Lead In Tap Water: CDC Public Health Communications Need Improvement
Published: 2011-03-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In February 2004, the Centers for Disease Control and Prevention (CDC) was asked to assess the effects of elevated lead levels in tap water on Washington, D.C., residents. In April 2004, CDC published the results. However, an inaccurate statement and incomplete descriptions of the limitations of the analyses resulted in confusion about CDC's intended message. GAO was asked to examine (1) CDC's actions to clarify its published results and communicate current knowledge about the contribution of lead in tap water to elevated blood lead levels (BLL) in children and (2) CDC's changes to its procedures to improve the clarity of the information in its public health communications. GAO reviewed CDC communication policies and procedures and interviewed CDC officials.
section_title: What GAO Found
paragraphs: CDC officials told GAO that although the agency does not have a policy to monitor the use of or clarify information in public health publications, the agency took actions to address confusion it created related to the 2004 Morbidity and Mortality Weekly Report (MMWR) article about elevated lead levels in Washington, D.C., tap water. For example, in 2008, CDC officials contacted District of Columbia Water and Sewer Authority officials requesting corrections to a statement in a fact sheet published by the water authority that incorrectly characterized information from the 2004 MMWR article. In addition, CDC also published articles in the 2010 MMWR intended to clarify the confusion, such as a June 25, 2010, article that discussed limitations about how information in the 2004 article could be used. While CDC took these actions, among others, to clarify confusion about the effect of elevated lead levels in District tap water, as of January 2011, CDC had no plans to publish an overview of the current knowledge about the contribution of elevated lead levels in tap water to BLLs in children, as suggested by a CDC internal incident analysis of issues surrounding the 2004 MMWR article. CDC officials told GAO they had begun an initiative and revised procedures designed to help ensure the accessibility and clarity of CDC public health communications, both agencywide and in the National Center for Environmental Health, the center responsible for lead poisoning prevention programs. For example, under the new initiative, CDC will revise existing procedures to help ensure that information that CDC publishes, such as guidelines and recommendations, is easily accessible by a common portal on CDC's Web site. While the initiative and revised procedures focus on making CDC information more accessible and on preventing errors or unclear statements in CDC communications, they do not include actions to address confusion that may arise after information is published, such as occurred with the 2004 MMWR article. Without agency procedures specifically addressing how and when to take action about confusion after publication, CDC runs the risk of inconsistent responses across the agency when its published information is not interpreted as CDC intended. CDC's mission to promote the nation's public health relies on its credibility in presenting accurate, reliable, and timely information. Communicating the agency's current knowledge about the health effects of lead levels in tap water and developing procedures that allow it to address confusion in a timely, consistent manner could improve the public's understanding of the effect of lead in water and help CDC mitigate the risk of confusion in other situations and protect its credibility.
section_title: What GAO Recommends
paragraphs: GAO is making two recommendations to CDC: (1) publish an article providing a comprehensive overview of tap water as a source of lead exposure and communicating the potential health effects on children and (2) develop procedures to address any confusion after information is published. CDC generally concurred with GAO's recommendations. For the second recommendation, while CDC described procedures it is developing, the agency did not explicitly address all components of the recommendation.

section_title: Letter
paragraphs: In February 2004, the District of Columbia Department of Health  (DCDOH) requested assistance from the Centers for Disease Control and  Prevention (CDC) to assess the effects of elevated lead levels in the city’s  residential tap water on the city’s residents. Elevated levels of lead in tap  water can result in elevated blood lead levels (BLL), which can cause  adverse health effects in adults and children. CDC, an agency in the  Department of Health and Human Services (HHS), is responsible for  developing lead poisoning prevention programs and policies, and  collaborating with federal and state partners, health departments, and  health care providers to prevent lead poisoning. CDC assists state and  local partners in developing laboratory-based surveillance systems for  BLLs among children and assists states in the analysis and dissemination  of lead surveillance data. These activities help contribute to CDC’s efforts  in support of HHS’s Healthy People 2020 goal of eliminating elevated BLLs  in children.
