Research

JAMA Pediatrics | Original Investigation

Individual- and Community-Level Factors Associated

With Detectable and Elevated Blood Lead Levels in US Children
Results From a National Clinical Laboratory
Marissa Hauptman, MD, MPH; Justin K. Niles, MA; Jeffrey Gudin, MD; Harvey W. Kaufman, MD

Editorial
IMPORTANCE No safe level of exposure to lead has been identified.

OBJECTIVE To evaluate individual- and community-level factors associated with detectable

and elevated blood lead levels (BLLs) in children.

DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, retrospective study analyzed

deidentified results from blood lead tests performed at a large clinical laboratory from
October 1, 2018, to February 29, 2020. Participants were 1 141 441 children younger than
6 years living in all 50 US states and the District of Columbia who underwent blood lead
testing during the study period. Children who underwent lead testing of unknown source and
those with elevated BLLs who received capillary blood lead testing without confirmatory
venous testing were excluded.

EXPOSURES Individual demographic categories included sex, age, and insurance type;
community-level demographic categories included pre-1950s housing, poverty, predominant
race and ethnicity, and geographical regions.

MAIN OUTCOMES AND MEASURES Proportions of children with detectable (ⱖ1.0 μg/dL) and
elevated (ⱖ5.0 μg/dL) BLLs, by exposure category.

RESULTS Of the 1 141 441 children (586 703 boys [51.4%]; mean [SD] age, 2.3 [1.4] years) in
the study, more than half of the children tested (576 092 [50.5%; 95% CI, 50.4%-50.6%])
had detectable BLLs, and 21 172 children (1.9% [95% CI, 1.8%-1.9%]) had BLLs of 5.0 μg/dL
or more. In multivariable analyses, children with public insurance had greater odds of having
detectable BLLs (adjusted odds ratio [AOR], 2.01 [95% CI, 1.99-2.04]) and elevated BLLs
(AOR, 1.08 [95% CI, 1.04-1.12]). The proportion of children with detectable and elevated BLLs
increased significantly for progressive pre-1950s housing and poverty quintiles (P < .001).
The odds of detectable BLLs were significantly higher among children in the highest vs
lowest quintile of pre-1950s housing (AOR, 1.65 [95% CI, 1.62-1.68]) and of poverty (AOR,
1.89 [95% CI, 1.86-1.93]). A similar association was found for those with elevated BLLs, with
an AOR of 3.06 (95% CI, 2.86-3.27) for the highest vs lowest quintile of pre-1950 housing
and 1.99 (95% CI, 1.88-2.11) for the highest quintile of poverty. Children residing in zip codes
with predominantly Black non-Hispanic and non-Latinx populations had higher odds of
detectable BLLs (AOR, 1.13 [95% CI, 1.11-1.15]) but lower odds for elevated BLL (AOR, 0.83
[95% CI, 0.80-0.88]).

CONCLUSIONS AND RELEVANCE This study suggests that, despite progress in reducing Author Affiliations: Division of
pediatric lead exposure, substantial individual- and community-level disparities persist. General Pediatrics, Boston Children’s
Hospital, Boston, Massachusetts
(Hauptman); Region 1 New England
Pediatric Environmental Health
Specialty Unit, Boston,
Massachusetts (Hauptman); Quest
Diagnostics, Secaucus, New Jersey
(Niles, Gudin, Kaufman); Department
of Anesthesiology, Pain Management,
and Perioperative Medicine,
University of Miami, Miller School
of Medicine, Miami, Florida (Gudin).
Corresponding Author: Marissa
Hauptman, MD, MPH, Division of
General Pediatrics, Boston Children’s
Hospital, 300 Longwood Ave,
JAMA Pediatr. doi:10.1001/jamapediatrics.2021.3518 Boston, MA 02115 (marissa.hauptman
Published online September 27, 2021. @childrens.harvard.edu).

