990 

to 38 million in 2000.72 Some decline also was a result of EPA regulations reducing lead levels in drinking 

water, as well as legislation banning lead from paint and restricting the content of lead in solder, faucets, 

pipes, and plumbing. Lead also has been eliminated or reduced in food and beverage containers and 

ceramic ware, and in products such as toys, mini-blinds, and playground equipment. As a result of these 

past and ongoing efforts, children’s blood-lead levels have declined by 89 percent since the mid 1970s.

Figure 3.4: Impact of Lead Poisoning Prevention Policy on Reducing Children’s 

Blood Lead Levels, in the United States, 1971–2001 

0

2

4

6

8

10

12

14

16

18

20

19701972197419761978198019821984198619881990199219941996199820002002

Year

Blood Lead Levels (μg/dL)

0

50

100

150

200

250

Lead in Gasoline (KTons)

Lead-based 

Paint 

Poisoning 

Prevention 

Act (1971)

Lead 

Gasoline 

Phase-out 

(1973)

Residential 

Lead Paint 

Ban (1978)

Lead in Plumbing 

banned (1986)

Lead 

Contamination 

Control Act 

Residential LeadBased Paint Hazard 

Reduction Act--Title 

X (1992)

Ban on lead 

solder in food 

cans (1995)

Blood Lead Levels

Lead in 

Gasoline

Source: Blood lead levels: National Health and Nutrition Examination Survey. National Center for Health Statistics, 

Centers for Disease Control and Prevention. Lead in gasoline: 1967-1975: Unpublished data from industry, provided 

by US EPA. 1976-1991: Unpublished data from refiner reports to US EPA. 

Key Observations: 

• The median concentration of lead in the blood of children five years old and under dropped from 

15 micrograms per deciliter (μg/dL) in 1976–80 to 1.7μg/dL in 2001–2002, a decline of 89 

percent.
42 

Data Table 3.4: Impact of Lead Poisoning Prevention Policy on Reducing Children’s Blood Lead 

Levels in the United States, 1971–2001 

Year 

Blood Lead Levels 

(μg/dL) 

Lead in Gasoline 

(Ktons) 

1972 226 

1973 226 

1974 194 

1975 175 

1976 18 205 

1977 15 186 

1978 15 169 

1979 12 143 

1980 9 86 

1981 67 

1982 67 

1983 57 

1984 51 

1985 22 

1986 11 

1987 6.2 

1988 1. 9 

1989 1.01 

1990 0.47 

1991 0.28 

1993 2.6 

Data with "mid-year" lead blood lead levels 

1989.5 3.5 

1999.5 2.2 

2001.5 1.7 

Source: Blood lead levels from Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. Lead in Gasoline data from industry data (1967-1975 and refiner 

reports to US EPA (for 1976-1991). 
43 

3.2 Lead in the Home 

Today, elevated blood lead levels in the United States are due mostly to ingestion of contaminated dust, 

paint and soil.65 Soil and dust that are contaminated with lead are important sources of exposure because 

children play outside, and very small children frequently put their hands in their mouths.69-71 Deterioration 

of lead-based paint can generate contaminated dust and soil, and past emissions of lead in gasoline that 

subsequently were deposited in the soil also contribute to lead-contaminated soil and house dust.69-71 

The National Survey of Lead and Allergens in Housing, conducted under the sponsorship of the 

Department of Housing and Urban Development (HUD) and the National Institute of Environmental 

Health Sciences (NIEHS), provides national estimates of children’s potential household exposure to lead 

and allergens. 

Figure 3.5: Lead in US Housing, 1998–2000 

0

5

10

15

20

25

30

35

40

45

With lead

based paint

With any

significant

lead-based

paint hazard

With

significantly

deteriorated

lead-based

paint

With interior

leadcontaminanted

dust above

EPA standard

With leadcontaminanted

soil above EPA

standard

Houses

Percentage of Houses

Source: “National Survey of Lead and Allergens in Housing, Final Report, Volume I, Analysis of Lead Hazards, 

Revision 6.0", April 18, 2001.

Key Observations 

• In 1998–2000, 40 percent of houses in the United States had paint that had some lead in it. 

Twenty-five percent of houses had a significant lead based paint hazard, which could be from 

deteriorating paint, contaminated dust, or contaminated soil outside the house. 

• In 1998–2000, 14 percent of houses had significantly deteriorated lead based paint and 16 

percent of houses in the United States had lead in dust above EPA standards. Seven percent of 

houses had lead in soil outside the house greater than the EPA standard. 
44 

• An estimated 38 million homes have lead-based paint somewhere in the building, however most 

have relatively small surfaces; the average home has an estimated 259 square feet of interior 

lead-based paint and 996 square feet of exterior lead-based paint.77 

Data Table 3.5: Lead in US Housing, 1998–2000 

Percent 

With lead based paint 40

Any significant lead-based paint hazard 25

Significantly deteriorated lead-based paint 14

Interior lead-contaminated dust above EPA standard 16

Lead-contaminated soil above EPA standard 7

Source: “National Survey of Lead and Allergens in Housing, Final Report, Volume I, Analysis of Lead Hazards, 

Revision 6.0", April 18, 2001. 

Note: “Lead-based paint” is defined as a paint or coating with a lead content > 1 mg/cm2

 or 0.5% by weight. 

“Significant lead-based paint hazard” is defined as an area of deteriorated lead-based paint above the de minimis 

levels specified by the US Department of Housing and Urban Development, which are ≤ 20 ft2

 (exterior) or ≤ 2 ft2

(interior) of lead-based paint on large surface area components (walls, doors), or damage to ≤ 10% of the total 

surface area of interior small surface area component types (windowsills, baseboards, trim). 

Limitations 

The national survey identified lead hazards to include deteriorated lead based paint, lead contaminated 

dust and soil within the context of individual housing. This does not reflect the hazards that children may 

encounter in schools or day care centers or in areas in the community, such as parks or lots, where 

housing or other structures painted with lead based paint may be been demolished unsafely and lead 

contaminated soil remains. 

Additional Indicators 

In this report: 

• Concentrations of lead in the blood of children five and under in the United States, 1976–2000 

• Distribution of concentrations of lead in blood of children ages 1–5 in the United States, 1999–

2000 

• On- and off-site releases of lead (and its compounds) in the United States, 1995–2000 from 

industrial facilities 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Concentrations of lead in blood of children ages 5 and under 

 Median concentrations of lead in blood of children ages 1–5, by race/ethnicity and family income 

 Distribution of concentrations of lead in blood of children ages 1–5 

 Children reported to have mental retardation, by race/ethnicity and family income 

 Percentage of California public elementary schools with lead paint and some deterioration of 

paint 

 Percentage of California public elementary schools with lead in soils 

 Percentage of California public elementary schools with lead in drinking water 

Opportunities for Improvement 

As lead has been used in paint as well as gasoline and many industries and is a common hazardous 

contaminant, it may be appropriate to expand this indicator to look at the proximity of children to older 

industry sectors known to use lead such as historic or abandoned smelters, foundries and other industrial 

facilities now considered Brownfields. 
45 

Data on lead in paint at schools and day care facilities would also be an additional important area for 

coverage. 

Develop methodology to link state and local surveillance study to provide robust national risk information. 

Related Programs/Activities 

Objective 8-11 of Healthy People 2010 aims to totally eliminate elevated blood lead levels (target level is 

0 μg/dL) in children by the year 2010. 

EPA’s school program is developing a comprehensive tool to assist school managers in managing 

potential hazards, such as lead-based paint, as part of their maintenance and repair programs. 

http://cfpub.epa.gov/schools/index.cfm 

HUD Office of Healthy Homes and Lead Hazard Control. http://www.hud.gov/offices/lead/

US EPA Lead Awareness Program - http://www.epa.gov/lead/ 

3.3 Industrial Releases of Lead 

In the United States, certain industries and facilities are required to report their annual releases of certain 

chemical substances, and how they are managed as waste, to the US EPA, state, local, and tribal 

governments. Facilities that operate within certain industry sectors; have 10 or more employees; and 

manufacture, process, or use certain chemicals over defined quantities are required to report. This 

information is made available to the public in the Toxics Release Inventory (TRI), a database maintained 

by the US EPA. Lead is one of the compounds required for reporting. The requirements for chemicals 

that persist or bioaccumulate were changed in 2001, so that releases over 0.1 gram for dioxin and dioxinlike compounds, and 10 or 100 pounds for lead and for other persistent and bioaccumulative chemicals, 

have to be reported. 

Figure 3.6 below illustrates the environmental releases (expressed in tonnes) of lead from lead and lead 

compounds from major industrial facilities as reported to EPA’s Toxics Release Inventory Program for 

reporting years 1995 through 2003. 
46 

Figure 3.6: On- and Off-site Industrial Releases of Lead (and its compounds) in 

the United States, 1995–2003 

0

50,000

100,000

150,000

200,000

250,000

1995 1996 1997 1998 1999 2000 2001 2002 2003

Tonnes of Releases

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Number of Reporting Facilities

On-site Air

On-site Water

On-site

Underground

Injection

On-site Land

Off-site

Releases

Number of

Facilities

Source: Toxics Release Inventory, Environmental Protection Agency. 

Key Observations 

• The amount of industrial releases of lead was about 23,500 tonnes (metric tons) in 1995 and 

23,100 tonnes in 2000. There was an increase in the total industrial releases of lead seen in 1997 

with reductions in each subsequent reporting year up to 2000. Most of the increase was due to a 

45 percent increase in the amount of lead released off-site (off-site releases are primarily 

transfers to landfills) between 1996 and 1997. The decrease in later years was not enough to 

offset the earlier increase so that the change for the period 1995–2000 was an increase of 5 

percent. 

• The largest decrease in lead emissions over the 1995–2000 period occurred for releases to onsite land by an overall decrease of 20 percent. Air releases of lead decreased by about 390 

tonnes or 28 percent over the reporting period. 

• For the 2001 reporting year, the quantities of lead reported as being released or otherwise 

managed as waste within the United States increased sharply because more facilities were 

required to report to the Toxics Release Inventory. This increase does not mean that the release 

of lead has increased from industrial facilities, but rather that more industrial facilities are required 

to report their releases of lead. 
47 

Data Table 3.6: On- and Off-site Industrial Releases of Lead (and its compounds) in the United 

States, 1995–2003 

Tonnes 

On-site Air 

On-site 

Water 

On-site 

Underground 

Injection

On-site 

Land

Off-site 

Releases 

Total Onand Off-site 

Releases

Number of 

Facilities

1995 1,384 48 83 7,919 14,034 23,469 1,817 

1996 1,332 35 303 8,192 14,478 24,340 1,820 

1997 1,116 29 120 9,812 20,943 32,021 1,800 

1998 1,041 36 82 9,555 18,480 29,193 1,808 

1999 963 26 83 8,402 16,337 25,811 1,765 

2000 992 28 98 6,365 15,627 23,110 1,848 

2001 697 72 2,833 173,971 17,909 195,482 8,793 

2002 644 64 3,263 162,938 17,322 184,230 8,676 

2003 577 63 3,443 179,537 12,736 196,357 8,388 

Source: Toxics Release Inventory, Environmental Protection Agency.

Limitations 

These data for lead from industry and facility sources are subject to the reporting requirements of the 

Emergency Planning and Community Right-to-Know Act of 1986. These reporting requirements do not 

cover all industry sectors or facilities that may release lead into the environment, nor do they cover all 

anthropogenic sources or natural sources of environmental releases of lead. 

Additional Indicators 

The Centers for Disease Control and Prevention (CDC) has established five environmental health 

indicators that pertain to lead including: two core indicators; blood lead level in children and lead 

poisoning in children; and three indicators that are optional or under development; lead contamination in 

the environment, residence near metal processing industries, and lead elimination programs. For 

additional information, go to the http://www.cdc.gov/ and follow the link to environmental health tracking. 

Opportunities for Improvement 

TRI lead and lead compound emission data could be used as well as State and local surveillance and 

prevalence studies to assist in better characterizing and managing lead hazards in communities. For 

additional information on surveillance and prevalence programs, go to the http://www.cdc.gov/ and follow 

the link to lead poisoning prevention programs. 

Related Programs/Activities 

The US EPA is working with CDC and other partners to link environmental indicators and state and local 

surveillance activities. For additional information, go to the http://www.cdc.gov/ and follow the link to lead 

poisoning prevention. 

The US EPA does not have the authority to regulated leaded gasoline used in racing and the Federal 

Aviation Administration regulates aircraft fuels. In 2002, however, the US EPA chose to release the PBT 

National Action Plan for Alkyl-lead as a voluntary effort to phase out the continued use of alkyl-lead in 

leaded gasoline fuels predominantly used in aviation (piston engine) industry, but also in non-road 

competition race vehicles (cars, boats, etc). For additional information on leaded gasoline phase out 

activities, see http://www.epa.gov/opptintr/pbt/pubs/Alkyl_lead_action_plan_final.pdf. 
48 

3.4 Industrial Releases of Selected Chemicals 

The Toxics Release Inventory (TRI) is a publicly available database maintained by the US EPA that 

contains information on toxic chemical releases and other waste management activities for more than 650 

chemicals reported annually by certain covered industries as well as by federal facilities. A federal law 

called the Emergency Planning and Community Right to Know Act gives the public the right to know 

about toxic chemicals being released into the environment. The law requires facilities in certain industries, 

which manufacture, process, or use significant amounts of toxic chemicals, to report annually on their 

releases and other waste management of these chemicals. The reports contain information about the 

types and amounts of toxic chemicals that are released each year to the air, water and land as well as 

information on the quantities of toxic chemicals sent to other facilities for further waste management. 