In response to DCDOH’s request, CDC worked with individuals from  DCDOH and the U.S. Public Health Service to investigate the effect of  lead in the District of Columbia’s tap water on the BLLs of residents. On   April 2, 2004, CDC published the preliminary results in an article in the  Morbidity and Mortality Weekly Report (MMWR), the agency’s primary  vehicle for disseminating public health information. MMWR is intended to  provide information that is timely, reliable, and accurate. However,  according to CDC officials, the article inaccurately stated that no children  had BLLs over CDC’s established level of concern, when in fact some  children’s BLLs exceeded that level. Specifically, despite stating that “no  safe BLL has been identified” for children, the article indicated that  although lead in tap water contributed to a small increase in BLLs in the  District, no children were identified with BLLs above CDC’s established  level of concern, even in homes with water lead levels that were greatly in  excess of Environmental Protection Agency (EPA) standards.  Additionally, CDC officials have stated that the MMWR article did not fully  describe limitations on how the results should be interpreted and used. In  a June 2010 article in a District newspaper, CDC’s Director said that CDC  communicated scientific results poorly in the 2004 MMWR article and that  as a result the article “may have led some people to improperly minimize  concerns about lead exposure and conclude that lead in the water had  never been a problem.” Examples of confusion regarding the seriousness  of the health risks include a news report in which a District official was  quoted as saying that CDC’s view was that residents’ health had not been  affected by elevated water lead levels in the District, and a news report  from another city, which cited the article to downplay the seriousness of  the effect of elevated water lead levels in the city on the health of children.  CDC’s Director stated in a June 2010 letter to the Chairman of the  Subcommittee on Investigations and Oversight, House Committee on  Science and Technology, that the agency planned to make improvements  to agency procedures to enhance the accuracy and clarity of CDC  information.
You asked us to examine CDC’s efforts to address confusion and clarify  information in the 2004 MMWR article related to elevated BLLs in District  residents. In this report, we examine (1) the actions CDC has taken to  clarify the information in the agency’s 2004 MMWR article about BLLs of  District residents and to communicate current knowledge about the  contribution of lead in tap water to elevated BLLs in children and   (2) changes CDC has made to its procedures in an effort to ensure the  clarity of the information in its public health communications.
To describe the actions CDC has taken to clarify the information in the  agency’s 2004 MMWR article about BLLs of District residents and to  communicate current knowledge about the contribution of lead in tap  water to elevated BLLs in children, we reviewed CDC documents and  publications related to the elevated lead levels in the District’s tap water,  including the 2004 MMWR article and a 2010 MMWR article describing the  limitations of the 2004 article; CDC correspondence with local agencies,  such as the District of Columbia Water and Sewer Authority (Water and  Sewer Authority); CDC’s February 2010 internal incident analysis— requested by CDC’s Office of the Director—of its response to issues  surrounding elevated water lead levels in the District; media reports that  refer to information in the 2004 MMWR article; and congressional reports  and testimony. We also reviewed CDC reports and other documents  describing subsequent investigations related to or referenced in the 2004  MMWR article, such as EPA’s report on the potential causes of elevated  lead levels in District tap water. We interviewed CDC officials, including  officials from the National Center for Environmental Health (NCEH),  about their actions to clarify any confusion related to information in the  2004 MMWR article. We also interviewed CDC officials about any  ongoing work CDC has conducted since publishing its preliminary finding in the 2004 MMWR article, and any additional work planned for the futu re  to clarify information in the 2004 MMWR article. We interviewed officia ls  from the Office of the Director and other senior management officials to  determine their responses to the internal incident analysis and any related  directives from the Office of the Director to NCEH or other CDC entities,  and we examined the status of agency activities to respond to any related  directives. We also attended a meeting of the Advisory Committee on  Childhood Lead Poisoning Prevention—a federal advisory committee to  CDC—in November 2010 to obtain any updates to the findings presented  in 2004 or other relevant information.
To describe changes CDC has made to its procedures in an effort to ensure  the clarity of the information in its public health communications, we  reviewed CDC communication policies and procedures and interviewed  CDC officials about any initiatives the agency is developing or has  implemented since 2004 to help ensure that the messages presented in its  public health communications are clear and accurate.
We conducted this performance audit from August 2010 through February  2011 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: The MMWR series is one of three scientific publications published by CDC  and is regarded as CDC’s flagship publication. The publication’s primary  audience is made up of professionals, including medical professionals,  such as clinicians, and state and local public health officials, and the  publication also reaches CDC’s federal partners, such as EPA and the  Centers for Medicare & Medicaid Services (CMS). In addition to the  weekly reports, the MMWR series also includes MMWR Recommendations  and Reports, which contain in-depth articles that relay policy statements  for prevention and treatment on all areas in CDC’s scope of responsibility,  such as recommendations from CDC advisory committees. CDC can also  issue articles that it calls Dispatches to allow for immediate publication of  urgent public health information. The Dispatches are generally  subsequently published in the MMWR. The April 2, 2004, MMWR weekly  report included an article on the BLLs of District residents that was first  published as a Dispatch on March 30, 2004.
subsections: section_title: Exposure to Lead in the Environment
paragraphs: Lead is a dangerous contaminant commonly found in the environment that  can affect almost every organ and system in the body. The main target for  lead toxicity is the nervous system. In addition to causing behavior  problems and learning disabilities in young children, elevated BLLs can  cause such effects as damage to the brain and kidneys. In pregnant  women, elevated BLLs may cause miscarriage.
