Blood Lead Levels in Young Children: US, 2009-2015

Leland F. McClure, PhD, Justin K. Niles, MA, and Harvey W. Kaufman, MD

Objectives To evaluate trends in blood lead levels in children <6 years of age, this Quest Diagnostics Health
Trends report builds on previously reported National Health and Nutrition Examination Survey data with a much
larger national group and adds more detail and novel assessments.
Study design This report describes the results from a 6-year retrospective study (May 2009-April 2015) based on
>5 million blood lead level results (including >3.8 million venous results) from children <6 years old living in all 50
states and the District of Columbia. We evaluated yearly changes and examined demographic categories including
sex, pre-1950s housing construction, poverty income ratios (PIRs), Medicaid enrollment status, and geographic re-
gions.
Results Among children <6 years old, 3.0% exhibited blood lead levels $5.0 mg/dL (high). There were significant
differences in high blood lead levels based on sex, pre-1950s housing construction quintiles, and PIR <1.25 and
PIR >5 (all P < .01). Health and Human Services regions, states, and 3-digit ZIP code areas exhibited drastically
different frequencies of high blood lead levels and blood lead levels $10.0 mg/dL (very high). Generally, levels
declined over time for all groups.
Conclusion Examination of more than 5 million venous blood lead level results in children younger than 6 years
old allowed for a robust, detailed analysis of blood lead level group results by geography and other criteria that are
prohibited with the narrower National Health and Nutrition Examination Survey database. Progress in reducing the
burden of lead toxicity is a public health success story that is incomplete with some identified factors posing larger,
ongoing challenges. (J Pediatr 2016;175:173-81).

C
hildhood lead toxicity is a preventable environmental disease with long-lasting adverse health and behavioral effects.1
Public health services and other health professionals throughout the US have dedicated more than 4 decades of efforts
to screen children, especially those at high risk, for lead exposure and to identify primary sources of lead.2 Federal and
local environmental policies have included the removal of lead from gasoline, reduction of lead in paints, and testing of homes
for lead-based paint. These efforts along with laboratory testing and case management efforts have been instrumental in signif-
icantly reducing blood lead levels in the US. The 2007-2010 National Health and Nutrition Examination Survey (NHANES)
estimate of the geometric mean blood lead level was 1.3 mg/dL,3 which is a 90% decrease compared with the 1976-1980
NHANES II 12.8 mg/dL estimate.4
In 1991, the Centers for Disease Control and Prevention (CDC) recommended changes for preventing childhood lead
poisoning, which included a reduction for the blood lead level deemed safe (from 25 mg/dL to 10 mg/dL).5 In May 2012, the
CDC Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) identified that there is no safe blood lead level
and the CDC accepted ACCLPP recommendations to remove all CDC blood lead level references to blood lead level of
concern.6 The CDC position of no safe blood lead level is based on an absence of blood lead levels without effects and
low blood lead levels that are associated with intellectual deficits, attention deficit behaviors, and poor academic achievement.7,8
That these effects appear to be irreversible9-11 emphasizes a public health care shift to primary prevention rather than secondary
and tertiary prevention efforts, which are based on responses after detecting lead exposure.
In May 2012, the CDC also adopted the ACCLPP committee recommendations to use the NHANES 97.5th blood lead level
percentile (5.0 mg/dL) as an upper reference interval threshold to identify children with elevated blood lead levels. The 5.0 mg/dL
value is based on 2 consecutive cycles of the NHANES blood lead level data distribution among study children 1-5 years of age.
Based on the 5.0 mg/dL threshold, the 2012 ACCLPP committee report estimated 450 000 children in the US as having blood
lead levels greater than the new reference limit.12 The NHANES analysis includes
demographic categories with long-standing disparities of risk for elevated blood

From the Quest Diagnostics, Madison, NJ

Funded by Quest Diagnostics, which provided support in
the form of salaries for all authors but did not have any
ACCLPP Advisory Committee on Childhood Lead Poisoning Prevention additional role in the study design, collection, analysis
CDC Centers for Disease Control and Prevention and interpretation of data, writing of the manuscript, or
HHS US Department of Health and Human Services decision to publish. The authors declare no conflicts of
interest.
NHANES National Health and Nutrition Examination Survey
PIR Poverty income ratio 0022-3476/$ - see front matter. 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2016.05.005