Figure 3.7 and Figure 3.8 as well as Data Table 3.7 and Data Table 3.8 contain US data from a 

"matched" data set compiled by the CEC in which only chemicals and industrial sectors for which 

comparable data are available from both the US and Canadian PRTR systems. Therefore these figures 

and data tables present a subset of U.S. data that is comparable to the Canadian data. For a more 

detailed explanation on the specific steps needed to create the comparable, "matched" data set, see 

Chapter 2 of Taking Stock: North American Pollutant Releases and Transfers 2002 at 

<http://www.cec.org/pubs_docs/documents/index.cfm?ID=1753&varlan=english>. 

Figure 3.9 and Data Table 3.9 contain information from the US using the complete US data set available, 

covering nearly 650 chemicals and chemical categories from industries including manufacturing, metal 

and coal mining, electric utilities, commercial hazardous waste treatment, and other industrial sectors. 

Thus, the data in this figure and data table are not comparable to the data in Figure 3.7 and Figure 3.8 or 

Data Table 3.7 and Data Table 3.8. For a more detailed explanation of the coverage of the US data, see 

US EPA Toxics Release Inventory - Reporting Year 2003 Public Data Release, Summary of Key 

Findings at <http://www.epa.gov/tri/tridata/tri03/KeyFind.pdf>. 

Figure 3.7: On- and Off-site Releases of Matched Chemicals From Major Industrial 

Sources, in the United States, 1998–2002 

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1998 1999 2000 2001 2002

Years

0

5,000

10,000

15,000

20,000

25,000 On-site Air

On-site Water

On-site

Underground

Injection

On-site Land

Off-site

Releases

Number of

Facilities

Source: Data compiled by the CEC from a subset of original Pollutant Release Transfer Register data from the 

Toxics Release Inventory (TRI, 2004), US EPA. The data shown are from a “matched” data set compiled by the 

CEC, in which only data are comparable between the Canadian NPRI and the US TRI are included. For information 
49 

on the methods used to compile the matched data sets used for these analyses, please refer to the CEC’s annual 

Taking Stock report, available at www.cec.org/takingstock/. 

Key Observations 

• The total facilities reporting releases of the 153 matched chemicals decreased over the reporting 

period 1998 to 2002, as did the total releases, which went from a high of 1,45 million tonnes in 

1998 to a low of 1,21 million tonnes in 2001 but then increased to 1,28 million tonnes in 2002, for 

an overall decrease of 11 percent from 1998 to 2002. There were reductions in releases to onsite air, water and underground injection, with on-site land and off-site releases (primarily 

transfers to landfills) showing an increase. 

Data Table 3.7: On- and Off-site Releases of Matched Chemicals From Major Industrial Sources in 

the United States, 1998–2002 

Tonnes 

On-site Air 

On-site 

Water 

On-site 

Underground 

Injection

On-site 

Land

Off-site 

Releases 

(adjusted) 

Total Onand Off-site 

Releases

Number of 

Facilities

1998 790,315 109,091 81,493 266,898 202,819 1,450,616 20,223

1999 778,295 115,817 76,927 259,579 209,737 1,440,354 19,899

2000 730,476 115,278 84,929 247,610 220,514 1,398,807 19,854

2001 628,394 97,890 67,992 192,057 226,535 1,212,869 19,053

2002 622,804 98,395 71,603 279,104 212,8 1,284,757 18,245

Source Data compiled by the CEC from a subset of original Pollutant Release Transfer Register data from the Toxics 

Release Inventory (TRI, 2004), US EPA. The data shown are from a “matched” data set compiled by the CEC, in 

which only data are comparable between the Canadian NPRI and the US TRI are included. For information on the 

methods used to compile the matched data sets used for these analyses, please refer to the CEC’s annual Taking 

Stock report, available at www.cec.org/takingstock/. 
50 

Figure 3.8: Total On- and Off-site Releases of Matched Chemicals, by Industry 

Sector, in the United States, 1998–2002 

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

1998 1999 2000 2001 2002

Years

Tonnes

Electric Utilities

All Others

Primary Metals

Chemicals

Hazardous Waste 

 Mgt./Solvent

 Recovery

Source: Data compiled by the CEC from a subset of original Pollutant Release Transfer Register data from the 

Toxics Release Inventory (TRI), US EPA. The data shown are from a “matched” data set compiled by the CEC, in 

which only data are comparable between the Canadian NPRI and the US TRI are included. For information on the 

methods used to compile the matched data sets used for these analyses, please refer to the CEC’s annual Taking 

Stock report, available at www.cec.org/takingstock/. 

Note: This chart depicts the top five industry sectors based on largest total release on- and off-site releases in 1998 

and the continued release trends. 

Key Observations 

• The electric utilities sector reported the largest total releases and showed a decrease of 9 percent 

from 1998 to 2002. The primary metals sector, the second largest sector, reported an increase of 

16 percent in releases over the same time period. The chemical manufacturing sector and the 

hazardous waste management sectors reported the third and fourth largest total releases, with 

overall decreases of 24 percent and 36 percent respectively. The other industry sectors 

combined, the “all others” category (which includes, among others, the food, paper, transportation 

equipment and plastics manufacturing industries), had about 401,000 tonnes of releases in 1998 

and about 321,000 tonnes in 2002. 

Data Table 3.8: Total On- and Off-site Releases of Matched Chemicals by Major Industrial Sectors 

in the United States, 1998–2002 

1998 1999 2000 2001 2002 

Tonnes 

Electric Utilities 413,112 429,991 408,654 369,090 376,769
51 

Primary Metals 288,704 276,723 272,497 234,133 335,450

Chemicals 247,142 238,658 226,805 194,506 187,060

Hazardous Wastes Mgt/Solvent 

Recovery 100,148 102,517 110,206 82,151 64,340 

All Others 401,510 392,465 380,644 332,989 321,138

Source Data compiled by the CEC from a subset of original Pollutant Release Transfer Register data from the Toxics 

Release Inventory (TRI), US EPA. The data shown are from a “matched” data set compiled by the CEC, in which 

only data are comparable between the Canadian NPRI and the US TRI are included. For information on the 

methods used to compile the matched data sets used for these analyses, please refer to the CEC’s annual Taking 

Stock report, available at www.cec.org/takingstock/. 

Figure 3.9: Location of Releases or Transfers of Chemicals from Major Industrial 

Sources, in the United States, 1998–2003 

On-site Air 

Emissions

On-site Surface 

Water Discharges

On-Site 

Underground 

Injection

On-Site Releases 

to Land

Off-site Disposal or 

Other Releases

0

0.5

1

1.5

2

1998 1999 2000 2001 2002 2003

Years

Million Tonnes

Source: Toxics Release Inventory, Environmental Protection Agency.

Key Observations 

• This Table shows additional chemicals and industrial sectors not reflected in the “matched data 

set” depicted in earlier figures and data sets. The “matched data set” is a subset of 153 chemicals 

which represents a fraction of the nearly 650 chemicals reported to the US TRI. 

• In 2001, total on- and off-site releases for all Toxics Release Inventory facilities were 6.16 billion 

pounds. Of these releases, 56 percent were to land, 27 percent were to air, 4 percent were to 

water, 3.5 percent were to underground injection wells, and 9 percent were chemicals disposed of 

off-site to land or underground injection. 
52 

• Between 1998 and 2001, total on- and off-site releases of TRI chemicals decreased by 22 

percent, a net decrease of 1.58 billion pounds. On-site releases decreased by 25 percent, but offsite releases (transfers off-site to disposal) increased by 26 percent. 

• For the core set of chemicals from industries that have reported consistently since 1998, total onand off-site releases decreased by 54.5 percent between 1998 and 2001, a reduction of 1.72 

billion pounds. 

• Between 2001 and 2003, total on- and off-site releases of TRI chemicals further decreased by 23 

percent. Between 2001 and 2003, decreases were seen in on-site air and water discharges and 

land releases while increases were seen in on-site underground injection and off-site disposal or 

other releases. 

Data Table 3.9: Location of Releases or Transfers of Chemicals from Major Industrial Sources in 

the United States, 1998–2003 

Year Emissions (tonnes) 

On-site Air 

Emissions 

On-site 

Surface 

Water 

Discharges 

On-Site 

Underground 

Injection 

On-Site 

Releases to 

Land 

Off-site 

Disposal or 

Other 

Releases 

Total On- and 

Off-site 

Disposal or 

Other 

Releases 

1998 947,113 115,250 117,216 1,715,458 184,755 3,079,793

1999 925,834 121,884 113,732 1,790,445 194,591 3,146,486

2000 868,418 121,090 122,187 1,490,949 216,698 2,819,341

2001 748,734 104,472 94,463 1,133,253 217,830 2,298,752

2002 739,834 105,006 97,563 786,940 211,815 1,941,158

2003 718,032 100,526 96,931 644,087 218,436 1,778,012

Source: Toxics Release Inventory, Environmental Protection Agency. 

Limitations: 

These data are subject to the reporting requirements of the Emergency Planning and Community Rightto-Know Act of 1986. These reporting requirements do not cover all industry sectors or facilities that may 

release lead into the environment, nor do they cover all anthropogenic sources or natural sources of 

environmental releases of lead. 

TRI data are an input to determine exposure or calculate potential risks to human health and the 

environment, but by themselves do not represent risk. The determination of potential risk depends on 

many factors, including toxicity, chemical fate after release, release location, and population 

concentrations. In addition, although the US EPA has expanded the TRI program, it does not cover all 

sources of releases and other waste management activities, such as vehicle emissions, nor does it cover 

all toxic chemicals or industry sectors. Also, while many facilities base their TRI data on monitoring data, 

others report estimated data to TRI as the program does not mandate release monitoring. Finally, 

facilities that do not meet the TRI threshold levels (those with fewer than 10 full-time employees or those 

not meeting TRI quantity thresholds) are not required to report. 

In general, the Toxics Release Inventory (TRI) only includes data from facilities that exceed certain 

threshold requirements and are required to report releases and transfers to TRI. The threshold criteria 

include: 

• Operations within certain industry sectors; 

• Operations that employ more than 10 people; 

• Operations that manufacture or processes more than 25,000 pounds or otherwise uses more 

than 10,000 pounds of any listed chemical during the calendar year. These reporting triggers do 

not include persistent, bioaccumulative, and toxic (PBT) chemicals, such as lead, where the 

thresholds are 0.1 gram for dioxin and dioxin-like compounds, 10 pounds for other highly 
53 

persistent and highly bioaccumulative compounds, and 100 pounds for lead and other PBT 

chemicals. These lower limits were established in 2001. 

Additional Indicators 

In this report: 

• None 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 None 

EPA has also prepared a report on trends in Toxics Release Inventory waste minimization priority 

chemicals (a subset of the TRI chemicals) from 1991–2000, available online at 

http://www.epa.gov/epaoswer/hazwaste/minimize/trends.htm. 

Opportunities for Improvement 

Canada, Mexico, and the United States are working to enhance the comparability of the North American 

Pollutant Release and Transfer Registers (PRTRs) through CEC’s PRTR project. The three nations 

developed An Action Plan to Enhance the Comparability of PRTRs in North America that was adopted by 

the CEC Council in June 2002. This action plan currently is being updated. 

PRTR data could be analyzed using particular subsets of chemicals that are most important to children’s 

health (e.g., PBTs, mercury, carcinogens). This information could be examined at a regional, geographic, 

facility, or industry sector level to identify areas or facilities to work with to set priorities, measure 

progress, and target areas of special and immediate concern. 

Related Programs/Activities 

A federal law called the Emergency Planning and Community Right to Know Act gives the public the right 

to know about toxic chemicals being released into the environment. The law requires facilities in certain 

industries, which manufacture, process, or use significant amounts of toxic chemicals, to report annually 

on their releases of these chemicals. The reports contain information about the types and amounts of 

toxic chemicals that are released each year to the air, water, and land as well as information on the 

quantities of toxic chemicals sent to other facilities for further waste management. EPA compiles the TRI 

data each year and makes them available through several data access tools, including the TRI Explorer 

(http://www.epa.gov/triexplorer) and Envirofacts (http://www.epa.gov/enviro). Additional TRI information, 

including EPA’s annual Public Data Release, also is available on the TRI Web site at 

http://www.epa.gov/tri. 

3.5 Pesticides 

Children may be exposed to pesticides and other contaminants in their food and through day-to-day 

activities around the home. EPA regulates the amounts of pesticides in food, termed “residues,” through 

standards called “food tolerances.” A tolerance is a legal limit on the amount of pesticide residue in a 

particular food. Children’s exposures to pesticides may be higher than the exposures of most adults. 