Drinking contaminated tap water is one way humans may be exposed to  lead. While measures taken during the past two decades have greatly  reduced exposures to lead in tap water, lead still can be found in some  metal water fixtures, interior water pipes, or pipes connecting a house to  the main water pipe in the street. Lead in tap water usually comes from the  corrosion of older fixtures; lead service lines, including lead service pipes;  or the solder that connects pipes.
Federal law requires that blood lead screening tests be made available to  all children enrolled in Medicaid. CMS’s State Medicaid Manual requires  that these screenings be performed at ages 12 and 24 months and that all  children aged 36 to 72 months who have not previously been screened also  receive a blood lead test. The American Academy of Pediatrics agrees with  these requirements for screening and has also stated that efforts must  continue to test children who are at high risk for lead exposure. Beginning  in 1995, elevated BLLs—the first noninfectious condition—were  designated as a nationally notifiable condition reportable to CDC. The  District (along with 36 states and the city of New York) has reported  elevated BLLs of 10 micrograms per deciliter (μg/dL) of blood or higher for  children to CDC. The District has reported this BLL information to CDC  since 1997.
The District’s Childhood Lead Poisoning Screening and Reporting Act of  2002 requires that each health care provider or facility in the District  perform a blood test for lead poisoning as part of a well-child care visit for  each child that they serve who is under the age of six and resides in the  District. The test must occur between ages 6 months and 14 months, and a  second test must occur between ages 22 months and 26 months. Both tests  must be performed unless parental consent is withheld or an identical test  has already been performed within the previous 12 months. If a child’s  age exceeds 26 months and a blood lead screening has not been  performed, the child must be screened twice before age 6. The District  also requires health care providers or facilities to report the results of  blood tests for lead poisoning on every child under age 6 who resides in  the District to the child’s parents.
section_title: CDC’s Roles and Responsibilities regarding Lead
paragraphs: As the nation’s public health agency, CDC has set levels of concern—the  BLL that should prompt public health actions—for lead exposure since the  1960s. In 1991, CDC set the level of concern at 10 μg/dL of blood for   children aged 6 months to 15 years and 25 μg/dL for adults. However,  CDC has also recognized that a BLL of 10 μg/dL does not define a  threshold for the harmful effects of lead—in other words, no safe blood  lead level has been identified for children.
The Lead Contamination Control Act of 1988 authorized CDC to initiate  programs to eliminate childhood lead poisoning in the United States. As a  result of this act, the CDC Childhood Lead Poisoning Prevention Program  (CLPPP) was created. One of the program’s primary responsibilities is to  educate the public and health care providers about childhood lead  poisoning. CDC’s CLPPP also provides funding to state and local health  departments to determine the extent of childhood lead poisoning by  screening children for elevated BLLs. Since the inception of CDC’s lead  program, nearly 60 state and local jurisdictions have received funding for  their state and local CLPPPs. CDC’s efforts contribute to the Healthy  People 2020 initiative, which includes an objective to eliminate elevated  BLLs in children. As of 2007 to 2008, the latest years for which data were  available, approximately 1.2 percent of children aged 1 to 5 years  nationwide had BLLs exceeding 10 µg/dL.