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THE JOURNAL OF PEDIATRICS  www.jpeds.com
lead levels, including age, sex, race/ethnicity, age of housing,
poverty income ratio (PIR), and Medicaid enrollment status.
Despite the insights provided by the NHANES analysis, the
study has several limitations. One such limitation is that the
low numbers of NHANES-enrolled children with blood lead
levels $10 mg/dL (only 9 children in 2007-2008; 6 children in
2009-2010) make interpretation of population estimates of
very high blood lead levels unreliable. In addition, the
NHANES was not designed to produce estimates at the state
and local level and may not detect statistically significant dis-
parities with important public health implications.
This Quest Diagnostics Health Trends report describes the
results of a 6-year retrospective study based on a large na-
tional clinical laboratory database with more than 5 million
results from children younger than 6 years of age. Our anal-
ysis builds upon previously reported NHANES data and in-
cludes insights into yearly trends and the distributions of
blood lead levels by specimen type (venous and capillary),
sex, payer type, US Department of Health and Human Ser-
vices (HHS) region, residence state, PIR, and pre-1950s
housing construction.
Methods
The specimen requirement for venous blood lead level anal-
ysis is whole blood collected into an evacuated collection tube
certified for lead testing, such as tan-top and royal blue-top
tubes containing the anticoagulant EDTA. For the capillary
collection method, the specimen collection container is the
lavender-top capillary tube.
The blood lead level analyses were performed by the use of
either inductively coupled plasma/mass spectrometry or the
Zeeman graphite furnace atomic absorption spectroscopy.
Instrument calibrations are performed with standards trace-
able to the National Institutes of Standards and Technology.
Performance for all methods is in compliance with the 
4 mg/dL (or 10%, whichever is greater) CDC accuracy stan-
dards.13 The blood lead level results were evaluated with a
3.0 mg/dL lower reporting threshold. The laboratory analysis
of venous specimens is consistent with the CDC definition
for confirmed elevated blood lead level when indicated.14
The blood lead level data set includes deidentified results of
testing performed for children <6 years of age, from May
2009 through April 2015 (3 years before and after the 2012
CDC change from the 10 mg/dL level of concern to the
5.0 mg/dL reference interval threshold). Instances of blood
lead level results reported as a specimen submitted in a
tube/container not certified for lead testing were excluded
from the study. This study was deemed exempt by the West-
ern Institutional Review Board.
To avoid duplication of patient data, when 2 or more tests
were associated with the same individual, only the first
venous result (or the first capillary result if there were no
venous results) within the data set was included in this study.
The 3.0 mg/dL reporting threshold precluded our ability to
estimate the mean blood lead level for the study with suffi-
cient precision. Instead, analyses focused on the proportions
174
Volume 175
of the population falling into each of 4 blood lead level
groups: #3.0 mg/dL (below the reporting limit); 3.1-4.9 mg/dL
(above the reporting limit and below the CDC 2012 reference
interval threshold); 5.0-9.9 mg/dL (between the 2012 refer-
ence interval threshold and the previous 1991 CDC level
of concern); and $10.0 mg/dL.
Patient data were limited to patients <6 years of age, cor-
responding to the CDC age definition for high risk. Blood
lead levels results missing patient sex were excluded from
sex analysis.
Data from the US Census Bureaus 2009-2013 American
Community Survey 5-Year Estimates15 were used to deter-
mine the proportion of housing constructed before 1950 by
ZIP code. According to the CDC, houses built before 1950
pose the greatest hazard to children because they are much
more likely to contain lead-based paint than newer houses.16
Quintiles were defined as the percentage of the housing cate-
gory by ZIP code. Quintile thresholds for pre-1950s housing
were defined as <3.6%, 3.6%-12.9%, 13.0%-29.9%, 30.0%-
50.9%, and $51.0%. All quintile thresholds were chosen to
provide approximately equal numbers in each quintile group.
Demographics were divided into quintiles to demonstrate
trends in blood lead level proportions. ZIP codes are based
on patient residence, not the site of the blood collection.
Data from the United States Census Bureaus 2008-2012
American Community Survey 5-Year Estimates17 were used
to determine PIR of childrens area of residence by ZIP
code. Quintiles were defined as the percentage of PIR <1.25
(low income) and PIR >5 (high income) by ZIP code. Quin-
tile ranges were defined as <16.0%, 16.0%-27.9%, 28.0%-
38.9%, 39.0%-51.9%, and $52.0% for PIR <1.25, and
<2.8%, 2.8%-6.9%, 7.0%-13.9%, 14.0%-27.9%, and
$28.0% for PIR >5.
This study included specimens submitted for blood lead
level testing from all 50 states and the District of Columbia.
Data were grouped for analysis by HHS region, state, and
3-digit ZIP code region. We limited our state analyses to
those with at least 2000 children and our 3-digit ZIP code
analysis to areas with at least 1000 children. The proportion
of housing that was constructed before 1950 in various
geographical regions also was analyzed. These data were
weighted by the number of patients with specimens from in-
dividual ZIP codes.
Statistical Analyses
The Cochran-Armitage test was used to analyze trends in
proportions of children with blood lead levels $5.0 mg/dL
(high blood lead level) and $10.0 mg/dL (very high blood
lead level) for various groups. Testing for statistical signifi-
cance between the 2 groups was conducted with the c2 test.
Multivariable logistic regression models to determine charac-
teristics associated with high blood lead level and very high
blood lead level also are reported. Variables in both models
were chosen based on plausibility and/or statistical signifi-