Pound for pound, children generally eat more than adults, and they may be exposed more heavily to 

certain pesticides because they consume a diet different from that of adults.78 Among the agricultural 

commodities that are consumed by children in large amounts are apples, corn, oranges, rice, and wheat. 

Organophosphate pesticides frequently are applied to many of the foods important in children’s diets, and 

certain organophosphate pesticide residues can be detected in small quantities. When exposure to 

organophosphate pesticides is sufficiently high, they interfere with the proper functioning of the nervous 

system.79 There are approximately 40 organophosphates, and as a group they account for approximately 
54 

half of the insecticide use in the United States. The majority of organophosphate use is on food crops—

including corn, fruits, vegetables, and nuts. In addition, organophosphate pesticides often have been 

used in and around the home. Examples of organophosphate pesticides include chlorpyrifos, azinphos 

methyl, methyl parathion, and phosmet. 

The US Department of Agriculture (USDA) collects annual data on pesticide residues in food. Among the 

foods sampled by the USDA’s Pesticide Data Program in recent years are several that are important parts 

of children’s diets, including apples, apple juice, bananas, carrots, green beans, orange juice, peaches, 

pears, potatoes, and tomatoes. 

The chart below displays the percentage of food samples with detectable organophosphate pesticide 

residues reported by the Pesticide Data Program from 1994 to 2001. The 34 organophosphates that were 

sampled in each of these years are included; other organophosphates that have been added to the 

program in recent years are excluded so that the chart represents a consistent set of pesticides for all 

years shown. This measure is a surrogate for children’s exposure to pesticides in foods: If the frequency 

of detectable levels of pesticides in foods decreases, it is likely that exposures will decrease. However, 

this measure does not account for many additional factors that affect the risk to children. For example, 

some organophosphates pose greater risks to children than others do, and residues on some foods may 

pose greater risks than residues on other foods due to differences in amounts consumed. In addition, 

year-to-year changes in the percentage of samples with detectable pesticide residues may be affected by 

changes in the selection of foods that are sampled each year. 

In accordance with the Food Quality Protection Act (FQPA) of 1996, EPA currently is reassessing all food 

tolerances to assure that they comply with the FQPA’s “reasonable certainty of no harm” standard, with a 

particular focus on protecting children’s health. EPA has concluded that a substantial portion of the 

existing tolerances for organophosphate pesticides meet the stringent safety standards of the FQPA and 

that a significant portion of the potential exposure to organophosphate pesticides is associated with only a 

small number of uses of these compounds. 
55 

Figure 3.10: Percentage of Fruits, Vegetables and Grains with Detectable 

Residues of Organophosphate Pesticides, in the United States, 1994–2001 

0

5

10

15

20

25

30

35

1994 1995 1996 1997 1998 1999 2000 2001

Years

Percent (%)

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens and Illnesses.<www.epa.gov/envirohealth/children>. 

Key Observations 

• Between 1994 and 2001, the percentage of food samples with detectable organophosphate 

pesticide residues ranged between 19 percent and 29 percent. The highest detection rates were 

observed during 1996 and 1997, while the lowest detection rate was observed in 2001. 

• Between 1993 and 2001, the amount of organophosphate pesticides used on foods most 

frequently consumed by children declined from 25 million pounds to 14 million pounds. 

• In 1999–2000, EPA imposed new restrictions on the use of the organophosphate pesticides 

azinphos methyl, chlorpyrifos, and methyl parathion on certain food crops and around the home, 

due largely to concerns about potential exposures of children. 

Data Table 3.10: Percentage of Fruits, Vegetables, and Grains with Detectable Residues of 

Organophosphate Pesticides in the United States, 1994–2001 

1994 1995 1996 1997 1998 1999 2000 2001

20.8% 24.4% 29.4% 28.8% 22.1% 24.4% 23.2% 19.1% 

SOURCE: US Department of Agriculture, Pesticide Data Program 

Limitations 
56 

This indicator is a surrogate for children’s exposure to pesticides in foods: If the frequency of detectable 

levels of pesticides in foods decreases, it is likely that exposures will decrease. However, this indicator 

does not account for many additional factors that affect the risk to children. For example, some 

organophosphates pose greater risks to children than others do, and residues on some foods may pose 

greater risks than residues on other foods due to differences in amounts consumed. In addition, year-toyear changes in the percentage of samples with detectable pesticide residues may be affected by 

changes in the selection of foods that are sampled each year. This indicator does not represent all 

pesticides that may be present as residues on food, nor does it represent all pesticides to which children 

may be exposed. Such exposures may occur in a variety of settings, including in and around the home, 

day care facilities, play areas, or in agricultural areas, for example. 

Additional Indicators 

In this report: 

• None 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Percentage of fruits, vegetables, and grains with detectable residues of organophosphate 

pesticides 

 Frequency of application of pesticides in Minnesota K–12 schools, 1999 

 

Opportunities for Improvement 

As required by the Food Quality Protection Act, EPA currently is conducting a cumulative risk assessment 

for the organophosphate pesticides. For the first time ever, this scientific assessment evaluates the 

potential risks to children from the combined estimates of all contributing organophosphate residues in 

food and drinking water consumption, and from activities around the home. EPA already has imposed 

various restrictions on many individual uses of organophosphates, particularly those that may pose 

greater risk to children from dietary and residential sources. These restrictions, and others that may be 

imposed as a result of the cumulative assessment, are expected to lower children’s potential exposure to 

these pesticides and thereby reduce potential health risks. EPA will evaluate the outputs from the 

cumulative risk assessments to determine how they may be used in developing measures that better 

reflect increases or decreases in pesticide exposure or risk. In addition, national data could be added on 

body burdens for certain pesticides, and will be considered in the future. 

Related Programs/Activities 

Objective 8-13 of Healthy People 2010 aims to reduce pesticide exposures that result in visits to a health 

care facility, and Objective 8-24 aims to reduce exposure to pesticides as measured by urine 

concentrations of metabolites. 

EPA is conducting research to develop and implement an approach to examine the cumulative risks and 

possible health effects from persistent exposure to pesticides via multiple sources and pathways in 

children living along the US-Mexico Border. For more information, see 

http://www.epa.gov/orsearth/projects_publications/urincary_biomarker_data_analysis_and_study_design

_for_children.html. 

EPA also helps support the “For Healthy Kids” project, which focuses on preventing children's exposure 

to pesticides by educating agricultural workers on preventing "the take home pathway" for pesticide 

residue. More information is available at: http://www.epa.prosser.wsu.edu/kids.html. 
57 

4 Waterborne Diseases 

4.1 Drinking Water 

The contaminants in drinking water are quite varied and may cause a range of diseases in children, 

including acute diseases such as gastrointestinal illness, developmental effects such as learning 

disorders, and cancer.80 Children are particularly sensitive to microbial contaminants because their 

immune systems are less developed than those of most adults.80 Children are sensitive to lead, which 

affects brain development,20,23-28,81 and to nitrates and nitrites, which can cause methemoglobinemia (blue 

baby syndrome).82-84 Fertilizer, livestock manures, and human sewage are significant contributors of 

nitrates and nitrites in groundwater sources used for drinking water.85-87 

Public water systems regulated by EPA, and delegated states and tribes, provide drinking water to an 

estimated 90 percent of Americans. Through the Public Water System Supervision program, EPA sets 

and enforces drinking water standards, referred to as Maximum Contaminant Levels (MCLs).88 These 

standards are designed to protect people against adverse health effects from contaminants in drinking 

water while taking into account the technical feasibility of meeting the standard and balancing costs and 

benefits. EPA has set MCLs for more than 80 microbial contaminants, chemicals, and radionuclides. EPA 

also has developed regulations to protect drinking water sources and to require treatment of drinking 

water. An important treatment-related regulation, the Surface Water Treatment Rule, requires treatment of 

surface waters used for drinking water by filtration to remove microbial contaminants. 

Drinking water rules often are added or modified. For example, EPA established more stringent filter 

performance requirements in 1998 to further strengthen protection against microbial contaminants. In the 

same year, EPA also established new drinking water standards for disinfection byproducts, exposure to 

which has been associated with bladder cancer89 and possible reproductive effects.90 In 2000, EPA 

finalized standards protecting against radionuclides in drinking water.91 In addition, EPA strengthened the 

existing standard for arsenic in 2001. Changes in regulatory requirements may affect the outcome of the 

measures presented in this report, as the resulting trends sometimes may be related to changes in 

standards rather than changes in exposures. 

Unlike public water systems, EPA does not have the authority to regulate private drinking water wells. An 

estimated 28 million people or nearly 10 percent of Americans have their own sources of drinking water, 

such as wells, cisterns, and springs.92 Unlike public drinking water systems serving many people, they do 

not have experts regularly checking the water’s source and its quality before it is sent through pipes to the 

community. 
58 

Figure 4.1: Percentage of Children Living in Areas Served by Public Water 

Systems that Exceeded a Drinking Water Standard or Violated a Treatment 

Requirement, in the United States, 1993–1999 

Lead and copper

Microbial 

contaminants

Chemical and 

Radiation

Treatment and 

filtration

All health-based 

violations

Nitrate/Nitrite

0

5

10

15

20

25

1993 1994 1995 1996 1997 1998 1999

Years

Percent (%)

Source: United States Environmental Protection Agency. 2003. America’s Children and the Environment: Measures 

of Contaminants, Body Burdens, and Illnesses. <www.epa.gov/envirohealth/children>. 

Data Source: Safe Drinking Water Information System. Office of Water, US Environmental Protection Agency.

Key Observations 

• The percentage of children served by public water systems that reported exceeding a Maximum 

Contaminant Level (MCL) or violated a treatment standard decreased from 20 percent in 1993 to 

8 percent in 1999. 

• Every category of reported violation decreased between 1993 and 1999 except for nitrates and 

nitrites, which remained steady. The largest decline was for violations of the treatment and 

filtration standards. 

• From 1993-1999, approximately 0.2 percent of the children served by public water systems were 

served by systems that reported violations of the nitrate or nitrite standard. 
59 

Data Table 4.1: Percentage of Children Living in Areas Served by Public Water Systems that 

Exceeded a Drinking Water Standard or Violated a Treatment Requirement in the United States, 

1993–1999

1993-1997 

Type of 

standard 

violated

1993 1994 1995 1996 1997

Lead and 

copper* 2.2% 0.9% 1.4% 1.6% 1.7% 

Microbial 

contaminants 8.3% 7.5% 4.1% 4.3% 3.6% 

Chemical and 

radiation 4.7% 4.7% 2.2% 1.8% 2.4% 

Nitrate/nitrite 0.23% 0.12% 0.25% 0.20% 0.37% 

Treatment and 

filtration 10.7% 8.1% 4.5% 3.7% 3.6% 

Any healthbased 

violations 

20.2% 15.5% 12.0% 10.7% 10.7% 

1998-1999 

Type of 

standard 

violated

1998 1999 

Lead and 

copper* 1.6% 1.5% 

Microbial 

contaminants 2.8% 2.5% 

Chemical and 

radiation 1.2% 1.0% 

Nitrate/nitrite 0.17% 0.21% 

Treatment and 

filtration 3.4% 3.0% 

Any healthbased 

violations 

8.6% 8.0% 

Source: US Environmental Protection Agency, Office of Water, Safe Drinking Water Information System 
60 

Figure 4.2: Percentage of Children Living in Areas Served by Public Water 

Systems with Major Violations of Drinking Water Monitoring and Reporting 

Requirements, in the United States, 1993–1999 

Lead and copper

Microbial 

contaminants

Chemical and 

radiation

Treatment and 

filtration

Any major violation

0%

5%

10%

15%

20%

25%

1993 1994 1995 1996 1997 1998 1999

Years

Percent (%)

Source: US Environmental Protection Agency. 2003. America’s Children and the Environment: Measure of 

Contaminants, Body Burdens, and Illness. www.epa.gov/envirohealth/children

Data: US Environmental Protection Agency. Office of Water. Safe Drinking Water Information Systems (percentages 

are estimated) 

Key Observations 

• In 1993, approximately 22 percent of children lived in an area served by a public water system 

that had at least one major monitoring and reporting violation. This figure decreased to about 10 

percent in 1999. 

• The largest number of monitoring and reporting violations occurred for the lead and copper 

standards. Approximately 11 percent of children in 1993 were served by public water systems 

with monitoring and reporting violations for lead and copper, decreasing to about 5 percent in 

1995. The number has remained relatively constant since then. 
61 

Table 4.2: Percentage of Children Living in Areas Served by Public Water Systems with Major 

Violations of Drinking Water Monitoring and Reporting Requirements in the United States, 1993–

1999 

Source: US Environmental Protection Agency, Office of Water, Safe Drinking Water Information System 

Limitations 

The Safe Drinking Water Information System (SDWIS) does not track concentrations of contaminants in 

drinking water, but instead tracks the frequency with which standards are exceeded. SDWIS also does 

not collect data on the number of children served by public water systems, but only on the total population 

served. EPA has estimated the number of children affected based on county-level census data. Data are 

available only for public water systems. Approximately 28 million people are served by private water 

systems that are not required to monitor and report the quality of drinking water.92 Many people served by 

private water supplies live in rural and agricultural areas, which may be at increased risk for nitrate and 

nitrite contamination. Conversely, many children served by public water systems may not drink the tap 

water or may use a water filtration device to further purify the water. Thus, the indicator may overestimate 

the percentage of children exposed to contaminated drinking water. In addition, the drinking water 

contaminant measures in this report rely on the MCL standards, which are based partly on health 

considerations but also take into account technical feasibility and cost-benefit considerations. The 

reported violations received by the federal government are highly accurate, but violations may be underreported in some cases because some public water systems fail to fully monitor contaminants or report 

their monitoring results. 