In addition, the Advisory Committee on Childhood Lead Poisoning  Prevention advises and guides CDC regarding new scientific knowledge  and technical developments and their practical implications for childhood  lead poisoning prevention efforts. In November 2010, the advisory  committee initiated a work group to recommend new approaches,  terminology, and strategies for defining elevated BLLs among children.
section_title: EPA’s Roles and Responsibilities regarding Lead
paragraphs: Under the Safe Drinking Water Act, EPA is responsible for regulating  contaminants that may pose a public health risk and that are likely to be  present in public water supplies, including lead. EPA’s Lead and Copper  Rule established a 15 parts per billion (ppb) lead action level as a  regulatory standard for water utilities in an effort to prevent and mitigate  the adverse health consequences resulting from elevated lead levels in  drinking water. Water systems must sample tap water at locations that  are at high risk of lead contamination, generally because they are served  by lead service lines or are likely to contain lead solder in the household  plumbing. If more than 10 percent of the samples at residences contain  lead levels over 15 ppb, the water systems must take action to lower these  levels, such as replacing lead service lines in the distribution system or  treating water to reduce its corrosion of the service lines, and notify EPA  and residents.
section_title: The District’s Elevated Water Lead Levels Prior to CDC’s Involvement
paragraphs: The District’s Water and Sewer Authority owns and operates a system that  delivers water—produced by the U.S. Army Corps of Engineers  Washington Aqueduct—to customers in the District. In 2000, the  Washington Aqueduct began to use chloramine instead of chlorine in its  disinfection process. This change likely contributed to elevated water  lead levels.
By late 2001, the Water and Sewer Authority became aware that the levels  of lead in the District’s tap water were above EPA’s limit of 15 ppb, and it  notified EPA of that fact in August 2002. Beginning in 2002, the Water and  Sewer Authority notified its customers of the elevated water lead levels by  issuing notices, distributing educational brochures, and holding public  meetings. In the fall of 2003, the Water and Sewer Authority requested  assistance from DCDOH in responding to District residents’ inquiries  about the health effects of the elevated water lead levels. District  residents, including infants and children, would have been exposed to  elevated levels of lead in tap water during this period if they used  unfiltered water for drinking, cooking, or preparing infant formula or juice.
section_title: Information in the 2004 MMWR Article
paragraphs: Staff from NCEH, along with individuals from DCDOH and the U.S. Public  Health Service, contributed to CDC’s investigation on the effect of lead in  the District’s tap water on the BLLs of residents, which was presented in  the April 2, 2004, MMWR article. The 2004 MMWR article reported the  results of two analyses from CDC’s investigation, which was conducted in  February and March 2004. (See app. I for a copy of the 2004 MMWR  article.) The first analysis was conducted to identify trends in BLLs in  District residents before and after the changes in the water disinfection  process. The second analysis was conducted to determine whether  residents in homes with the highest water lead levels (300 ppb or greater)  had BLLs at or above CDC’s level of concern of 10 μg/dL.
The summary statement of the 2004 MMWR article’s findings noted that  the elevated water lead levels might have contributed to a small increase  in BLLs among District residents. The article’s Editorial Note section  opened with a sentence that incorrectly stated the results of the first  analysis. The sentence read, “The findings in this report indicate that  although lead in tap water contributed to a small increase in BLLs in D.C.,  no children were identified with BLLs ≥ 10 μg/dL, even in homes with the  highest water lead levels.” The statement that “no children were identified  with BLLs ≥ 10 μg/dL” was incorrect, relative to the first analysis. Since the  2004 MMWR article was published, CDC officials have said that in its first  analysis some children were identified with BLLs ≥ 10 μg/dL, which is  CDC’s level of concern for children. The last part of the statement  indicating that none of the children in homes with the highest water lead  levels had BLLs > 10 μg/dL was correct, in that none of the 30 children in  the second analysis had BLLs that reached CDC’s level of concern,  according to CDC officials. While the 2004 MMWR article discussed some  limitations to its findings, it did not discuss other limitations that  addressed how information in the 2004 MMWR article could be used. For  example, it did not state that the article should not be used to make  conclusions about the contribution of lead in tap water to BLLs in the  District.
section_title: Confusion about the 2004 MMWR Article’s Findings
paragraphs: The statement in the 2004 MMWR article that incorrectly links the results  of the two analyses in the same editorial note and the incomplete  description of the limitations to the article’s findings have resulted in this  information being interpreted in the press and by others in ways other  than as CDC intended. For example:  In a May 2004 hearing before the House Committee on Government  Reform, some business and environmental advocates included references  to the 2004 MMWR article to (1) support their assertion that the elevated  water lead levels did not warrant a panicked reaction in the District or   (2) draw conclusions about the relationship between BLLs and water lead  levels in the District, which CDC later stated were inappropriate.
In July 2004, a newspaper article from a major metropolitan city that was  experiencing elevated lead levels in schools’ tap water included  information about the 2004 MMWR article’s findings to support statements  that downplayed the seriousness of the effect of elevated water lead levels  in the city on the health of children.