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 Research Original Investigation Individual- and Community-Level Factors Associated With Lead Exposure

L
ead has no biological role in the body. Any detectable lead
level is abnormal and potentially harmful, particularly Key Points
in young children; no safe level of exposure to lead for
Question What individual- and community-level factors are
children has been identified.1-4 The existing literature on risk associated with detectable blood lead levels (BLLs) in children?
factors for lead exposure in children is extensive but focuses
Findings This cross-sectional study linking Quest Diagnostics
largely on elevated blood lead levels (BLLs), defined as
childhood lead testing and US Census data captured individual-
5.0 μg/dL or more (to convert to micromoles per liter, multi-
and community-level disparities in lead exposure from
ply by 0.0483). Less evaluation is available on lead exposure October 2018 through February 2020. In adjusted models, the
at levels that are lower but still detectable (≥1.0 μg/dL), even proportion of children with detectable (ⱖ1.0 μg/dL) and elevated
though BLLs in this range are associated with adverse effects (ⱖ5.0 μg/dL) BLLs increased significantly among those with
in infants and children.5,6 Understanding individual- and neigh- public insurance and for progressive quintiles of community
borhood-level risk factors that are associated with any expo- pre-1950s housing and poverty.
sure to lead in children may be important in targeting efforts Meaning Similar individual- and community-level disparities
to mitigate adverse effects. were seen among children with detectable BLLs and those with
During the past nearly 40 years, BLLs have decreased elevated BLLs.
because of successful policies aimed at controlling lead in the
environment and by eliminating it from gasoline, paint, plumb-
ing fixtures, and consumer products.7,8 As a result of these
policies, millions of children have been spared from the very Honoring the spirit of the Advisory Committee on Child-
high BLLs once ubiquitous in the United States.9 Neverthe- hood Lead Poisoning Prevention recommendation, this study
less, numerous environmental sources of legacy lead still follows up on an earlier report of national trends in pediatric
exist. Because of their developmentally appropriate hand-to- lead exposure,13 using a lower BLL threshold to analyze data
mouth exploratory behaviors, children are at particular risk in from one of the largest national reference clinical laborato-
environments contaminated with lead.10 ries in the United States. Like the earlier study on which
Disparities persist, meaning that lead exposure is dispro- it builds, the present study examines factors that may be as-
portionately associated with adverse effects in vulnerable sociated with patterns of BLLs, including insurance type,
groups including immigrant children, low-income families, and pre-1950 housing, poverty, latitude, age, sex, and geography
young children of ethnic and racial minorities,11 based on age, (US states).
socioeconomic, occupational, developmental, and cultural risk
factors.12 Children living at or below the poverty line in older
housing or in communities with high concentrations of pov-
erty are at the greatest risk of the toxic effects from lead.12-14
Methods
In addition, low socioeconomic status places children at in- Study Population
creased risk of nutritional problems. For example, iron defi- In this retrospective, cross-sectional, observational analysis
ciency has been associated with a 4- to 5-fold increase in base- of deidentified results from a clinical laboratory, blood lead
line risk of harm from lead because of increased absorption of testing results from children younger than 6 years, obtained
lead by the divalent metal transporter in the gastrointestinal from October 1, 2018, through February 29, 2020, were
tract.15 Less is known about whether these disparities and other selected for potential inclusion. October 2018 was selected as
factors apply to BLLs that are detectable at lower levels or the first full month after Quest Diagnostics began reporting
whether particular community-level factors can be identi- blood lead testing results with a detection threshold of
fied to refine strategies for the primary prevention of expo- 1.0 μg/dL. February 2020 was chosen to eliminate the poten-
sure to the toxic effects of lead. tial effects associated with the COVID-19 pandemic. A Quest
In 2012, the Advisory Committee on Childhood Lead Poi- Diagnostics unique patient identifier was required to assess
soning Prevention of the Centers for Disease Control and Pre- the number of test results per patient. If a participant had
vention (CDC) cited new scientific data indicating that there is 2 or more tests within the data set, only the first result within
no known lower threshold for lead-based health effects.16 In re- the data set was included. However, if the first specimen was
sponse, the CDC lowered the BLL reference value to 5.0 μg/dL from capillary blood and the result was 5.0 μg/dL or more,
(from 10 μg/dL) to trigger public health action and, at the same a confirmatory specimen was required within 90 days; in
time, emphasized the importance of primary prevention ef- this case, only the results from the confirmatory specimens
forts given the lack of an identified threshold for the deleteri- were considered in this analysis, consistent with the CDC
ous neurodevelopmental effects of lead.7,17,18 The reference level definition of “confirmed elevated BLL.”20 Capillary blood
of 5.0 μg/dL is based on the 97.5th percentile of the BLL distri- test results of 5.0 μg/dL or more without confirmation
bution in children reported by the National Health and Nutri- were excluded from analysis because of the possibility of
tion Examination Survey (NHANES), with a recommendation contamination.21 Specimens from an unknown source (capil-
to reevaluate this reference level every 5 years.7 More recently, lary or venous) were also excluded. This Quest Diagnostics
the CDC subcommittee on lead poisoning prevention recom- Health Trends study was deemed exempt by the Western
mended further lowering the reference value for BLL in chil- Institutional Review Board and parental consent was not
dren to 3.5 μg/dL, based on the 2011-2014 NHANES report.19 required, as the study is of aggregated deidentified data.