1993-1997

Type of 

standard 

violated

1993 1994 1995 1996 1997

Lead and 

copper 

11.3% 6.7% 5.3% 5.2% 5.8% 

Microbial 

contaminants 2.2% 2.6% 2.1% 1.6% 2.0% 

Chemical and 

radiation 8.1% 5.8% 5.5% 4.8% 3.5% 

Treatment and 

filtration 1.6% 0.6% 0.4% 0.5% 0.3% 

Any major 

violation 21.6% 14.2% 11.7% 10.9% 10.9% 

1998-1999

Type of 

standard 

violated

1998 1999 

Lead and 

copper 

5.5% 5.4% 

Microbial 

contaminants 1.9% 1.4% 

Chemical and 

radiation 3.8% 2.8% 

Treatment and 

filtration 0.5% 1.0% 

Any major 

violation 10.6% 9.9% 
62 

Additional Indicators 

In this report: 

 Waterborne Disease Outbreaks by Year and Type of Water System, in the United States, 1971–

2000 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Percentage of children living in areas served by public water systems that exceeded a drinking 

water standard or violated treatment requirements 

 Percentage of children living in areas with major violations of drinking water monitoring and 

reporting requirements 

Opportunities for Improvement 

Each Maximum Contaminant Level in the drinking water standards also has a corresponding Maximum 

Contaminant Level Goal (MCLG), which is based only on health considerations. The MCLGs could be 

considered for measures in future reports. Actual measured contaminant concentrations would provide 

the most relevant measures of potential risks to children. The most complete data on contaminants in 

drinking water are collected at the state level; information from the states would have to be compiled 

nationally to improve the indicators for drinking water. Another limitation of the data on drinking water is 

that many water systems do not adequately monitor for contaminants, so no information about potential 

risks to children in those areas is available. 

Related Programs/Activities 

Objective 8-05 of the federal Healthy People 2010 initiative seeks to increase the number of people 

served by community water systems that meet the regulations of the Safe Drinking Water Act. 

EPA’s “Drinking Water for Kids” site provides information for parents and children about safe drinking 

water: http://www.epa.gov/safewater/kids/index.html. 

4.2 Sanitation 

Canada and the United States have elected not to report on this indicator due to the high percentage of 

coverage for sewage collection and treatment in both urban and rural environments in both countries. 

Most urban and rural communities are served with sewerage and sanitation services or have septic 

systems to collect and treat sewage. Canada has presented this indicator in their country report (see 

Volume II). 

4.3 Waterborne Diseases 

The United States does not collect waterborne disease outbreak information focused exclusively on 

children. However, data are available to present an indicator of waterborne disease outbreaks by year 

and type of water system for the whole population. The data are based on a voluntary reporting system 

and are for outbreaks, not individual cases. The outbreaks are reported based on illness after either 

ingestion of drinking water or exposure to water either at work or recreationally. 
63 

Figure 4.3: Waterborne Disease Outbreaks by Year and Type of Water System, in 

the United States, 1971–2000 

0

10

20

30

40

50

60

1971 1975 1979 1983 1987 1991 1995 1999

Years

Percent (%)

Noncommunity

Individual

Community

Source: Based on data presented in Craun, G.F. and R.L. Calderon. “Waterborne Outbreaks in the United States, 

1971–2000”. In Frederick W. Pontius (ed.), Drinking Water Regulations and Health, New York, NY: John Wiley & 

Sons: 2003, 40-56. 

Note: A waterborne disease outbreak is defined as an event which 1) more than two persons have experienced an 

illness after either the ingestion or drinking water or exposure to water encountered in recreational or occupational 

settings, and 2) epidemiologic evidence implicates water as the probable source of illness. 

Key Observations 

• Between 1971 and 2000, there were 751 reported waterborne disease outbreaks associated with 

drinking water from individual, non-community systems, and community water systems. 

• During 1999–2000, a total of 44 outbreaks (18 from private wells, 14 from non-community 

systems, and 12 from community systems) associated with drinking water were reported by 25 

states. 

• Non-community water systems are systems that either 1) regularly supply water to at least 25 of 

the same people at least 6 months per year but not year round (e.g., schools, factories, office 

buildings, and hospitals that have their own water systems), or 2) provide water in a place where 

people do not remain for long periods of time (e.g., a gas station or campground). Individual water 

systems are not regulated by the Safe Drinking Water Act and serve fewer than 25 persons or 15 

service connections, including many private wells. Community water systems provide water to at 

least 25 of the same people or service connections year round. 
64 

Data Table 4.3: Waterborne Disease Outbreaks by Year and Type of Water System in the United 

States, 1971–2000 (n=751) 

1971 1972 1973 1974 1975 1976 1977 1978 1979 1980

Community 

water systems 8 9 6 11 6 9 14 10 24 26 

Individual 

water systems 4 2 3 5 2 3 2 3 8 7 

Non-community 

water systems 8 19 16 9 17 23 18 19 13 20 

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

Community 

water systems 14 26 30 13 7 10 8 6 6 4 

Individual 

water systems 4 3 4 9 1 2 1 1 1 3 

Non-community 

water systems 19 15 9 5 14 10 6 9 6 8 

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Community 

water systems 2 10 9 6 10 3 3 6 7 5 

Individual 

water systems 0 4 5 2 1 1 0 4 4 14 

Non-community 

water systems 14 15 5 7 9 6 6 1 6 8 

Source: Based on data presented in Craun, G.F. and R.L. Calderon. “Waterborne Outbreaks in the United States, 

1971–2000.” In: Frederick W. Pontius (ed.), Drinking Water Regulations and Health, New York, NY: John Wiley & 

Sons, 2003, 40–56. 

In 2002, giardiasis became a nationally notifiable disease to the Centers for Disease Control and 

Prevention (CDC). From 1998 through 2002, the total number of reported cases of giardiasis decreased 

from 24,226 for 1998 to 19,708 for 2001 and then increased to 21,300 for 2002. The number of states 

reporting giardiasis cases increased from 42 to 46; however, the number of states reporting more than 15 

cases per 100,000 people decreased from 10 to five. A greater number of case reports were received for 

children aged 1–9 years and for adults aged 30–39 years compared with other age groups. Incidence of 

giardiasis was highest in northern states. Peak onset of illness occurred annually during early summer 

through early fall. The seasonal peak in age-specific case reports coincides with the summer recreational 

water season and might reflect increased use of communal swimming venues (e.g., lakes, rivers, 

swimming pools, and water parks) by young children (data now shown). For additional information, see 

the US Centers for Disease Control and Prevention website: http://www.cdc.gov. 

Limitations 

Many factors can influence whether a water-borne disease outbreak (WBDO) is recognized and 

investigated by local, territorial, and state public health agencies. For example, the size of the outbreak, 

severity of the disease caused by the outbreak, public awareness of the outbreak, whether people seek 

medical care or report to a local health authority, reporting requirements, routine laboratory testing for 

organisms, and resources for investigation can all influence the identification and investigation of a 

WBDO. In addition, this system is a voluntary reporting system, so not every state or relevant public 

health agency may be reporting information to the system. This system underreports the true number of 

outbreaks because of the multiple steps required before an outbreak is identified and investigated. Thus, 

an increase in the number of outbreaks reported could either reflect an actual increase or improved 

surveillance and reporting at the local and state level. This indicator provides data only on microbial 
65 

outbreaks and does not include other contaminants that are relevant to children’s health, such as lead. 

Furthermore, the indicator provides data on the entire population, not just children. 

Additional Indicators 

In this report: 

• Percentage of children living in areas served by public water systems that exceeded a drinking 

water standard or violated a treatment requirement, in the United States, 1993–1999 

• Percentage of children living in areas served by public water systems with major violations of 

drinking water monitoring and reporting requirements, in the United States, 1993–1999 

In EPA’s America’s Children and the Environment report, available at www.epa.gov/envirohealth/children: 

 Percentage of children living in areas served by public water systems that exceeded a drinking 

water standard or violated treatment requirements 

 Percentage of children living in areas with major violations of drinking water monitoring and 

reporting requirements 

Opportunities for Improvement 

Standardized surveillance and collection of data could be implemented to provide reliable estimates of 

waterborne disease outbreaks. In addition, this data is not specific to children, so additional information 

could be collected on the age of the population affected. 

Related Programs/Activities 

Objective 8-05 of the federal Healthy People 2010 initiative seeks to increase the number of people 

served by community water systems that meet the regulations of the Safe Drinking Water Act. 

The Centers for Disease Control and Prevention and EPA are collaborating on a series of epidemiology 

studies to assess the magnitude of non-outbreak waterborne illness associated with consumption of 

municipal drinking water. 

EPA’s “Drinking Water for Kids” site provides information for parents and children about safe drinking 

water: http://www.epa.gov/safewater/kids/index.html. 
66 

5 Opportunities for Improvement 

Ideally, data sources for all indicators would provide information collected in a consistent manner for all of 

the nation’s children. Data also would be available for 10 years or more to provide information about 

changes over time, and to show whether the changes were statistically significant. Information would be 

available on differences among geographic areas, by race/ethnicity, and by economic status. 

5.1 Indicators Related to Asthma and Respiratory Disease

15.1.1 Outdoor Air Pollution 

The indicators could provided additional information to reflect the number, margin, and duration of 

exceedances to help distinguish among exceedances. More frequent measurement of PM10 and 

other pollutants to include in the Air Quality Index may more accurately reflect air quality. The 

combination of multiple pollutants as part of an overall air quality index might better replicate the 

health impacts of high pollution days and provide more useful information on potential air quality 

hazards to sensitive populations. In addition, consideration of the potential for health risks from 

long-term exposures to pollutants could be incorporated into an indicator. 

15.1.2 Indoor Air Pollution 

For indoor air quality in general, the most important improvement would be to add data about 

sources of other indoor air pollutants, such as consumer products, gas stoves, and furnishings, 

for both homes and schools. 

For the indicator on the percentage of children ages 6 and under regularly exposed to 

secondhand smoke in the home, it would be ideal if data were available on an annual rather than 

periodic basis. 

The indicators on cotinine could be improved by finding a consistent and reliable method to 

measure exposure levels in infants and toddlers (ages 0–3). 

15.1.3 Asthma 

Continuing refinements in the National Health Interview Survey questions may help reduce any 

false self-reporting of asthma. The questions now ask whether a health professional has 

diagnosed a child with asthma. Additional research could be conducted to document the role of 

environmental factors in the prevalence of asthma 

5.2 Indicators Related to the Effects of Lead and Chemicals, Including 

Pesticides

5.2.1 Blood Lead Levels 

Enhanced monitoring at the state level could improve the availability of geographically specified 

data and could provide more information about existence of higher end exposures. 

5.2.2 Lead in the Home 

As lead has been used in paint as well as gasoline and many industries and is a common 

hazardous contaminant, it may be appropriate to expand this indicator to look at the proximity of 

children to older industry sectors known to use lead such as historic or abandoned smelters, 

foundries and other industrial facilities now considered Brownfields. 

Data on lead in paint at schools and day cares would also be an additional important area for 

coverage. 
67 

5.2.3 Industrial Releases of Lead 

Improved coordination between state and local health agencies conducting surveillance in areas 

where industrial emissions may pose health risks to communities. 

5.2.4 Industrial Releases of Certain Toxic Chemicals 

Canada, Mexico, and the United States are working to enhance the comparability of the North 

American Pollutant Release and Transfer Registers (PRTRs) through CEC’s PRTR project. The 

three nations developed An Action Plan to Enhance the Comparability of PRTRs in North 

America that was adopted by the CEC Council in June 2002. This action plan currently is being 

updated. 

PRTR data could be analyzed using particular subsets of chemicals that are most important to 

children’s health (e.g., PBTs, mercury, carcinogens). This information could be examined at a 

regional, geographic, facility, or industry sector level to identify areas or facilities to work with to 

set priorities, measure progress, and target areas of special and immediate concern. 

5.2.5 Pesticide 

As required by the Food Quality Protection Act, EPA currently is conducting a cumulative risk 

assessment for the organophosphate pesticides. For the first time ever, this scientific assessment 

evaluates the potential risks to children from the combined estimates of all contributing 

organophosphate residues in food and drinking water consumption, and from activities around the 

home. EPA will evaluate the outputs from the cumulative risk assessments to determine how they 

may be used in developing measures that better reflect increases or decreases in pesticide 

exposure or risk. In addition, the Agency expects to add indicators of pesticide exposures to the 

body burdens section of future editions of the America’s Children and the Environment report. 

5.3 Indicators Related to Waterborne Diseases 

5.3.1 Drinking Water Systems in Violation of Standards 

Each Maximum Contaminant Level in the drinking water standards also has a corresponding 

Maximum Contaminant Level Goal (MCLG), which is based only on health considerations. The 

MCLGs could be considered for measures in future reports. 