In a February 2008 fact sheet, the Water and Sewer Authority referenced  the 2004 MMWR article and included statements that gave the impression  that the health of District children had not been affected by elevated lead  levels in the District’s tap water.
In February 2009, the General Manager of the Water and Sewer Authority  was quoted in a newspaper article as saying that CDC’s view was that  residents’ health had not been affected by elevated water lead levels in the  District.
As recently as December 2010, news articles in the District reported that in  the 2004 MMWR article CDC indicated that it found no evidence of  measurable or significant harm to the public health of District children  from elevated lead levels in tap water.
In addition, CDC officials have recognized that the 2004 MMWR article  may have led people to conclude that there was no danger to children  from the elevated water lead levels.
section_title: CDC Has Issued Statements to Address Confusion It Created Related to the 2004 MMWR Article, but Has Not Published an Overview of the Effects of Lead in Tap Water on BLLs in Children
paragraphs: Although CDC does not have a policy to monitor the use of or clarify  information in public health publications, such as the information in the  2004 MMWR article, the agency issued statements to address confusion it  created related to elevated lead levels in the District’s tap water. However,  as of January 2011, the agency had no plans to publish an overview of the  current knowledge about the effects of lead in tap water on BLLs in  children. Specifically, CDC has not published an overview of what is  known and not known about tap water as a source of lead exposure and  the potential health effects on children, as suggested by the CDC internal  incident analysis.
subsections: section_title: CDC Has Issued Statements and Taken Other Actions to Address Confusion It Created Related to the 2004 MMWR Article
paragraphs: CDC officials told us that although the agency does not have a policy to  monitor the use or clarify interpretations of information in public health  publications, such as the 2004 MMWR article, the agency has issued  statements to address confusion it created related to the 2004 MMWR  article. Specifically, agency officials said they have taken some actions  since 2006 to address confusion CDC created about the 2004 MMWR  article when they became aware of specific instances of confusion. For  example:  In July 2006, a CDC official was interviewed for an article published in an  environmental science journal and provided information to address public  statements attributed to a health advisor for the District’s Water and  Sewer Authority that incorrectly characterized information from the 2004  MMWR article. The CDC official stated that the 2004 MMWR article did not  say that drinking water with very high water lead levels, such as those  found in some District homes, was safe.
In February 2008, a CDC official corresponded with the District’s Water  and Sewer Authority officials about a statement in a February 2008 fact  sheet published by the water authority that incorrectly characterized  information in the 2004 MMWR article. Specifically, the CDC official noted  that the fact sheet misstated the conclusions of the 2004 MMWR article  and gave the impression that the health of District residents had not been  affected by elevated lead levels in the tap water. The CDC official  requested that the statement be corrected. In April 2009, the Director of  NCEH sent a letter to the General Manager of the water authority noting  that this correction and others had not been made and once again asked  that statements published in the fact sheet be corrected to accurately  reflect the conclusions in the 2004 MMWR article: that because no  threshold for adverse health effects in young children had been  demonstrated, public health interventions should focus on eliminating all  lead exposures in children.
In 2009, the Chief of the Healthy Homes and Lead Poisoning Prevention  Branch contacted officials responsible for drinking water safety in Seattle  and New York City to discuss reports that officials were quoted in  newspaper articles in those localities and had mischaracterized  information in the 2004 MMWR article to downplay the effect of lead in  water and that these cities had relaxed their drinking water standards  based on the 2004 MMWR article. The CDC official said that she contacted  the officials to clarify the 2004 MMWR article’s message about the public  health effect of elevated lead levels in the District’s tap water and was  assured that they had not used the 2004 MMWR article to make any  changes in their drinking water standards.
More recently, CDC sent a letter to state and local CLPPP managers,  published articles in the MMWR, and contacted District newspaper  officials to address confusion it created related to the 2004 MMWR article.  Specifically:  In May 2010, CDC provided clarifying information in a letter to state and  local CLPPP managers. (See app. II for a copy of the May 2010 letter.) The  Chief of the Healthy Homes and Lead Poisoning Prevention Branch sent a  letter dated May 20, 2010, to state and local CLPPP managers saying that  the first sentence in the Editorial Note section in the 2004 MMWR article  incorrectly stated the results of the first analysis, as some children were  identified with BLLs above 10 μg/dL. Additionally, the letter presented  results of a 2009 analysis that included new BLL data that had not been  available to CDC in 2004. The letter further stated that the results of this  new analysis confirmed the original finding, which CDC stated was that  lead in water was associated with an increase in BLLs. The letter also  restated CDC’s intended message presented in the 2004 MMWR article— that no safe blood lead level had been identified and all sources of lead  exposure should be controlled or eliminated. The letter was also posted on  the CDC Web site.