cance in previous studies.3 Living in ZIP codes associated
with the greatest quintile of pre-1950s housing, low income,
and high income were included as binary variables. Living in
McClure, Niles, and Kaufman
August 2016
HHS regions 1, 3, or 7 also was included as a binary variable.
Despite the small measures of association determined by un-
adjusted ORs in logistic regression models, year of service,
patient age, sex, and payer status were included in the multi-
variable models because of their potential as confounding
factors. Results of adjusted and unadjusted models were
stated as ORs and 95% CIs. Data were analyzed with SAS,
version 9.4 (SAS Institute, Cary, North Carolina).18
Results
This study included 5 266 408 blood lead levels from children
<6 years of age. Venous blood draws represent 72.2% of all
specimen submissions (n = 3 803 070). Blood lead levels
were below the reporting threshold of #3.0 mg/dL in 94.9%
of venous specimens; 3.1-4.9 mg/dL in 2.2%; and $5.0 mg/
dL in 3.0%. Results from the 1 178 000 capillary specimens
were slightly, but statistically significantly (P < .01), more
likely to fall into greater blood lead level categories: capillary
blood lead levels were #3.0 mg/dL in 93.6%, 3.1-4.9 mg/dL in
3.3%, and $5.0 mg/dL in 3.1%. There also was a group of
285 338 specimens with unknown draw type with the
following blood lead level distribution: 95.8% #3.0 mg/dL,
2.3% between 3.0 and 4.9 mg/dL, and 1.9% $5.0 mg/dL.
The remainder of the results section will focus on the
3 803 070 children with venous blood results.
Sex
Of the venous specimens tested, 1 947 693 (51.2%) were from
boys and 1 842 881 (48.5%) were from girls; the other 12 496
(0.3%) specimens had no sex information. High blood lead
level was only slightly greater for boys (3.1%) than girls
(2.8%), although the difference was statistically significant
(P < .01; Table I).
Pre-1950s Housing Construction
Living in an area with a high proportion of pre-1950 housing
construction was strongly associated with having a high blood
lead level (Table I). Living in a ZIP code where $51.0% of
housing units were constructed before 1950 (the highest
quintile) was associated with a significantly larger
proportion of high blood lead levels (OR 5.86, 95% CI 5.71-
6.01) or very high blood lead levels (OR 6.34, 95% CI 5.97-
6.74) than living in an area with the lowest quintile. There
was a statistically significant trend for both high blood lead
levels and very high blood lead levels among the pre-1950s
housing quintiles (both P < .01, Table I).
Payer Type and PIRs
Approximately 20% of patients (n = 768 879) with venous
blood draws had Medicaid as the payer and 687 had Medicare
as the payer. Patients with Medicaid or Medicare had a
slightly, but statistically significantly, lower frequency of
high blood lead level than did those with private payers
(2.6 vs 2.9%; P < .01).
Comparisons of other lead groups between payer types
were also similar (Table I). The data also showed a
Blood Lead Levels in Young Children: US, 2009-2015
ORIGINAL ARTICLES
positive association between percentage of PIR <1.25 in
patient ZIP codes and high blood lead level (Table I).
Children living in ZIP codes in which $52.0% have PIR
<1.25 (the highest quintile) had a greater proportion of
high blood lead level (OR 2.85, 95% CI 2.79-2.91) and
very high blood lead level (OR 2.67, 95% CI 2.54-2.80)
compared with those living in the lowest quintile. There
was a statistically significant trend in both high blood lead
level and very high blood lead level among the poverty
quintiles (Table I). There was an inverse association
between the greater-income ZIP codes and high blood
lead level. Those living in ZIP codes with the greatest
percentage of PIR >5 (the highest quintile) were much less
likely to exhibit high blood lead levels (OR 0.43, 95% CI
0.42-0.44) and very high blood lead level (OR 0.43, 95%
CI 0.41-0.46) than were those in the lowest quintile. There
was a statistically significant trend in both high blood lead
level and very high blood lead level among the PIR >5
quintiles (Table I).
Geographic Regions
Blood lead levels group results were analyzed by HHS region
(Table I). Region 7 (Iowa, Kansas, Missouri, and Nebraska)
had the largest proportion of both high blood lead levels
(5.7%) and very high blood lead levels (1.1%). Region 1
(Connecticut, Massachusetts, Maine, New Hampshire,
Rhode Island, and Vermont) and Region 3 (Delaware,
District of Columbia, Maryland, Pennsylvania, Virginia,
and West Virginia) also had notably large proportions of
high blood lead levels (5.4% and 5.1%, respectively), and
very high blood lead levels (1.0% and 1.1%, respectively).
The states with the largest proportions of high blood lead
levels were Minnesota (10.3%), Pennsylvania (7.8%), Ken-
tucky (7.1%), Ohio (7.0%), and Connecticut (6.7%)
(Table II). All these states and 20 others (25/37, 68%)
exhibited a decline in the proportion of high blood lead
levels between the first year and the final year of the study.
New Hampshire had the largest absolute decline (from
9.7% to 2.6% high blood lead levels), and Mississippi had
the largest absolute increase (from 3.1% to 6.3% high
blood lead levels) between the first year and the final year
of the study. Florida and California had the lowest
proportions of high blood lead levels (1.1% and 1.4%,
respectively) and very high blood lead levels (0.1% and
0.2%, respectively).
Data from 325 3-digit ZIP code regions with more than
1000 specimens (36.0% of all 3-digit ZIP codes with speci-
mens in the study) also were analyzed to assess their impact
on state data. In 6 regions, >14.0% of specimens had high
blood lead levels: Syracuse, NY (40.1%), Buffalo, NY
(18.8%), Cincinnati, OH (16.0%), Poughkeepsie, NY
(14.9%), York, PA (14.4%), and Oil City, PA (14.0%).
The 11 regions with the largest proportions of specimens
with very high blood lead levels also were all in New York,
Pennsylvania, or Ohio. Syracuse, NY (16.0%), Buffalo,
NY (6.0%), York, PA (5.5%), Poughkeepsie, NY (4.9%),
and Oil City, PA (4.3%) had the greatest rates in the study.
175
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume 175