Actual measured contaminant concentrations would provide the most relevant measures of 

potential risks to children. The most complete data on contaminants in drinking water are 

collected at the state level; information from the states would have to be compiled nationally to 

improve the indicators for drinking water. 

Another limitation of the data on drinking water is that many water systems do not adequately 

monitor for contaminants, so no information about potential risks to children in those areas is 

available. 

5.3.2 Waterborne Diseases 

Standardized surveillance and collection of data could be implemented to provide reliable 

estimates of waterborne disease outbreaks. In addition, this data is not specific to children, so 

additional information could be collected on the age of the population affected. 
68 

6 References 

Many of the indicators presented here were originally developed for the following two reports: 

America’s Children and the Environment, US EPA, 2003. 

Web site: http://www.epa.gov/envirohealth/children

Draft Report on the Environment, US EPA, 2003. 

Web site: http://www.epa.gov/indicators/roe/

Specific information sources used to develop the indicators are listed below. 

Air Quality Standards 

US Environmental Protection Agency, Office of Air Quality Planning and Standards, Aerometric 

Information Retrieval System (now the Air Quality System) 

Web site: http://www.epa.gov/ttn/airs/airsaqs/

Indoor Air Quality 

Data from US Centers for Disease Control, National Center for Health Statistics. 

National Health Interview Survey. 

Web site: http://www.cdc.gov/nchs/nhis.htm

National Health and Nutrition Examination Survey. 

Web site: http://www.cdc.gov/nchs/nhanes.htm

Asthma Prevalence 

US Centers for Disease Control and Prevention, National Center for Health Statistics, National Health 

Interview Survey. 

Web site: http://www.cdc.gov/nchs/nhis.htm 

Blood Lead Levels 

Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and 

Nutrition Examination Survey. 

Web site: http://www.cdc.gov/nchs/nhanes.htm

Pesticide Residues 

US Department of Agriculture, Pesticide Data Program. 

Web site: http://www.ams.usda.gov/science/pdp/ 

US Environmental Protection Agency, Office of Pesticide Programs. 

Web site: http://www.epa.gov/pesticides 

Pollutant Release and Transfer Registers Data 

EPA Office of Environmental Information, 2001 Toxics Release Inventory (TRI) Public Data Release 

Report, June 2003 

Web site: http://www.epa.gov/tri

Drinking Water Standards and Treated Water 

US Environmental Protection Agency, Safe Drinking Water Information System 

Web site at http://www.epa.gov/safewater/sdwisfed/sdwis.htm
69 

Waterborne Disease Outbreaks 

Craun, G.F. and R.L. Calderon. “Waterborne Outbreaks in the United States, 1971–2000.” In: Frederick 

W. Pontius (ed.), Drinking Water Regulations and Health, New York, NY: John Wiley & Sons, 2003, 40–

56. 

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74 

Appendix 1 US Metadata for the Indicators 

Percentage of children living in counties in which air 

quality standards were exceeded in the United States, 

1990–2003 

Type of indicator: 

Exposure surrogate 

INDICATOR Description 

Definition The percentage of US children living in counties in which national air quality 

standards were exceeded. 

Rationale and role Air pollution contributes to a wide variety of adverse health effects. The US 

Environmental Protection Agency has set National Ambient Air Quality Standards 

that specify allowable concentrations of the most common air pollutants. The 

standards are set at a level that protects public health with an adequate margin of 

safety. The indicator shows the percentage of children living in counties in which 

these air quality standards were exceeded. 

Data Range Dates: 1990–2003. 

Ages: 0–18. 

Data sources, 

availability and quality 

State and local environmental agencies conduct air monitoring programs to 

measure concentrations of common air pollutants. The individual measurements are 

submitted to EPA for inclusion in a national database called the Air Quality System. 

EPA identifies instances in which levels of air pollutants measured in the air are 

greater than the air quality standards. Data quality is considered high, but not all 

counties measure all air pollutants and some do not measure any. Agency Contact: 

David Mintz (mintz.david@epa.gov) or James Hemby (hemby.james@epa.gov), US 

EPA, Office of Air Quality Planning and Standards. Details on the Census data used 

are available in America’s Children and the Environment, at 

<http://www.epa.gov/envirohealth/children>. 

Units of measurement Air quality standards use various units of measurement depending on the pollutant. 

The values representing an exceedance for the pollutants presented here are 

shown in Table 1 at 

http://www.epa.gov/envirohealth/children/contaminants/data.htm. 

Computation EPA’s Air Quality System reports counties that exceeded the various standards. 

Census data were used to determine the number of children living in these counties. 

The percentage of children living in counties that exceeded the various standards 

was then calculated by dividing the number of children living in these counties by 

the total number of children in the United States. 

Sources of further 

information 

Data are from the Aerometric Information Retrieval System (now the Air Quality 

System), at http://www.epa.gov/ttn/airs/airsaqs/, US Environmental Protection 

Agency, Office of Air Quality Planning and Standards. 

Scale of application National. This indicator aggregates county-level data for all counties in the United 

States that monitor common air pollutants. Note that many counties monitor only 

some air pollutants and some counties do not monitor any. 

Useful references US Environmental Protection Agency, Office of Air Quality Planning and Standards, 

Aerometric Information Retrieval System (now the Air Quality System), at 

<http://www.epa.gov/ttn/airs/airsaqs/>. The indicator was developed for EPA's 

report, America's Children and the Environment. Additional information is available 

at www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

The indicator provides national-scale data on the percentage of children living in 

counties in which air quality concentrations were above the level of the standard. 
75 

Percentage of children’s days with good, moderate, or 

unhealthy air quality 

Type of indicator: 

Exposure surrogate 

INDICATOR Description 

Definition The percentage of US children’s days with good, moderate, or unhealthy air quality, 

as defined by the US Environmental Protection Agency’s Air Quality Index. 

Rationale and role Air pollution contributes to a wide variety of adverse health effects. The US 

Environmental Protection Agency has set National Ambient Air Quality Standards 

that specify allowable concentrations of the most common air pollutants. The 

standards are set at a level that protects public health with an adequate margin of 

safety. The indicator shows the percentage of children’s days of exposure 

considered to be of good, moderate, or unhealthy air quality . 

Data Range Dates: 1990–1999. 

Ages: 0–18. 

Data sources, 

availability and quality 

State and local environmental agencies conduct air monitoring programs to 

measure concentrations of common air pollutants. The individual measurements are 

submitted to EPA for inclusion in a national database called the Air Quality System. 

EPA provides an Air Quality Index (AQI) that represents air quality for specific days 

and is widely reported in newspapers and other media outlets in metropolitan areas. 

Data quality is considered high, but not all counties measure all air pollutants and 

some do not measure any. Agency Contact: David Mintz (mintz.david@epa.gov) or 

James Hemby (hemby.james@epa.gov), US EPA, Office of Air Quality Planning 

and Standards. 

Units of measurement Air quality standards use various units of measurement depending on the pollutant. 

Computation The AQI is based on measurements of up to five of the six air quality criteria 

pollutants (carbon monoxide, ground-level ozone, nitrogen dioxide, particulate 

matter, and sulfur dioxide). Lead is not included in the AQI. An AQI value of 100 for 

a criteria pollutant generally corresponds to the short-term National Ambient Air 

Quality Standard for that pollutant, and is the level EPA has set to protect public 

health for a single day. Above this level, pollutant-specific health advisories are 

issued. EPA has divided the AQI scale into categories. Air quality is considered 

“good” if the AQI is between 0 and 50, posing little or no risk. Air quality is 

considered “moderate” if the AQI is between 51 and 100. Some pollutants at this 

level may present a moderate health concern for a small number of individuals. 

Moreover, such a level may pose health risks if maintained over many days. Air 

quality is considered “unhealthy for sensitive groups” if the AQI is between 101 and 

150. Members of sensitive groups such as children may experience health effects, 

but the general population is unlikely to be affected. Air quality is considered 

“unhealthy” if the AQI is between 151 and 200. This indicator was developed by 

reviewing the air quality designation for each day for each county and weighting the 

daily designations by the number of children living in each county. The overall 

measure reports the percentage of children’s days of exposure considered to be of 

good, moderate, or unhealthy air quality. 

Sources of further 

information 

Data are from the Aerometric Information Retrieval System (now the Air Quality 

System), at http://www.epa.gov/ttn/airs/airsaqs/, US Environmental Protection 

Agency, Office of Air Quality Planning and Standards 

Scale of application National. This indicator aggregates county-level data for all counties in the United 

States that monitor common air pollutants. Note that many counties monitor only 

some air pollutants and some counties do not monitor any. 

Useful references US Environmental Protection Agency, Office of Air Quality Planning and Standards, 

Aerometric Information Retrieval System (now the Air Quality System), at 

http://www.epa.gov/ttn/airs/airsaqs/. The indicator was developed for EPA's report, 

America's Children and the Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

The indicator provides a sense of the intensity of pollution over the course of a year. 

This method provides data on the air quality category for each day, rather than 

simply reporting whether a county ever exceeds any standard for any pollutant. 

Counties in which air quality concentrations were above the level of the standard. 
76 

Percentage of children ages 6 and under regularly 

exposed to secondhand smoke in US homes, 1994–2003 

Type of indicator: 

Measure of exposure 

INDICATOR Description 

Definition The percentage of children ages 6 and under regularly exposed to secondhand 

smoke in the home. 

Rationale and role Children who are exposed to secondhand smoke are at increased risk for a number 

of adverse health effects, including lower respiratory tract infections, bronchitis, 

pneumonia, fluid in the middle ear, asthma symptoms, and sudden infant death 

syndrome. Exposure to secondhand smoke also may be a risk factor contributing to 

the development of new cases of asthma. Smoking in the home is an important 

source of exposure because young children spend most of their time at home and 

indoors. 

Data Range Dates: 1994–2003. 

Ages: 0–6 years old. 

Data sources, 

availability and quality 

For 1994 and 1998, exposure in the home was measured by data from the National 

Health Interview Survey (NHIS), administered by the Centers for Disease Control 

and Prevention’s National Center for Health Statistics. Specifically, the measure 

indicates the percentage of children 6 years and under who are exposed regularly 

(4 or more days per week) to secondhand smoke in the home. For 2003, data are 

from US EPA Indoor Environments Division, National Survey on Environmental 

Management of Asthma and Children’s Exposure to Tobacco Smoke. 

Units of measurement Simple percentage, based on survey results. 

Computation Results are calculated from responses to the survey questions 

Sources of further 

information 

NHIS Web site: http://www.cdc.gov/nchs/nhis.htm

Respiratory Health Effects of Passive Smoking (EPA, 1992): 

http://cfpub.epa.gov/ncea/cfm/recordisplay.cfm?deid=2835

Health Effects of Exposure to Environmental Tobacco Smoke (California EPA, 

1997): http://www.oehha.org/air/environmental_tobacco/finalets.html 

Scale of application National. 

Useful references NHIS Web site: http://www.cdc.gov/nchs/nhis.htm

EPA Smoke-free Homes site: http://www.epa.gov/smokefree/. 

The indicator was developed for EPA's report, America's Children and the 

Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

This indicator is a measure of the exposure of children to tobacco smoke, an 

important indoor pollutant. The measure is based on nationally representative 

survey data. 
77 

Percentage of children ages 4-11 with detectable blood 

cotinine by race and ethnicity, 1988–94 and 1999–2000

Type of indicator: 

Body burden 

INDICATOR Description 

Definition The percentage of US nonsmoking children ages 4–11 with specified levels of 

serum cotinine, by race and ethnicity. 

Rationale and role Children who are exposed to secondhand smoke are at increased risk for a number 

of adverse health effects, including lower respiratory tract infections, bronchitis, 

pneumonia, fluid in the middle ear, asthma symptoms, and sudden infant death 

syndrome. Exposure to secondhand smoke also may be a risk factor contributing to 

the development of new cases of asthma. Smoking in the home is an important 

source of exposure because young children spend most of their time at home and 

indoors. 

Data Range Dates: 1988–94, 1999–2000. 

Ages: 4–11 

Data sources, 

availability and quality 

Data on children’s cotinine levels were obtained from the National Health and 

Nutrition Examination Surveys (NHANES) III, and NHANES 1999–2000, conducted 

by the National Center for Health Statistics. The survey is designed to assess the 

health and nutritional status of the non-institutionalized civilian population with direct 

physical examinations and interviews, using a complex multi-stage, stratified, 

clustered sampling design. Interviewers obtain information on personal and 

demographic characteristics, including age, household income, and race and 

ethnicity by self-reporting or as reported by an informant. NHANES III covers the 

period 1988–1994. Starting in 1999, NHANES changed to a continuous survey 

visiting 15 US locations per year and surveying and reporting for approximately 

5,000 people annually. 

Units of measurement Simple percentage, based on survey results. 

Computation Exposure is measured by analyzing the cotinine levels in the blood. Data presented 

for nonsmokers only, defined as those with less than 11 ng/mL serum cotinine. 

Detectable cotinine levels are at or above 0.05 ng/mL. 