On May 21, 2010, CDC issued a Notice to Readers in the MMWR providing  the same information about the 2009 analysis and addressing the  confusion CDC created related to the 2004 MMWR article. (See app. III  for a copy of the May 21, 2010, MMWR Notice to Readers.)
On June 25, 2010, CDC issued a Notice to Readers in the MMWR noting the  limitations of the results of the second analysis in the 2004 MMWR  article. (See app. IV for a copy of the June 25, 2010, MMWR Notice to  Readers.) The Notice to Readers stated that the results of the second  analysis should not be used to (1) make conclusions about the  contribution of lead in tap water to BLLs in the District, (2) predict what  might occur in other situations where lead levels in tap water are high, or  (3) determine safe levels of lead in tap water.
In December 2010, CDC officials said that they contacted a District  newspaper when it published news reports that included misinterpretions  of the results of the 2004 MMWR article. CDC officials said that they  contacted the newspaper the same day that the first news report was  published, and for several days thereafter when additional news reports  were published, to request clarifications. CDC officials told us that they  also had submitted a letter to the newspaper to provide more information  to help ensure that the public correctly understood the 2004 MMWR  article’s intended message. The letter was published in December 2010 and  stated that CDC’s opinion on the health impact of lead in the District’s  water supply has not changed and that a new study reports what the  agency has been saying since 2004—the presence of lead service lines  increases the BLLs in the District’s children.
section_title: CDC Has Not Published an Overview of the Effects of Lead in Tap Water on BLLs in Children
paragraphs: Although CDC has taken actions to address confusion specific to the 2004  MMWR article, as of January 2011, CDC had not taken action to publish an  overview of the current knowledge about the contribution of elevated lead  levels in tap water to BLLs in children and the associated health effects.  The 2010 internal incident analysis of CDC’s involvement in and response  to issues surrounding elevated water lead levels in the District noted that  because the relative contribution of tap water to elevated BLLs in children  has become more apparent as exposure to lead paint and leaded gasoline  has been reduced or eliminated, a systematic evaluation of the relative  contribution of tap water to elevated BLLs should be conducted.  Specifically, the internal incident analysis suggested that CDC conduct  such an evaluation and publish the information in an article in the MMWR  Recommendations and Reports that would serve as a position paper  covering the issues of lead in municipal water supplies and summarizing  what is known and not known about its contribution to historic and  contemporary BLLs in children. A CDC official said that as of January  2011, CDC had no plans to conduct such an evaluation and publish an  overview on the effects of lead in water on BLLs in children in the MMWR  Recommendations and Reports. CDC noted that while the agency does  not lack the authority to undertake such an evaluation, the agency believes  that such an evaluation is better suited to EPA, given EPA’s responsibility,  regulatory authority, and expertise. The agency also noted that EPA is  currently in the process of reviewing EPA’s regulations for the control of  lead and copper in drinking water. CDC noted that the agency could  provide technical assistance to EPA and would consider publishing an  article after the EPA review is complete. However, publishing an article in  the MMWR Recommendations and Reports on the latest findings  regarding the relationship between BLLs and lead in water could be of  assistance to EPA. Moreover, it would allow CDC, in a timely manner, to  address any remaining confusion related to the health effects of lead in  water in a venue targeted to CDC’s audience. Because CDC has not  published an overview of the health effects of lead in water in the MMWR  Recommendations and Reports, clinicians and state and local health  officials who look to CDC for comprehensive information on public health  issues may be uncertain about what is known and not known about the  contribution of elevated lead levels in tap water to BLLs in children.