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 Individual- and Community-Level Factors Associated With Lead Exposure Original Investigation Research

Laboratory Methods Testing for the statistical significance of differences between

Venous blood specimens were collected into evacuated tubes 2 groups was conducted using the χ2 test. Multivariable logis-
certified for lead testing, such as tan-top and royal blue–top tic regression models to evaluate characteristics associated with
tubes containing the anticoagulant EDTA. Capillary blood detectable BLLs and elevated BLLs are reported. Variables in
specimens were collected in lavender-top capillary tubes. Speci- both models were chosen based on plausibility and/or statis-
mens were analyzed using either inductively coupled plasma tical significance in previous studies13,14 and remained in the
mass spectrometry or Zeeman graphite furnace atomic absorp- final model using a stepwise entry criterion of P < .01. Model
tion spectroscopy. Instrument calibrations were performed using performance was assessed using the area under the receiver
National Institute of Standards and Technology traceable operating curve. Analyses were performed using SAS Studio
Standard Reference Material 3128.22 The coefficient of varia- 3.6 on SAS, version 9.4 (SAS Institute Inc).
tion of the lead measurement of quality control material of
approximately 3.0 μg/dL was consistently less than 10%.

Results
Estimates by Zip Code
To analyze demographic factors that were not available for Test results from 1 150 948 children were selected for poten-
individual children, estimates from the US Census were obtained tial inclusion. Of these results, 9507 were excluded because
for each zip code and linked to patient residential zip code. For the first specimen was from an unknown blood source
race and ethnicity,23 poverty,24 and pre-1950s housing,25 esti- (n = 7508) or because a child with an initial capillary blood test
mates were obtained from the 2018 5-year American Commu- result of 5.0 μg/dL or more did not undergo confirmation test-
nity Survey. Zip codes with estimated proportions of Black non- ing within 90 days (n = 1999). The final analytic cohort thus
Hispanic and non-Latinx patients of more than 50% were clas- comprised 1 141 441 children (99.2% of the children consid-
sified as predominately Black non-Hispanic and non-Latinx ered; 586 703 boys [51.4%]; mean [SD] age, 2.3 [1.4] years). Most
(hereafter referred to as Black). The same pattern was followed children in this study had BLL test results obtained from
for zip codes with predominantly Hispanic and Latinx and pre- venous blood specimens (844 961 [74.0%]) and were be-
dominantly White non-Hispanic and non-Latinx populations tween 1.0 and 2.9 years of age (699 359 [61.3%]). The demo-
(hereafter referred to as White) in a manner consistent with pre- graphic characteristics of children included in the study and
vious literature.26 Pre-1950s housing was analyzed because, the distribution of BLL results are shown in the Table.
although the manufacture of lead-based paint was banned More than half of the children (576 092 [50.5%; 95% CI,
nationally in 1978, some cities had enacted legislation on lead- 50.4%-50.6%]) had detectable BLLs, including most children
