Prepared for: The Lead Exposure and Prevention Advisory Committee

Prepared by: The Blood Lead Reference Value (BLRV) Workgroup

Disclaimer: The findings and conclusions in this report are those of the BLRV workgroup and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC). This document has not been revised or edited to conform to agency standards.

No safe level of lead exposure has been identified for children. Protecting children from childhood lead poisoning requires the collective work of many partners, including but not limited to a range of federal, state, territorial, and local agencies, as well as homeowners, landlords, and clinical providers. The CDC blood lead reference value (BLRV), defined as the 97.5th percentile of blood lead level (BLL) concentrations for U.S. children aged 1 to 5 years, is an important tool guiding the efforts of these stakeholders, but is not a clinical reference level defining an acceptable range of blood lead levels in children, nor is it a health-based toxicity threshold, and it cannot be used to predict the health outcome for any particular child. The BLRV is also not an action level in most states or localities; however, it does provide vital information to healthcare providers and parents that a child has been exposed to lead and has a BLL that is higher than most children, paving the way for early intervention and the prevention of additional exposure and associated harm. The BLRV is also a useful tool for targeting services, identifying racial and other disparities in lead exposure, monitoring progress in reducing lead exposure, and informing policies to eliminate childhood lead poisoning at the federal, state, and local levels.

Ultimately, primary prevention by eliminating lead exposure before children are exposed and harmed is the goal; revising the BLRV downward is consistent with that aim. However, the Workgroup also considered and acknowledged a variety of potential challenges associated with lowering the BLRV. Notably, this includes the need for enhanced manufacturing, specimen collection and testing practices, and that POC technologies improve analytical sensitivity and precision. We also recognize concerns about messaging for parents, healthcare providers, and other stakeholders, particularly in instances where local action levels (and related follow-up services) do not align with a lowered BLRV. Lowering the BLRV may also impact governmental agencies at the federal, state, and local levels, necessitating increased capacity or resources to address a larger and more varied case load. Potential challenges and risks were evaluated and weighed against the potential benefits of lowering the BLRV and the workgroup offers several recommendations to address and overcome these and other identified barriers.

The Blood Lead Reference Value Workgroup recommends that the CDC Lead Exposure and Prevention Advisory committee adopt a revised reference value of 3.5 micrograms of lead per deciliter of blood (μg/dL) (based upon most recent NHANES cycles 2015-2018) and implement a plan to address barriers associated with specimen collection, testing, messaging, and capacity of affected agencies and stakeholders at the federal, state, and local levels. These implementation challenges and recommendations to address them are outlined in detail in this document. Some of these barriers exist even at the current BLRV, but all deserve priority consideration as CDC moves forward with their lead poisoning prevention efforts. To create stability and consistency for stakeholders, the Workgroup also recommends that the CDC reaffirm their commitment to regular and timely monitoring of the 97.5th percentile of the NHANES blood lead levels and clarify that although this statistic may increase or decrease over time, that the BLRV will only ever be maintained or decreased, but never increased.

BLRV-recommendation-report-508.pdf