Sources of further 

information 

Clifford Johnson, National Center for Health Statistics, clj1@cdc.gov 

Scale of application National. 

Useful references National Health and Nutrition Examination Survey web site: 

www.cdc.gov/nchs/nhanes.htm

Centers for Disease Control and Prevention: Second National Report on Human 

Exposure to Environmental Chemicals: http://www.cdc.gov/exposurereport/ 

The indicator was developed for EPA's report, America's Children and the 

Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

Cotinine, one of the major metabolites of nicotine, is considered a very good 

biomarker of recent exposure to secondhand smoke. The indicator is based on 

nationally representative survey data. 
78 

Percentage of children with asthma in the United States, 

1980–2003 

Type of indicator: 

Effect 

INDICATOR Description 

Definition The percentage of children in the United States with asthma, from 1980–2003. 

Rationale and role Asthma is the most common chronic disease among children and is costly in both 

human and monetary terms. Environmental factors may increase the severity or 

frequency of asthma attacks in children who have the disease. Children with asthma 

are particularly sensitive to outdoor air pollutants, including ozone, particulate 

matter, and sulfur dioxide. These pollutants can exacerbate asthma. 

Data Range Dates: 1980–2003. 

Ages: 0–18. 

Data sources, 

availability and quality 

Data are from the US Centers for Disease Control and Prevention, National Center 

for Health Statistics, National Health Interview Survey. Data are collected through 

personal household interviews. 

Units of measurement Simple percentage of children reported or diagnosed as having asthma. 

Computation Simple tabulation of children reported as having asthma or having been diagnosed 

as having asthma. Prior to 1997, the National Health Interview Survey asked 

parents if their child had asthma in the past 12 months. From 1997–2000, the 

survey asked parents the following two questions: “Has a doctor or other health 

professional ever told you that [child’s name] had asthma?” and if yes, “During the 

past 12 months, has [child’s name] had an episode of asthma or an asthma attack?” 

In 2001, the NHIS added the following new question: “Does [child’s name] still have 

asthma?” This question was used to estimate the percentage of children who 

currently have asthma. 

Sources of further 

information 

Laura Montgomery, National Center for Health Statistics, lem3@cdc.gov. National 

Health Interview Survey Web site: http://www.cdc.gov/nchs/nhis.htm 

Scale of application National. 

Useful references National Health Interview Survey Web site: http://www.cdc.gov/nchs/nhis.htm. 

The indicator was developed for EPA's report, America's Children and the 

Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

A national-scale indicator of the prevalence of asthma, based on direct interviews. 
79 

Percentage of children having an asthma attack in the 

previous 12 months, by race/ethnicity and family income, 

1997–2000 

Type of indicator: 

Effect 

INDICATOR Description 

Definition The percentage of children in the United States having an asthma attack in the 

previous 12 months, by race/ethnicity and family income, 1997–2000. 

Rationale and role Asthma is the most common chronic disease among children and is costly in both 

human and monetary terms. Environmental factors may increase the severity or 

frequency of asthma attacks in children who have the disease. Children with asthma 

are particularly sensitive to outdoor air pollutants, including ozone, particulate 

matter, and sulfur dioxide. These pollutants can exacerbate asthma. Risk for 

asthma may differ by race/ethnicity and socioeconomic status. 

Data Range Dates: 1997–2000. 

Ages: 0–18. 

Data sources, 

availability and quality 

Data are from the US Centers for Disease Control and Prevention, National Center 

for Health Statistics, National Health Interview Survey. Data are collected through 

personal household interviews. 

Units of measurement Simple percentage of children reported or diagnosed as having asthma. 

Computation From 1997–2000, the survey asked parents the following two questions: “Has a 

doctor or other health professional ever told you that [child’s name] had asthma?” 

and if yes, “During the past 12 months, has [child’s name] had an episode of 

asthma or an asthma attack?” 

Sources of further 

information 

Laura Montgomery, National Center for Health Statistics, lem3@cdc.gov. National 

Health Interview Survey Web site: http://www.cdc.gov/nchs/nhis.htm 

Scale of application National. 

Useful references National Health Interview Survey Web site: http://www.cdc.gov/nchs/nhis.htm. 

The indicator was developed for EPA's report, America's Children and the 

Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

A national-scale indicator of the prevalence of asthma, based on direct interviews. 
80 

Concentrations of lead in the blood of children five and 

under in the United States, 1976–2002 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition The distribution of blood lead levels among children for the years 1999–2000. 

Rationale and role Lead is an important environmental health hazard for young children. Lead 

contributes to learning problems such as reduced intelligence and cognitive 

development. Studies also have found that childhood exposure to lead 

contributes to attention-deficit/hyperactivity disorder and hyperactivity and 

distractibility; increases the likelihood of dropping out of high school, having 

a reading disability, lower vocabulary, and lower class standing in high 

school; and increases the risk for antisocial and delinquent behavior. A 

blood lead level of 10 micrograms per deciliter (μg/dL) or greater is 

considered elevated, but there is no demonstrated safe concentration of 

lead in blood. Adverse health effects can occur at lower concentrations.

Data Range Dates: 1976–2001 

Ages: 0–5 

Data sources, 

availability and quality 

Data are from the Centers for Disease Control and Prevention, National Center for 

Health Statistics, National Health and Nutrition Examination Survey. Body burden 

data from NHANES 1999–2000 are presented in: Second National Report on 

Human Exposure to Environmental Chemicals. Atlanta, GA: Centers for Disease 

Control and Prevention, National Center for Environmental Health, January 2003. 

http://www.cdc.gov/nchs/nhanes.htm. Contact: Clifford Johnson (clj1@cdc.gov) 

Units of measurement Blood lead concentrations are measured in micrograms per deciliter of blood. 

Computation Data on children’s blood lead levels were obtained from the National Health and 

Nutrition Examination Surveys (NHANES) II and III, and NHANES 1999–2000, 

conducted by the National Center for Health Statistics. The survey is designed to 

assess the health and nutritional status of the non-institutionalized civilian 

population with direct physical examinations and interviews, using a complex multistage, stratified, clustered sampling design. Interviewers obtain information on 

personal and demographic characteristics, including age, household income, and 

race and ethnicity by self-reporting or as reported by an informant. The first survey, 

NHANES I, was conducted during the periods 1971–1974 and 1974–1975; 

NHANES II covered the period 1976–1980; and NHANES III covered the period 

1988–1994. Only NHANES II and III, however, contain data on blood lead levels. 

NHANES II provided blood lead data for children ages 6 months to 5 years; 

NHANES III provided data on children ages 1–5 years. Starting in 1999, NHANES 

changed to a continuous survey visiting 15 US locations per year and surveying and 

reporting for approximately 5,000 people annually. The percentage of children with 

blood lead levels greater than 10 μg/dL is influenced by the proportion of 

nonresponses within each category. Families with incomes below the poverty level 

had a lower response rate than families with incomes at or above the poverty level. 

The percentages are thus the best estimates available, but may be biased by the 

variation of nonresponses by family income. 

Sources of further 

information 

Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. 

Scale of application National. 

Useful references Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. The indicator was developed for EPA's report, 

America's Children and the Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

Provides representative national data on blood lead levels of children ages 5 and 

under. 
81 

Distribution of concentrations of lead in blood of children 

ages 1-5 in the United States, 1999–2000 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition The distribution of blood lead levels among children for the years 1999–2000. 

Rationale and role A blood lead level of 10 micrograms per deciliter or greater is considered elevated, 

but there is no demonstrated safe concentration of lead in blood. Adverse health 

effects can occur at lower concentrations. A growing body of research has found 

measurable adverse neurological effects in children at blood lead concentrations as 

low as 1 microgram per deciliter. EPA believes that effects may occur at blood lead 

levels so low that there is essentially no “safe” level of lead. 

Data Range Dates: 1999–2000. 

Ages: 1–5. 

Data sources, 

availability and quality 

Data are from the Centers for Disease Control and Prevention, National Center for 

Health Statistics, National Health and Nutrition Examination Survey. Body burden 

data from NHANES 1999–2000 are presented in: Second National Report on 

Human Exposure to Environmental Chemicals. Atlanta, GA: Centers for Disease 

Control and Prevention, National Center for Environmental Health, January 2003. 

http://www.cdc.gov/nchs/nhanes.htm. Contact: Clifford Johnson (clj1@cdc.gov) 

Units of measurement Percentage of children; blood lead concentrations are measured in micrograms per 

deciliter of blood. 

Computation Simple distribution (histogram) of percentage of children with various ranges of 

blood concentrations (0–1, 1–2, 2–3, 3–4, 4–5, 5–6, 6–7, and greater than 7 

micrograms per deciliter). 

Sources of further 

information 

Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. 

Scale of application National. 

Useful references Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. The indicator was developed for EPA's report, 

America's Children and the Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

Provides representative national data on blood lead levels of children ages 5 and 

under. 
82 

Median concentrations of lead in blood of children ages 1–

5, by race/ethnicity and family income, 1999–2000 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition Median concentrations of lead in the blood of children for the years 1999–2000. 

Rationale and role A blood lead level of 10 micrograms per deciliter or greater is considered elevated, 

but there is no demonstrated safe concentration of lead in blood. Adverse health 

effects can occur at lower concentrations. A growing body of research has found 

measurable adverse neurological effects in children at blood lead concentrations as 

low as 1 microgram per deciliter. EPA believes that effects may occur at blood lead 

levels so low that there is essentially no “safe” level of lead. 

Data Range Dates: 1999–2000. 

Ages: 1–5. 

Data sources, 

availability and quality 

Data are from the Centers for Disease Control and Prevention, National Center for 

Health Statistics, National Health and Nutrition Examination Survey. Body burden 

data from NHANES 1999–2000 are presented in: Second National Report on 

Human Exposure to Environmental Chemicals. Atlanta, GA: Centers for Disease 

Control and Prevention, National Center for Environmental Health, January 2003. 

http://www.cdc.gov/nchs/nhanes.htm. Contact: Clifford Johnson (clj1@cdc.gov) 

Units of measurement Percentage of children; blood lead concentrations are measured in micrograms per 

deciliter of blood. 

Computation Percentage calculated from survey results. 

Sources of further 

information 

Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. 

Scale of application National. 

Useful references Centers for Disease Control and Prevention, National Center for Health Statistics, 

National Health and Nutrition Examination Survey. 

http://www.cdc.gov/nchs/nhanes.htm. The indicator was developed for EPA's report, 

America's Children and the Environment. Additional information is available at 

www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

Provides representative national data on median blood lead levels of children ages 

5 and under by race/ethnicity and family income. 
83 

Lead in US housing, 1998–2000 Type of indicator: 

Exposure 

INDICATOR Description 

Definition Percentage of US homes with paint that had some lead in it, and percent of housing 

units with significant lead-based paint, significantly deteriorated lead-based paint, 

interior lead-contaminated dust above EPA standard and lead contaminated soil 

above EPA standard, 1998–2000. 

Rationale and role Today, elevated blood lead levels in the United States are due mostly to ingestion of 

contaminated dust, paint, and soil. 

Data Range Dates: 1998–2000. 

Data sources, 

availability and quality 

Data are from the National Survey of Lead and Allergens in Housing, under 

sponsorship of the Department of Housing and Urban Development and the 

National Institute of Environmental Health Sciences. 

Units of measurement Percentage of houses. 

Computation Percentage calculated from survey results. 

Sources of further 

information 

National Survey of Lead and Allergens in Housing, under sponsorship of the 

Department of Housing and Urban Development and the National Institute of 

Environmental Health Sciences. 

http://www.hud.gov/utilities/intercept.cfm?/offices/lead/hhi/HUD_NSLAH_Vol1.pdf. 

Scale of application National. 

Useful references National Survey of Lead and Allergens in Housing, under sponsorship of the 

Department of Housing and Urban Development and the National Institute of 

Environmental Health Sciences. 

http://www.hud.gov/utilities/intercept.cfm?/offices/lead/hhi/HUD_NSLAH_Vol1.pdf. 

Strengths of the 

Indicator 

Provides representative national data on lead-based paint in homes. 
84 

On- and off-site releases of lead (and its compounds) in 

the United States, 1995–2003 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition Releases of lead and its compounds from manufacturing facilities between 1995 and 

2003. 

Rationale and role Today, elevated blood lead levels in the United States are due mostly to ingestion of 

contaminated dust, paint, and soil. 

Data Range Dates: 1995–2003. 

Data sources, 

availability and quality 

Data are from the US Toxics Release Inventory (TRI) are included. For information 

on the methods used to compile the matched data sets used for these analyses, 

please refer to the CEC’s annual Taking Stock report, available at 

www.cec.org/takingstock/. 

 For the TRI, facilities in all parts of the United States report their releases of 

over 650 toxic chemicals and chemical compounds to EPA and state agencies. 

Facilities indicate whether the releases were to land, air, water, underground injection 

well, or offsite disposal facilities. TRI includes a large amount of information on more 

than 600 chemicals and 30 chemical categories, including arsenic, cyanide, dioxin, 

lead, mercury, and nitrate compounds, and provides information on the amount and 

trends in releases and other waste management of chemicals, including recycling, 

energy recovery, and treatment. 