based paint as early as the 1950s, and some manufacturers had from 24 different states (Figure 1), and 21 172 children (1.9%
initiated voluntary reduction of lead concentrations in paints.27 [95% CI, 1.8%-1.9%]) had BLLs of 5.0 μg/dL or more. The high-
As a result, paint produced after the 1950s tended to have lower est proportions of children with detectable BLLs were found
concentrations of lead than that produced earlier.28 Poverty is in Nebraska (83% [95% CI, 81%-85%]), Missouri (82% [95% CI,
defined as the proportion of the community population below 82%-83%]), Michigan (78% [95% CI, 78%-79%]), Iowa (76%
the poverty threshold, defined by the poverty to income ratio of [95% CI, 74%-77%]), and Utah (73% [95% CI, 70%-76%]). Six
less than 1.0. A latitude for each zip code was assigned using states had proportions of elevated BLLs more than double
SAS Institute reference data, and the results were stratified into the national rate of 1.9% (95% CI, 1.8%-1.9%): Nebraska
3 groups: above 40 degrees (northern), 32 to 40 degrees (central), (6.0% [95% CI, 4.8%-7.2%]), Ohio (5.2% [95% CI, 4.7%-
and below 32 degrees (southern). 5.6%]), Pennsylvania (5.0% [95% CI, 4.9%-5.2%]), Missouri
(4.5% [95% CI, 4.2%-4.8%]), Michigan (4.5% [95% CI, 4.1%-
Reporting Thresholds and BLL Groups 4.9%]), and Wisconsin (4.3% [95% CI, 3.8%-4.8%]). Results
Any value at or above the reporting threshold of 1.0 μg/dL was for detectable BLLs and BLLs of 5.0 μg/dL or more from
considered a detectable BLL. Any value of 5.0 μg/dL or more additional states are displayed in Figure 1. These differences
was considered an elevated BLL. Also, the proportion was persisted in multivariate regression models, adjusting for
analyzed among children with BLL values of 1.0 to 1.9, 2.0 to individual- and community-level factors.
2.9, 3.0 to 3.9, 4.0 to 4.9, 5.0 to 9.9 μg/dL (between the 2012 The proportion of children with detectable BLLs in-
CDC reference level and the previous 1991 CDC level of con- creased significantly with progressive quintiles of pre-1950s
cern), and 10 μg/dL or more. housing (from 42.6% [95% CI, 42.4%-42.8%] to 57.2% [95%
CI, 57.0%-57.4%]; P < .001) (Figure 2A) and of poverty (from
Geographical Categories 38.8% [95% CI, 38.6%-39.0%] to 60.2% [95% CI, 60.0%-
This study includes children from all 50 US states and the District 60.4%]; P < .001) (Figure 2B). In addition, the proportion of
of Columbia. The proportion of children with detectable BLLs of children with BLLs of 5.0 μg/dL or more increased signifi-
1.0 μg/dL or more and BLLs of 5.0 μg/dL or more (elevated BLLs) cantly with progressive quintiles of pre-1950s housing (from
are reported for US states with results from at least 500 children. 0.9% [95% CI, 0.8%-0.9%] to 3.5% [95% CI, 3.4%-3.6%];
P < .001) and of poverty (from 1.2% [95% CI, 1.1%-1.2%] to 2.9%
Statistical Analysis [95% CI, 2.8%-2.9%]; P < .001). Zip codes with predomi-
The Cochran-Armitage test was used to analyze trends in pro- nately Black populations had significantly higher propor-
portions of children with different BLLs for quintile groups. tions of children with detectable BLLs and BLLs of 5.0 μg/dL

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 Research Original Investigation Individual- and Community-Level Factors Associated With Lead Exposure

Table. Demographic Characteristics of Children by Blood Lead Level

Blood lead level, μg/dL, No. (%)