section_title: CDC Has Begun an Initiative and Revised Procedures to Help Ensure That CDC Information Is Accessible and Clear, but These Procedures Do Not Address Confusion after Publication
paragraphs: CDC officials told us they had begun an initiative and revised procedures  to help ensure the accessibility and clarity of CDC public health  communications prior to publication, both agencywide and in NCEH.  Specifically, an official from the Office of the Director told us that the CDC  Office of the Associate Director of Science has begun an initiative to revise  existing procedures to help ensure that information that CDC publishes,  such as guidelines and recommendations, is easily accessible by a  common portal on CDC’s Web site. As of January 2011, CDC officials were  still determining what type of CDC products and communication methods  would be included in the initiative. In addition, CDC officials told us that  NCEH, the center responsible for lead poisoning prevention programs and  the 2004 MMWR article, had revised its clearance procedures for certain  products, including those submitted to the MMWR, in an effort to ensure  that the information presented is accurate and clear. CDC officials said  that the revised NCEH clearance procedures are more rigorous and  systematic and include requirements for additional peer review of some  products, as well as review of some products by the Office of the Director,  to help ensure that senior officials are aware of the products. For example,  CDC documents that include major scientific findings or conclusions  representing scientific breakthroughs or that directly contradict previous  science that served as the basis for public health policy will be elevated to  the Office of the Director for review. The officials said that the agency  believes the initiative and revised procedures will help to mitigate the risk  of other communications being subject to the type of confusion or  misinterpretation surrounding the 2004 MMWR article. As of January 2011,  CDC did not have time frames for completing the Office of the Director’s  initiative.
Despite the agency’s current actions to strengthen review of CDC  communications prior to publication, CDC officials said that neither the  initiative nor the revised procedures will include actions to address  confusion after publication. For example, if CDC becomes aware that  information is being interpreted incorrectly, the procedures will not direct  CDC staff to reach out to newspapers or other entities that have published  the information to request corrections or clarifications. The importance of  having procedures for this type of outreach was noted in the internal  incident analysis, which stated that when CDC messages are not on target  or are misinterpreted, such as happened in reaction to the 2004 MMWR  article, CDC should respond in appropriate visible forums to publicly and  expeditiously correct itself or correct those who are interpreting the  message. Further, neither the initiative nor the revised procedures will  include any postpublication review of certain types of communications  that are similar to the 2004 MMWR article, such as those that are published  in an expedited time frame and address urgent or high-profile issues, to  determine whether corrections or clarifications are needed based on how  the communications have been interpreted or used. Because CDC does not  have procedures for addressing confusion after publication, the agency  runs the risk that its staff will provide inconsistent responses to  interpretations of its information that differ from what CDC intended.
section_title: Conclusions
paragraphs: Although CDC has taken some belated actions to clarify confusion related  to the 2004 MMWR article on BLLs of residents in the District, the agency  does not plan to publish a comprehensive review of the role of tap water  as a source of lead exposure that would communicate what is known  about the contribution of lead in water to elevated BLLs in children. A goal  of the Healthy People 2020 initiative is to eliminate elevated BLLs in  children. Although significant progress has been made in reducing lead  exposure from lead-based paint and leaded gasoline, CDC has an  opportunity to refocus its efforts toward accomplishing this Healthy  People 2020 goal and to make a significant contribution to scientific  literature by clearly describing what is known about the effect of lead in  tap water on BLLs in children.
CDC’s credibility as the nation’s premier public health agency relies on  presenting accurate, reliable, and timely information to the public.  Information that is inaccurate or unclear in a CDC public health  publication could result in confusion—such as resulted when some  readers understood the 2004 MMWR article to state that elevated lead  levels in tap water were not a concern in the District or in their area—and  could undermine the agency’s credibility. The potential for presenting  confusing information may increase when the agency has to respond  quickly, as it did when it published the 2004 MMWR article 6 weeks after  the DCDOH requested CDC’s assistance. When CDC presents potentially  confusing information and does not respond in a timely or consistent  fashion to clarify confusion following publication of a public health  product, the agency runs the risk that an incorrect interpretation of the  intended message could put the public at risk of adverse health effects,  such as those that result from elevated water lead levels. CDC can mitigate  the risk of such misinterpretations as well as the resulting risk to its  credibility by developing procedures that allow it to address confusion in a  timely, consistent manner.
section_title: Recommendations for Executive Action
paragraphs: We are recommending that the Director of CDC take two actions, the first  to clarify confusion about the contribution of lead in tap water to elevated  BLLs, and the second to improve the clarity of CDC’s published  information on public health issues.  1.  Publish an article in an MMWR Recommendations and Reports that  conveys what is known and not known about tap water as a source of  lead exposure and communicates the potential health effects in  children of elevated lead levels in water in consultation with EPA, as  appropriate. 2.  Develop procedures to review previously published information and  determine whether additional information should be published to help  ensure the correct understanding of the public health message. The  procedures could include criteria to use when deciding how to  respond in certain situations, such as the event in the District, in which    CDC learns of confusion about the public health message and  determines that clarification or additional information should be  published or    CDC issues or releases a product in an expedited time frame or based  on uncertain or incomplete information and determines additional  information should be published to clarify the original public health  message, even if there is no evidence of confusion.
section_title: Agency Comments
paragraphs: CDC reviewed a draft of this report and provided written comments,  which are reprinted in appendix V. CDC generally concurred with our  recommendations and submitted general comments on the draft.