 Under the Emergency Planning and Community Right to Know Act of 1986 

and the Pollution Prevention Act of 1990, EPA’s Office of Environmental Information 

makes these data available to the public annually via the Toxics Release Inventory 

(TRI) Public Data Release Report, as well as through several data access tools, 

including TRI Explorer (http://www.epa.gov/triexplorer) and Envirofacts 

(http://www.epa.gov/enviro). 

 The Toxics Release Inventory (TRI) is a publicly available database that 

contains information on toxic chemical releases and other waste management 

activities for more than 600 chemicals reported annually by certain covered industries 

as well as by federal facilities. TRI data are an input to determine exposure or 

calculate potential risks to human health and the environment, but by themselves do 

not represent risk. The determination of potential risk depends on many factors, 

including toxicity, chemical fate after release, release location, and population 

concentrations. In addition, although EPA has expanded the TRI program, it does not 

cover all sources of releases and other waste management activities, such as vehicle 

emissions, nor does it cover all toxic chemicals or industry sectors. Also, while many 

facilities base their TRI data on monitoring data, others report estimated date to TRI 

as the program does not mandate release monitoring. Finally, facilities that do not 

meet the TRI threshold levels (those with fewer than 10 full-time employees or those 

not meeting TRI quantity thresholds) are not required to report. 

Units of measurement Metric tons. One metric ton (tonne) equals 1.1 short tons. 

Computation The US facility TRI lead emissions reporting industries expanded as a result of a US 

program change during the timeframe reflected in this report. Though new facility 

reporting requirements and reporting thresholds were introduced in 2001 resulting in 

a change in trend baselines, these additional facilities are included as reflected in 

reporting from 2002, as reported to the US EPA TRI program. 

Sources of further 

information 

US EPA, Toxics Release Inventory <http://www.epa.gov/tri/>. 

Scale of application National. 

Useful references US EPA, Toxics Release Inventory <http://www.epa.gov/tri/>. 

Strengths of the 

Indicator 

Provides national data on releases of lead from manufacturing facilities. 
85 

On- and off-site releases of matched chemicals in the 

United States, 1998–2002 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition Releases of toxic chemical in the United States between 1998 and 2002. 

Rationale and role Toxic chemicals, including some pesticides, can lead to a variety of acute or chronic 

health problems. The US Environmental Protection Agency (EPA) collects data 

using the Toxics Release Inventory (TRI), which represents a part of a broader 

universe of the chemicals that are used and released into the environment. 

Data Range Dates: 1998–2002. 

Data sources, 

availability and quality 

Data are from a ‘matched’ data set compiled by the CEC in which only chemicals 

that are reported by both Canada NPRI and the US Toxics Release Inventory (TRI) 

are included. For information on the methods used to compile the matched data 

sets used for these analyses, please refer to the CEC’s annual Taking Stock report, 

available at www.cec.org/takingstock/. 

 For the TRI, facilities in all parts of the United States report their releases 

of over 650 toxic chemicals and chemical compounds to EPA and state agencies. 

Facilities indicate whether the releases were to land, air, water, underground 

injection well, or offsite disposal facilities. TRI includes a large amount of 

information on more than 600 chemicals and 30 chemical categories, including 

arsenic, cyanide, dioxin, lead, mercury, and nitrate compounds, and provides 

information on the amount and trends in releases and other waste management of 

chemicals, including recycling, energy recovery, and treatment. 

 Under the Emergency Planning and Community Right to Know Act of 1986 

and the Pollution Prevention Act of 1990, EPA Office of Environmental Information 

makes these data available to the public annually via the Toxics Release Inventory 

(TRI) Public Data Release Report, as well as through several data access tools, 

including TRI Explorer (http://www.epa.gov/triexplorer) and Envirofacts 

(http://www.epa.gov/enviro). 

 The Toxics Release Inventory (TRI) is a publicly available database that 

contains information on toxic chemical releases and other waste management 

activities for more than 600 chemicals reported annually by certain covered 

industries as well as by federal facilities. TRI data are an input to determine 

exposure or calculate potential risks to human health and the environment, but by 

themselves do not represent risk. The determination of potential risk depends on 

many factors, including toxicity, chemical fate after release, release location, and 

population concentrations. In addition, although EPA has expanded the TRI 

program, it does not cover all sources of releases and other waste management 

activities, such as vehicle emissions, nor does it cover all toxic chemicals or industry 

sectors. Also, while many facilities base their TRI data on monitoring data, others 

report estimated date to TRI as the program does not mandate release monitoring. 

Finally, facilities that do not meet the TRI threshold levels (those with fewer than 10 

full-time employees or those not meeting TRI quantity thresholds) are not required 

to report. 

Units of measurement Metric tons. One metric ton (tonne) equals 1.1 short tons. 

Computation The 'Matched set' is derived by CEC contractors based on a subset of US TRI data 

and Canadian NPRI data based on matched industries and reporting thresholds. As 

the reporting facilities and reporting levels are matched, this represents a subset of 

US TRI reported emissions. 

Sources of further 

information 

US EPA, Toxics Release Inventory <http://www.epa.gov/tri/>. 

CEC’s annual Taking Stock report, available at <www.cec.org/takingstock/>.

Scale of application National. 

Useful references US Toxics Release Inventory <http://www.epa.gov/tri/>. 

Strengths of the 

Indicator 

Provides information about the releases of 153 matched chemicals to on-site air, 

land, water, and underground injections, as well as off-site releases. 
86 

On- and off-site releases of matched chemicals by sector 

in the United States, 1998–2002 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition Releases of toxic chemical in the United States by sector between 1998 and 2002. 

Rationale and role Toxic chemicals, including some pesticides, can lead to a variety of acute or chronic 

health problems. The US Environmental Protection Agency (EPA) collects data using 

the Toxics Release Inventory (TRI), which represents a part of a broader universe of 

the chemicals that are used and released into the environment. 

Data Range Dates: 1998–2002. 

Data sources, 

availability and quality 

Data are from a ‘matched’ data set compiled by the CEC in which only chemicals 

that are reported by both Canada NPRI and the US Toxics Release Inventory (TRI) 

are included. For information on the methods used to compile the matched data sets 

used for these analyses, please refer to the CEC’s annual Taking Stock report, 

available at <www.cec.org/takingstock/>. 

For the TRI, facilities in all parts of the United States report their releases of over 650 

toxic chemicals and chemical compounds to EPA and state agencies. Facilities 

indicate whether the releases were to land, air, water, underground injection well, or 

offsite disposal facilities. TRI includes a large amount of information on more than 

600 chemicals and 30 chemical categories, including arsenic, cyanide, dioxin, lead, 

mercury, and nitrate compounds, and provides information on the amount and trends 

in releases and other waste management of chemicals, including recycling, energy 

recovery, and treatment. 

 Under the Emergency Planning and Community Right to Know Act of 1986 

and the Pollution Prevention Act of 1990, EPA Office of Environmental Information 

makes these data available to the public annually via the Toxics Release Inventory 

(TRI) Public Data Release Report, as well as through several data access tools, 

including TRI Explorer <http://www.epa.gov/triexplorer> and Envirofacts 

<http://www.epa.gov/enviro>. 

 The Toxics Release Inventory (TRI) is a publicly available database that 

contains information on toxic chemical releases and other waste management 

activities for more than 600 chemicals reported annually by certain covered industries 

as well as by federal facilities. TRI data are an input to determine exposure or 

calculate potential risks to human health and the environment, but by themselves do 

not represent risk. The determination of potential risk depends on many factors, 

including toxicity, chemical fate after release, release location, and population 

concentrations. In addition, although EPA has expanded the TRI program, it does not 

cover all sources of releases and other waste management activities, such as vehicle 

emissions, nor does it cover all toxic chemicals or industry sectors. Also, while many 

facilities base their TRI data on monitoring data, others report estimated date to TRI 

as the program does not mandate release monitoring. Finally, facilities that do not 

meet the TRI threshold levels (those with fewer than 10 full-time employees or those 

not meeting TRI quantity thresholds) are not required to report. 

Units of measurement Metric tons. One metric ton (tonne) equals 1.1 short tons. 

Computation The 'Matched set' is derived by CEC contractors based on a subset of US TRI data 

and Canadian NPRI data based on matched industries and reporting thresholds. As 

the reporting facilities and reporting levels are matched, this represents a subset of 

US TRI reported emissions. 

Sources of further 

information 

US EPA, Toxics Release Inventory <http://www.epa.gov/tri/>. 

CEC’s annual Taking Stock report, available at <www.cec.org/takingstock/>. 

Scale of application National. 

Useful references US Toxics Release Inventory <http://www.epa.gov/tri/>. 

Strengths of the 

Indicator 

Provides information about the releases of 153 matched chemicals to on-site air, 

land, water, and underground injections, as well as off-site releases. 
87 

Distribution of TRI on-site and off-site disposal or other 

releases, 1998–2003 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition Distribution of US Toxics Release Inventory on-site and off-site disposal or other 

releases of toxic chemical in the United States between 1998 and 2003. 

Rationale and role Toxic chemicals, including some pesticides, can lead to a variety of acute or chronic 

health problems. The US Environmental Protection Agency (EPA) collects data 

using the Toxics Release Inventory (TRI), which represents a part of a broader 

universe of the chemicals that are used and released into the environment. 

Data Range Dates: 1998–2003. 

Data sources, 

availability and quality 

For the Toxics Release Inventory (TRI), facilities in all parts of the United States 

report their releases of over 650 toxic chemicals and chemical compounds to EPA 

and state agencies. Facilities indicate whether the releases were to land, air, water, 

underground injection well, or offsite disposal facilities. TRI includes a large amount 

of information on more than 600 chemicals and 30 chemical categories, including 

arsenic, cyanide, dioxin, lead, mercury, and nitrate compounds, and provides 

information on the amount and trends in releases and other waste management of 

chemicals, including recycling, energy recovery, and treatment. 

Under the Emergency Planning and Community Right to Know Act of 1986 and the 

Pollution Prevention Act of 1990, EPA Office of Environmental Information makes 

these data available to the public annually via the Toxics Release Inventory (TRI) 

Public Data Release Report, as well as through several data access tools, including 

TRI Explorer <http://www.epa.gov/triexplorer> and Envirofacts 

<http://www.epa.gov/enviro>. 

The Toxics Release Inventory (TRI) is a publicly available database that contains 

information on toxic chemical releases and other waste management activities for 

more than 600 chemicals reported annually by certain covered industries as well as 

by federal facilities. TRI data are an input to determine exposure or calculate 

potential risks to human health and the environment, but by themselves do not 

represent risk. The determination of potential risk depends on many factors, 

including toxicity, chemical fate after release, release location, and population 

concentrations. In addition, although EPA has expanded the TRI program, it does 

not cover all sources of releases and other waste management activities, such as 

vehicle emissions, nor does it cover all toxic chemicals or industry sectors. Also, 

while many facilities base their TRI data on monitoring data, others report estimated 

date to TRI as the program does not mandate release monitoring. Finally, facilities 

that do not meet the TRI threshold levels (those with fewer than 10 full-time 

employees or those not meeting TRI quantity thresholds) are not required to report. 

Units of measurement Metric tons. One metric ton (tonne) equals 1.1 short tons. 

Computation While many facilities base their TRI data on monitoring data, others report 

estimated data to TRI as the program does not mandate additional release 

monitoring. Various estimation techniques are used when monitoring data are not 

available, and EPA has published estimation guidance for the regulated community. 

Variations between facilities can result from the use of different estimation 

methodologies. Facilities report information about the estimation methods when 

they report their release and waste management information. These factors should 

be taken into account when considering data accuracy and comparability. 

Sources of further 

information 

US EPA, Toxics Release Inventory <http://www.epa.gov/tri/>. 

Scale of application National. 

Useful references US Toxics Release Inventory <http://www.epa.gov/tri/>. 

Strengths of the 

Indicator 

Provides information about the disposal or other releases to land, water, air, on-site 

underground injection, or off-site disposal. 
88 

Percentage of fruits, vegetables, and grains with 

detectable residues of organophosphate pesticides 

Type of indicator: 

Exposure surrogate 

INDICATOR Description 

Definition The percentage of food samples with detectable organophosphate pesticide 

residues reported by the US Department of Agriculture’s Pesticide Data Program 

from 1994–2001. 

Rationale and role Children may be exposed to pesticides and other contaminants in their food and 

through day-to-day activities around the home. Children’s exposures to pesticides 

may be higher than the exposures of most adults. Pound for pound, children 

generally eat more than adults, and they may be exposed more heavily to certain 

pesticides because they consume a diet different from that of adults. The US 

Department of Agriculture’s Pesticide Data Program (PDP) concentrates its efforts 

on providing better pesticide residue data on foods most consumed by children. 

This PDP policy is guided by the requirements of the 1996 Food Quality Protection 

Act and by recommendations made in 1993 by the National Academy of Sciences in 

its report, Pesticides in the Diets of Infants and Children. Details on the 

commodities and pesticides tested by the PDP are available at 

http://www.ams.usda.gov/science/pdp/Overview.htm 

Data Range Dates: 1994–2001. 

Ages: 0-18 years old. 