Characteristic Total No. <1.0 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-9.9 ≥10.0
All children 1 141 441 565 349 (49.5) 408 689 (35.8) 99 885 (8.8) 30 839 (2.7) 15 507 (1.4) 15 963 (1.4) 5209 (0.5)
Blood source
Venous 844 961 441 738 (52.3) 279 960 (33.1) 68 616 (8.1) 22 016 (2.6) 11 622 (1.4) 15 843 (1.9) 5166 (0.6)
Capillary 296 480 123 611 (41.7) 128 729 (43.4) 31 269 (10.6) 8823 (3.0) 3885 (1.3) 120 (0.04) 43 (0.01)
Sexa
Female 554 172 278 213 (50.2) 197 849 (35.7) 47 024 (8.5) 14 279 (2.6) 7121 (1.3) 7313 (1.3) 2373 (0.4)
Male 586 703 286 770 (48.9) 210 721 (35.9) 52 816 (9.0) 16 548 (2.8) 8373 (1.4) 8646 (1.5) 2829 (0.5)
Age group, y
<1.0 114 685 65 888 (57.5) 34 953 (30.5) 8528 (7.4) 2517 (2.2) 1220 (1.1) 1220 (1.1) 359 (0.3)
1.0-1.9 411 833 201 190 (48.9) 151 288 (36.7) 35 931 (8.7) 10 907 (2.7) 5348 (1.3) 5407 (1.3) 1762 (0.4)
2.0-2.9 287 526 131 750 (45.8) 109 203 (38.0) 27 920 (9.7) 8469 (3.0) 4301 (1.5) 4402 (1.5) 1481 (0.5)
3.0-3.9 129 162 61 161 (47.4) 47 268 (36.6) 11 840 (9.2) 3947 (3.1) 1966 (1.5) 2214 (1.7) 766 (0.6)
4.0-4.9 120 411 61 951 (51.5) 41 900 (34.8) 9732 (8.1) 3110 (2.6) 1621 (1.4) 1599 (1.3) 498 (0.4)
5.0-5.9 77 824 43 409 (55.8) 24 077 (30.9) 5934 (7.6) 1889 (2.4) 1051 (1.4) 1121 (1.4) 343 (0.4)
Latitude (degrees)b
Northern (>40) 505 841 262 765 (52.0) 156 846 (31.0) 50 106 (9.9) 15 898 (3.1) 8048 (1.6) 9058 (1.8) 3120 (0.6)
Central (32-40) 482 470 207 780 (43.1) 207 133 (42.9) 41 138 (8.5) 12 523 (2.6) 6276 (1.3) 5881 (1.2) 1739 (0.4)
Southern (<32) 151 206 94 172 (62.3) 43 822 (29.0) 8426 (5.6) 2351 (1.6) 1143 (0.8) 954 (0.6) 338 (0.2)
b
SI conversion factor: To convert blood lead level to micromoles per liter, Missing data for 1924 patients.
multiply by 0.0483.
a
Missing data for 566 patients.

or more than did zip codes with predominately White popu- populations had an AOR of 0.44 (95% CI, 0.42-0.47) for
lations (detectable BLLs, 57.6% [95% CI, 57.3%-57.9%] vs 48.7% elevated BLLs compared with children residing in zip codes
[95% CI, 48.6%-48.9%]; P < .001; BLLs ≥5.0 μg/dL, 2.5% with predominantly White populations. In adjusted models,
[95% CI, 2.4%-2.6%] vs 2.0% [95% CI, 2.0%-2.1%]; P < .001) children residing in zip codes with predominantly Black popu-
(Figure 2C). Zip codes with predominately Hispanic and Latinx lations had an AOR of 1.13 (95% CI, 1.11-1.15) for detectable
populations had a significantly higher proportion of children BLLs, but this finding did not hold for elevated BLLs (AOR, 0.83
with detectable BLLs than did zip codes with predominately [95% CI, 0.80-0.88]) compared with children living in pre-
White populations (56.0% [95% CI, 55.8%-56.2%] vs 48.7% dominantly White populations. In the model showing ad-
[95% CI, 48.6%-48.9%]; P < .001), but they had a signifi- justed associations with BLLs of 5.0 μg/dL or more, children
cantly lower proportion of children with BLLs of 5.0 μg/dL or with public insurance had an AOR of 1.08 (95% CI, 1.04-1.12)
more (1.1% [95% CI, 1.1%-1.2%] vs 2.0% [95% CI, 2.0%-2.1%]; for elevated BLLs compared with children with private insur-
P < .001). ance. The AOR for BLLs of 5.0 μg/dL or more was 3.06 (95%
To assess the association of these factors when consid- CI, 2.86-3.27) for children residing in the highest quintile of
ered together, multivariable models were created with detect- pre-1950 housing compared with those in the lowest quintile
able BLLs (Figure 3) and elevated BLLs (Figure 4) as the de- and 1.99 (95% CI, 1.88-2.11) for those in the highest quintile of
pendent variables. In general, the associations with detectable poverty compared with those in the lowest quintile.
BLLs for most factors found by looking at simple proportions
were confirmed in adjusted analyses. The adjusted odds ratio
(AOR) of having a detectable BLL was 1.65 (95% CI, 1.62-1.68)
for the highest quintile of pre-1950 housing compared with
Discussion
the lowest quintile and was 1.89 (95% CI, 1.86-1.93) for the This large, cross-sectional, retrospective national study, using
highest quintile of poverty compared with the lowest quin- both mapping techniques and multivariate analyses, demon-
tile. Children with public insurance had an AOR of 2.01 strates that there is an association between where a child lives
(95% CI, 1.99-2.04) for a detectable BLL compared with chil- and the risk of any lead exposure, an important health issue
dren with private insurance. An exception was children resid- with long-term outcomes at a population level. Most children
ing in zip codes with predominately Hispanic and Latinx popu- evaluated had detectable BLLs. Similar associations were seen
latons, with an AOR of 0.98 (95% CI, 0.96-0.99) for detectable with individual- and community-level factors and associa-
BLLs, compared with children residing in zip codes with pre- tions with both detectable and elevated BLLs. This result is
dominantly White populations. In adjusted models, children important because prior studies have demonstrated that, if the
residing in zip codes with predominantly Hispanic and Latinx US achieved BLLs of zero in US children born in 2018, it would