CDC agreed with our first recommendation to publish an article in an  MMWR Recommendations and Reports. While CDC previously stated that  it had no plans to publish such an article, it stated in its written comments  that it now plans to publish an article in an MMWR Recommendations and  Reports that will focus on what is known about tap water as a source of  lead exposure and summarize the potential health effects in children from  lead exposures.
Related to our second recommendation to develop procedures to review  previously published information and determine whether additional  information should be published to help ensure the correct understanding  of the public health message, CDC said it planned to adopt several  procedures for taking action when the agency becomes aware of  confusion about its message. CDC’s written comments indicated that these  procedures will be effective when approved by the CDC Director.  Specifically, CDC stated that when appropriate, it may take actions to  address significant errors of understanding or perception resulting from  public health information disseminated by the agency. For example, for  errors of understanding or perception in which there is a persistent, broad,  or otherwise significant misinterpretation of information in a public health  product, CDC will present the scientific conclusions in clear language in  several ways, such as a posting on the CDC Web site or by direct outreach  to the news and electronic media, including via press releases or letters to  the editor. However, within these procedures, CDC did not explicitly  address situations where CDC issues or releases a product in an expedited  time frame or based on uncertain or incomplete information and  determines additional information should be published to clarify the  original public health message, even if there is no evidence of confusion. It  is important that CDC take this additional step in order to help ensure that  the agency can address confusion in a timely manner and thereby mitigate  risk to the public’s health or the agency’s credibility.
CDC also provided technical comments, which we incorporated as  appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of Health  and Human Services and other interested parties. The report also will be  available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-7114 or at bascettac@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. Other major contributors to this report are listed in  appendix VI.
section_title: Appendix I: 2004 Morbidity and Mortality Weekly Report Article about Blood Lead Levels of District Residents
paragraphs: On April 2, 2004, the Centers for Disease Control and Prevention (CDC)  published the following article in the Morbidity and Mortality Weekly  Report, which presented results of the investigation on the effect of lead in  the District’s tap water on the blood lead levels of residents. Additionally,  in 2010 CDC added the information contained in the box under the  article’s title. The article is presented here in its electronic version, which  was accessed from CDC’s Web site.
section_title: Appendix II: 2010 Letter Clarifying Information about the 2004 Morbidity and Mortality Weekly Report Article
paragraphs: On May 20, 2010, the Centers for Disease Control and Prevention (CDC)  sent the following letter to state and local Childhood Lead Poisoning  Prevention Program managers to address confusion related to the first  sentence in the Editorial Note section of the 2004 Morbidity and  Mortality Weekly Report article, which contained an incorrect statement.  Additionally, the letter presented results of a recent analysis that included  new blood lead level data that had not been available to CDC in 2004. The  letter is presented here in its electronic version, which was accessed from  CDC’s Web site.
section_title: Appendix III: May 21, 2010, Notice Clarifying Information about the 2004 Morbidity and Mortality Weekly Report Article
paragraphs: On May 21, 2010, the Centers for Disease Control and Prevention (CDC)  published the following Notice to Readers in the Morbidity and Mortality  Weekly Report (MMWR) to clarify information about the first sentence in  the Editorial Note in the 2004 MMWR article and to present results of a  recent analysis that included new blood lead level data that had not been  available to CDC in 2004. The Notice to Readers is presented here in its  electronic version, which was accessed from CDC’s Web site.
section_title: Appendix IV: June 25, 2010, Notice Clarifying Information about the 2004 Morbidity and Mortality Weekly Report Article
paragraphs: On June 25, 2010, the Centers for Disease Control and Prevention (CDC)  published the following Notice to Readers in the Morbidity and Mortality  Weekly Report (MMWR) that noted the limitations of the results of an  analysis in the 2004 MMWR article. The Notice to Readers is presented  here in its electronic version, which was accessed from CDC’s Web site.
section_title: Appendix V: Comments from the Centers for Disease Control and Prevention
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Karen Doran, Assistant  Director; April W. Brantley; Natalie Herzog; Amy C. Leone; Lisa  Motley; and Roseanne Price made key contributions to this report.