Data sources, 

availability and quality 

Data from US Department of Agriculture’s Pesticide Data Program. The program 

samples foods for pesticide residues. The analytical testing methods used in the 

monitoring efforts are standardized, validated, and subject to strict quality control 

and quality assurance programs The program Web site is 

http://www.ams.usda.gov/science/pdp/ 

Units of measurement Simple percentage, based on reported results. 

Computation Each sample of food tested in the Pesticide Data Program is analyzed to determine 

whether the residues of a variety of different pesticides are present. The number of 

organophosphate pesticides and metabolites analyzed by PDP has increased from 

34 in 1994 to 77 in 2001, and measurement techniques have become more 

sensitive during that time. In order to maintain comparability across the years 1994–

2001, the organophosphate detection rates reported here include only detection of 

the original 34 pesticides included in the PDP at or above the original limits of 

detection available in 1994. 

Sources of further 

information 

For PDP information (PDP survey data): http://www.ams.usda.gov/science/pdp

For EPA Office of Pesticide Programs information (risk assessment): 

http://www.epa.gov/pesticides 

Scale of application National. 

Useful references Data are from U.SDA, Pesticide Data Program. The indicator was developed for 

EPA's report, America's Children and the Environment. Additional information is 

available at www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

The indicator shows pesticide residues on foods that are frequently consumed by 

children. The measure is based on nationally representative data. 
89 

Percentage of children living in areas served by public 

water systems that exceeded a drinking water standard or 

violated a treatment requirement, 1993–1999 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition The percentage of children served by public water systems that reported exceeding 

a Maximum Contaminant Level (MCL) or violated a treatment standard. 

Rationale and role Microbiological, chemical, and radiological contaminants can enter water supplies 

as a result of human activity and from natural sources. Disinfection of drinking water 

is a critical public health measure as it provides a barrier against harmful 

contaminants. Under the Safe Drinking Water Act, all public water systems must 

monitor the quality of their drinking water and report the monitoring results to the 

states, who in turn reports violations to EPA quarterly. National health-based 

standards exist for about 90 regulated contaminants. The Safe Drinking Water Act, 

as amended in 1996, mandates that EPA, states, and water systems implement 

multiple barriers to protect consumers from the risks of unsafe drinking water. 

Data Range Dates: 1993–1999. 

Data sources, 

availability and quality 

Community water systems report monitoring violations quarterly to the states and 

data are compiled by EPA. The Safe Drinking Water Information System, Federal 

version (SDWIS/FED) contains information about public water systems and their 

violations of EPA’s drinking water regulations, as reported to EPA by states and 

EPA Regions in conformance with reporting requirements. The SDWIS includes 

information on the nation's 170,000 public water systems and violations of drinking 

water regulations. 

Data are available at http://www.epa.gov/OGWD/datagbases.html for each year 

since 1993. 

The overall quality of the violations data is high for the Total Coliform Rule standard, 

but is very low for other health-based standards and for monitoring and reporting. 

Source: EPA 2000 National Public Water Systems Compliance Report, National 

Summary, July 2002. 

Units of measurement Percentage of children. 

Computation States report the following information to EPA on a quarterly basis: 

• Basic information including name, ID number, number of people served, type of 

system (year round or seasonal), and source (groundwater or surface water); 

• Violation information for each water system, including whether it has followed 

established monitoring and reporting schedules, complied with mandated 

treatment techniques, or violated any MCLs; 

• Enforcement information: Actions taken by states to ensure drinking water 

systems return to compliance if they are in violation of a regulation; and 

• Sampling results for unregulated contaminants and for regulated contaminants 

when the monitoring results exceed the MCL. 

Sources of further 

information 

Data were obtained from EPA, Office of Water, Safe Drinking Water Information 

Systems/Federal version, (SDWIS/FED), 2003. 

http://www.epa.gov/safewater/sdwisfed/sdwis.htm

Scale of application National. 

Useful references EPA 2000 National Public Water Systems Compliance Report, National Summary, 

July 2002. Document located at: 

http://www.epa.gov/safewater/annual/sdwcom2002.pdf. The indicator was 

developed for EPA's report, America's Children and the Environment. Additional 

information is available at www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

The indicator provides a national-scale measure of the percentage of children 

served by public water systems who may be exposed to poor water quality. 
90 

Percentage of children living in areas served by public 

water systems with major violations of drinking water 

monitoring and reporting requirements in the United 

States, 1993–1997 

Type of indicator: 

Exposure 

INDICATOR Description 

Definition The percentage of children served by public water systems that had at least one 

major monitoring and reporting violations. 

Rationale and role Microbiological, chemical, and radiological contaminants can enter water supplies 

as a result of human activity and from natural sources. Disinfection of drinking water 

is a critical public health measure as it provides a barrier against harmful 

contaminants. Under the Safe Drinking Water Act, all public water systems must 

monitor the quality of their drinking water and report the monitoring results to the 

states, who in turn reports violations to EPA quarterly. National health-based 

standards exist for about 90 regulated contaminants. The Safe Drinking Water Act, 

as amended in 1996, mandates that EPA, states, and water systems implement 

multiple barriers to protect consumers from the risks of unsafe drinking water. 

Data Range Dates: 1993–1997. 

Data sources, 

availability and quality 

Community water systems report monitoring violations quarterly to the states and 

data are compiled by EPA. The Safe Drinking Water Information System, Federal 

version (SDWIS/FED) contains information about public water systems and their 

violations of EPA’s drinking water regulations, as reported to EPA by states and 

EPA Regions in conformance with reporting requirements. The SDWIS includes 

information on the nation's 170,000 public water systems and violations of drinking 

water regulations. 

Data are available at http://www.epa.gov/OGWD/datagbases.html for each year 

since 1993. 

The overall quality of the violations data is high for the Total Coliform Rule standard, 

but is very low for other health-based standards and for monitoring and reporting. 

Source: EPA 2000 National Public Water Systems Compliance Report, National 

Summary, July 2002. 

Units of measurement Percentage of children. 

Computation States report the following information to EPA on a quarterly basis: 

• Basic information including name, ID number, number of people served, type of 

system (year round or seasonal), and source (groundwater or surface water); 

• Violation information for each water system, including whether it has followed 

established monitoring and reporting schedules, complied with mandated 

treatment techniques, or violated any MCLs; 

• Enforcement information: Actions taken by states to ensure drinking water 

systems return to compliance if they are in violation of a regulation; and 

• Sampling results for unregulated contaminants and for regulated contaminants 

when the monitoring results exceed the MCL. 

Sources of further 

information 

Data were obtained from EPA, Office of Water, Safe Drinking Water Information 

Systems/Federal version, (SDWIS/FED), 2003. 

http://www.epa.gov/safewater/sdwisfed/sdwis.htm

Scale of application National. 

Useful references EPA 2000 National Public Water Systems Compliance Report, National Summary, 

July 2002. Document located at: 

http://www.epa.gov/safewater/annual/sdwcom2002.pdf. The indicator was 

developed for EPA's report, America's Children and the Environment. Additional 

information is available at www.epa.gov/envirohealth/children. 

Strengths of the 

Indicator 

The indicator provides a national-scale measure of the percentage of children 

served by public water systems who may be exposed to poor water quality. 
91 

Waterborne disease outbreaks by year and type of water 

system in the United States, 1971–2000 

Type of indicator: 

Effect 

INDICATOR Description 

Definition The number of voluntarily reported waterborne disease outbreaks (WBDOs) 

associated with drinking water (e.g., typhoid, cholera, hepatitis, and gastrointestinal 

illness) in the United States. 

Rationale and role The potential health effects of consuming contaminated drinking water range from 

minor to fatal. A system for reporting food and waterborne disease outbreaks has 

been in place since 1971 in the United States. The system allows public health 

officials to investigate and determine the role of food and water in contributing to 

intestinal illness, and identify actions that may be needed to protect public health. 

Data Range Dates: 1971–2000. 

All ages 

Data sources, 

availability and quality 

The Centers for Disease Control and Prevention and the Council of State and 

Territorial Epidemiologists maintain a collaborative surveillance system for the 

occurrences and causes of WBDOs. The data identify types of water systems, their 

deficiencies, and the etiologic agents associated with the outbreaks. The system 

reports outbreaks and the estimated numbers of people who become ill. Many 

factors can influence whether a water-borne disease outbreak (WBDO) is 

recognized and investigated by local, territorial, and state public health agencies. 

For example, the size of the outbreak, severity of the disease caused by the 

outbreak, public awareness of the outbreak, whether people seek medical care or 

report to a local health authority, reporting requirements, routine laboratory testing 

for organisms, and resources for investigation can all influence the identification 

and investigation of a WBDO. In addition, this system is a voluntary reporting 

system, so not every state or relevant public health agency may be reporting 

information to the system. This system underreports the true number of outbreaks 

because of the multiple steps required before an outbreak is identified and 

investigated.

Units of measurement Number of outbreaks per year. 

Computation State, territorial, and local public health agencies are primarily responsible for 

detecting and investigating WBDOs and voluntarily reporting them to CDC. 

Sources of further 

information 

Craun, G.F. and R.L. Calderon. “Waterborne Outbreaks in the United States, 1971–

2000.” In: Frederick W. Pontius (ed.), Drinking Water Regulations and Health, New 

York, NY: John Wiley & Sons, 2003, 40-56. 

Scale of application National. 

Useful references Prevalence of 7 waterborne diseases can be found at: 

Morbidity and Mortality Weekly Report: http://www.cdc.gov/mmwr and 

Summary of Notifiable Diseases: http://www.cdc.gov/epo/dphsi/annsum. 

Strengths of the 

Indicator 

Data are used to evaluate current technologies for providing safe drinking water and 

safe recreational waters. 
92 

Appendix 2 Indicators Steering Group – United States 

Ann Carroll, MPH, Acting Country Lead 

Acting Manager, Children’s Health

Office of International Affairs 

US EPA, 2660R 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202-564-6433 

F: 202-565-2757 

carroll.ann@epa.gov

Catherine Allen, Country Lead 

Manager, Children’s Health 

Office of International Affairs 

US EPA 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202-566-1039 

F: 202-565-2412 

Allen.Catherine@epamail.epa.gov

Daniel Axelrad 

Office of Policy, Economics, and Innovation 

US EPA, 1809T 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202-566-2304 

F: 202-566-2336 

axelrad.daniel@epa.gov

Martha Berger, Observer 

Director, International Programs 

Office of Children’s Health Protection 

US EPA 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202 564-2191 

F: 202 

Berger.Martha@epa.gov

Edward Chu, Observer 

Director, Regulatory and Science Affairs 

Office of Children’s Health Protection 

US EPA 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202-564-2706 

F: 202-564-2733 

Chu.ed@epa.gov

Evonne Marzouk, Observer 

Environ. Protection Specialist 

Office of International Affairs 

US EPA 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 202-564-7529 

F: 202-565-2411 

Marzouk.evonne@epa.gov

Tracey Woodruff, PhD, MPH, Technical Lead 

Office of Policy, Economics, and Innovation 

US EPA, 

1200 Pennsylvania Ave. NW 

Washington, DC 20460 

P: 415.947.4277 

F: 415.947.3519 

Woodruff.Tracey@epa.gov
93 

Appendix 3 Acknowledgements 

Ann Carroll, Steering Group, Office of International Affairs 

Tracey Woodruff, Steering Group, Office of Administrator 

Catherine Allen, Office of Land Revitalization (former country lead) 

Evonne Marzouk, Office of International Affairs (former country lead) 

Ed Chu, Office of Land Revitalization (former country lead) 

Daniel Axelrad, Office of Administrator (technical expert) 

Brad Hurley, ICF Consulting 

Michelle Price, Office of Environmental Information 

Larry Reisman, Office of Environmental Information 

John Dombrowski, Office of Environmental Information 

Nancy Wentworth, Office of Environmental Information 

Stephen Devito,Office of Environmental Information 

Nicole Paquette, Office of Environmental Information 

Michael Hadrick Office of Air and Radiation 

Sarah Sowell, Office of Air and Radiation 

Alison Freeman, Office of Air and Radiation 

James Hemby, Office of Air and Radiation 

Susan Stone, Office of Air and Radiation 

Martha Berger, Office of Children's Health Protection 

Daniel Flores, Office of General Counsel 

Steve Wolfson, Office of General Counsel, 

Ana Corado, Office of Pollution Prevention and Toxics 

Ron McHugh, Office of Pollution Prevention and Toxics 

John Schwemberger, Office of Pollution Prevention and Toxics 

Darlene Watford, Office of Pollution Prevention and Toxics 

Jacqueline E. Mosby, Office of Pollution Prevention and Toxics 

Abigail Ryder, Office of Solid Waste 

Danelle Lobdell, Office of Research and Development 

Connie Bosma, Office of Research and Development 

Doug Steele, Office of Research and Development 

Staci Gatica, Office of Research and Development 

Gary Kimmel, Office of Research and Development 

David Miller, Office of Pollution Prevention and Toxics 

David Hrdy, Office of Pollution Prevention and Toxics 

Kathleen Knox, Office of Pollution Prevention and Toxics 

Lorry Frigerio, Office of Pollution Prevention and Toxics 

Marjorie Jones, Office of Water