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 Individual- and Community-Level Factors Associated With Lead Exposure Original Investigation Research

Figure 1. Children With Detectable or Elevated Blood Lead Levels by State

A Percentage of children with detectable blood lead levels

Excluded (≤500 children) 17.1-30.0% 30.1%-45.0% 45.1%-65.2% 65.3%-70.0% 70.1%-83.1%

34

43 43
68
65
44
50 27
78
68
76 58
45 83 21
52
68 46 22 DE
73
63 29 23 MD
72 20 17 DC
65 82
70

67
70
34
63 66 38

72 66
54

59
72

17
36

B Percentage of children with elevated blood lead levels

Excluded (≤500 children) 0.5%-1.0% 1.1%-1.4% 1.4%-2.1% 2.2%-3.0% 3.1%-6.0%

1.4

1.4
2.0
3.7
1.6 4.3 1.7 1.5
4.5
2.4
3.6 5.0
1.6
6.0
0.5 5.2 2.8 DE
2.6 3.7
0.8 1.2 MD
1.4 2.3 0.9 DC
1.2 1.3
2.6 4.5 1.6

2.7
1.1
2.2
1.0
1.3 1.0 A, Percentage of children with
detectable blood lead levels.
1.1 3.0 0.8 B, Percentage of children with
2.1
elevated blood lead levels. Analysis
1.2
limited to states and the Discrict of
Columbia with results for more than
0.8 0.6
500 children. Detectable blood lead
level, 1.0 μg/dL or more; elevated
blood lead level, 5.0 μg/dL or more
(to convert to micromoles per liter,
multiply by 0.0483).

result in an overall benefit of approximately $84 billion dur- not consistent. Further studies are needed to characterize these
ing the lifetimes of these children.29 These projected savings associations.
are primarily the result of the expected increases in produc-
tivity among children who will be able to achieve their full po- Limitations
tential ($77.2 billion). The associations between lead expo- This study has limitations, especially with regard to conclu-
sure and elevated BLLs in children residing in zip codes with sions about the prevalence of lead exposure, owing to poten-
predominantly Black or Hispanic and Latinx populations were tial selection bias. These data should only be interpreted as

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 Research Original Investigation Individual- and Community-Level Factors Associated With Lead Exposure

Figure 2. Distribution of Blood Lead Levels Based on Risk Factor Quintiles Assessed by Zip Code
A Pre-1950 housing quintiles

70

60 Q1 (lowest) Q2 Q3 Q4 Q5 (highest)

50
Percentage

40

30

20

10

0
<1.0 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 ≥5.0
Blood lead level, μg/dL

B Poverty quintiles

70

60 Q1 (lowest) Q2 Q3 Q4 Q5 (highest)

50
Percentage

40

30

20

10

0
<1.0 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 ≥5.0
Blood lead level, μg/dL

C Predominant race and ethnicity zip codes

70

60 Black non-Hispanic Hispanic Other race and ethnicity White non-Hispanic

50
Percentage

40

30

20

10

0
<1.0 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 ≥5.0
Blood lead level, μg/dL

A, Pre-1950s housing quintile; 6778 missing estimates. B, Poverty quintile; 6901 Cochran-Armitage test for trend, P < .001 for progressive quintiles of pre-1950s
missing estimates. C, Predominant race and ethnicity. “Predominant” refers to housing construction (A) and poverty (B) within each blood lead measurement
zip codes with estimated proportions of the given race and ethnicity over 50%. level.
To convert blood lead levels to micromoles per liter, multiply by 0.0483.

a large sample of national data because Quest Diagnostics reported in the results represent the data of clinical facilities
does not perform all lead testing in the US. Specimen type that send laboratory testing to this reference laboratory. The
could create a selection bias because some clinical practices proportion of overall lead testing represented by these facili-
rely on venous blood testing as a confirmatory test after a ties varies by state owing to multiple factors, including
capillary blood point-of-care test is conducted in the office. differing levels of Quest Diagnostics market share. There
Unfortunately, we cannot determine which venous blood is significant state-level variability in how health care profes-
specimens were confirmatory as the result of testing that sionals determine who to test for lead exposure. 30 For
was conducted outside of Quest Diagnostics. The rates example, 10 US states and the District of Columbia require

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 Individual- and Community-Level Factors Associated With Lead Exposure Original Investigation Research

Figure 3. Factors Associated With Detectable Blood Lead Levels in Children Younger Than 6 Years:
Multivariable Model

Favors no Favors
detectable detectable
blood lead blood lead
Factor AOR (95% CI) levels levels
Malea 1.06 (1.05-1.07)
Age, yb
<1 0.93 (0.91-0.95)
1-1.9 1.40 (1.37-1.42)
2-2.9 1.58 (1.55-1.61)
3-3.9 1.35 (1.32-1.38)
4-4.9 1.15 (1.12-1.17)

Medicaid or Medicarec 2.01 (1.99-2.04)

Black non-Hispanicd,e 1.13 (1.11-1.15)
Hispanicd,e 0.98 (0.96-0.99)
Included in this model were 942 428
Pre-1950 housingf children, with no values missing for
Q2 1.14 (1.13-1.16) any variable (83% of those included).
Q3 1.29 (1.27-1.30) Area under receiver operator
Q4 1.41 (1.39-1.43) curve = 0.66. AOR indicates adjusted
Q5 (highest) 1.65 (1.62-1.68) odds ratio.
a
Povertyg Reference, female.
b
Q2 1.16 (1.14-1.17) Reference, 5 to 5.9 years.
c
Q3 1.41 (1.39-1.43) Reference, private payers.
Q4 1.68 (1.65-1.70) d
Predominantly White non-Hispanic
Q5 (highest) 1.89 (1.86-1.93) and non-Latinx populations.
Northern latitudesh 1.85 (1.82-1.89) e
Reference, all other zip codes.
Central latitudesh 1.82 (1.79-1.84) f
Reference, pre-1950 housing
quintile (Q) 1.
0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 g
AOR (95% CI)
Reference, poverty Q1.
h
Reference, southern latitudes.

Figure 4. Factors Associated With Elevated Blood Lead Levels in Children Younger Than 6 Years:
Multivariable Model

Favors no Favors
elevated elevated
blood lead blood lead
Factor AOR (95% CI) levels levels
Malea 1.12 (1.08-1.15)
Age, yb
<1 0.56 (0.52-0.59)
1-1.9 0.90 (0.87-0.93)
2-2.9 0.78 (0.74-0.82)
Medicaid or Medicarec 1.08 (1.04-1.12)
Black non-Hispanicd,e 0.83 (0.80-0.88)
Hispanicd,e 0.44 (0.42-0.47) Included in this model were 942 428
Pre-1950 housingf children, with no values missing for
Q2 1.21 (1.14-1.28) any variable (83% of those included).
Q3 1.40 (1.31-1.49) Area under receiver operator
curve = 0.68. AOR indicates adjusted
Q4 2.27 (2.13-2.41)
odds ratio.
Q5 (Highest) 3.06 (2.86-3.27)
a
Reference, female.
Povertyg b
Reference, 3 to 5.9 years.
Q2 1.09 (1.03-1.16)
c
Q3 1.20 (1.14-1.28) Reference, private payers.
d
Q4 1.56 (1.47-1.65) Predominantly White non-Hispanic
Q5 (Highest) 1.99 (1.88-2.11) and non-Latinx populations.
e
Northern latitudesh 1.48 (1.38-1.59) Reference, all other zip codes.
f
Central latitudesh 1.40 (1.31-1.49) Reference, pre-1950 housing
quintile (Q) 1.
0.4 0.5 1.0 1.5 2.0 2.5 3.0 3.5
g
AOR (95% CI) Reference, poverty Q1.
h
Reference, southern latitudes.

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 Research Original Investigation Individual- and Community-Level Factors Associated With Lead Exposure

universal testing, generally for all children at the ages 1 and

2 years; 8 states require targeted testing (eg, based on receipt Conclusions
of public insurance, or living in a community with high pro-
portions of older housing or a high proportion of elevated To eliminate the effect of lead exposure on all children’s health,
BLLs in children); 27 states provide only recommendations; the US must focus efforts to prevent children from being ex-
and 5 states have no requirements or recommendations posed to lead, beginning in areas where risk is highest. Chil-
listed on their websites. These differences were likely associ- dren, families, and society achieve the most benefit from in-
ated with significant variability in the rate of children repre- terventions that ensure that the US mitigates lead exposures
sented in this study population. Sectors of the population in homes and other settings before a child is ever exposed. To
determined to be at higher risk of lead exposure may be our knowledge, this is one of the first comprehensive na-
tested more frequently; clinical judgement, variability in tional analyses investigating the association of lead exposure
state and regional guidance, and socioenvironmental factors with individual- and community-level factors. In adjusted
likely factor in to determining who is tested for lead. Another models, the proportions of children with detectable and el-
study limitation was the use of zip code–level data instead of evated BLLs increased significantly among children with pub-
individual-level patient data or a smaller geographically lic insurance and for progressive quintiles of communities with
aggregated area for race and ethnicity estimates, pre-1950s pre-1950s housing and poverty rates. We did not see consis-
housing, and poverty levels. The precision of the laboratory tent associations between lead exposure and elevated BLLs
is critical in identifying any detectable lead exposure; our in children residing in zip codes with predominantly Black or
method reports a 1.0-μg/dL limit of detection. Last, the mul- Hispanic and Latinx populations. There has been significant
tivariable models displayed poor overall fit statistics. The progress in reducing lead exposure throughout the country;
intent of the model was to evaluate the relative importance this study demonstrates, however, that there are still substan-
of each of the factors assessed in this study after adjustment tial individual- and community-level disparities that have im-
for all other factors. portant implications for addressing childhood lead exposure.

ARTICLE INFORMATION award NU61TS000296-02 (to the Region 1 4. National Toxicology Program, US Department
Accepted for Publication: June 23, 2021. New England Pediatric Environmental Health of Health and Human Services. NTP monograph:
Specialty Unit). The US Environmental Protection health effects of low-level lead. Accessed February
Published Online: September 27, 2021. Agency supports the Pediatric Environmental 25, 2021. https://ntp.niehs.nih.gov/ntp/ohat/lead/
doi:10.1001/jamapediatrics.2021.3518 Health Specialty Units by providing funds to final/monographhealtheffectslowlevellead_
Author Contributions: Mr Niles and Dr Kaufman ATSDR under Inter-Agency agreement newissn_508.pdf
had full access to all of the data in the study and DW-75-95877701-02. 5. Trasande L, Liu Y. Reducing the staggering costs
take responsibility for the integrity of the data Role of the Funder/Sponsor: The funding sources of environmental disease in children, estimated at
and the accuracy of the data analysis. had no role in the design and conduct of the study; $76.6 billion in 2008. Health Aff (Millwood). 2011;
Concept and design: All authors. collection, management, analysis, and 30(5):863-870. doi:10.1377/hlthaff.2010.1239
Acquisition, analysis, or interpretation of data: interpretation of the data; preparation, review, or
Hauptman, Niles, Kaufman. 6. Council on Environmental Health. Prevention of
approval of the manuscript; and decision to submit childhood lead toxicity. Pediatrics. 2016;138(1):
Drafting of the manuscript: All authors. the manuscript for publication.
Critical revision of the manuscript for important e20161493. doi:10.1542/peds.2016-1493
intellectual content: Hauptman, Niles. Disclaimer: The contents of this article are the 7. Centers for Disease Control and Prevention.
Statistical analysis: Hauptman, Niles. responsibility of the authors and do not necessarily CDC response to Advisory Committee on Childhood
Administrative, technical, or material support: represent the official views of the ATSDR. Neither Lead Poisoning Prevention recommendations
Hauptman, Gudin. the National Institutes of Health, ATSDR, nor the in “Low Level Lead Exposure Harms Children:
US Environmental Protection Agency endorse the A Renewed Call of Primary Prevention.” Accessed
Conflict of Interest Disclosures: Dr Hauptman purchase of any commercial products or services
reported receiving grants from the National February 18, 2021. https://www.cdc.gov/nceh/lead/
mentioned in this publication. acclpp/cdc_response_lead_exposure_recs.pdf
Institutes of Health/National Institute of
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