Table I. Blood lead levels in children <6 years old: 2009-2015

10.0 mg/dL 5.0 mg/dL
Total 3.0 mg/dL >3.0 and <5.0 mg/dL 5.0 and <10.0 mg/dL (Very high BLL) (High BLL)
Number (Percent)
Total 3 803 070 3 607 874 (94.87) 82 867 (2.18) 90 092 (2.37) 22 237 (0.58) 112 329 (2.95)
Sex1
Male 1 947 693 1 843 442 (94.65) 44 032 (2.26) 48 312 (2.48) 11 907 (0.61) 60 219 (3.09)
Female 1 842 881 1 752 875 (95.12) 38 384 (2.08) 41 384 (2.25) 10 238 (0.56) 51 622 (2.80)
Pre-1950s housing quintile2
<3.6% 660 387 647 545 (98.06) 5777 (0.87) 5817 (0.88) 1248 (0.19) 7065 (1.07)
3.6-12.9% 662 327 643 939 (97.22) 8522 (1.29) 7994 (1.21) 1872 (0.28) 9866 (1.49)
13.0-29.9% 661 936 637 074 (96.24) 11 099 (1.68) 11 116 (1.68) 2647 (0.40) 13 763 (2.08)
30.0-50.9% 659 314 617 464 (93.65) 17 581 (2.67) 19 334 (2.93) 4935 (0.75) 24 269 (3.68)
$51.0% 627 376 564 372 (89.96) 25 622 (4.08) 29 936 (4.77) 7446 (1.19) 37 382 (5.96)
Payer type3
Private 2 665 330 2 531 010 (94.96) 57 982 (2.18) 61 863 (2.32) 14 475 (0.54) 76 338 (2.86)
Medicaid/Medicare 769 566 734 185 (95.40) 15 157 (1.97) 16 288 (2.12) 3936 (0.51) 20 224 (2.63)
Low income (PIR <1.25) quintile4
<16.0% 703 782 682 503 (96.98) 9066 (1.29) 9779 (1.39) 2434 (0.35) 12 213 (1.74)
16.0-27.9% 624 981 602 837 (96.46) 9874 (1.58) 9816 (1.57) 2454 (0.39) 12 270 (1.96)
28.0-38.9% 643 452 614 280 (95.47) 12 798 (1.99) 13 141 (2.04) 3233 (0.50) 16 374 (2.54)
39.0-51.9% 698 627 658 817 (94.30) 17 067 (2.44) 18 214 (2.61) 4529 (0.65) 22 743 (3.26)
$52.0% 597 828 549 471 (91.91) 19 730 (3.30) 23 144 (3.87) 5483 (0.92) 28 627 (4.79)
High income (PIR >5) quintile4
<2.8% 657 317 613 075 (93.27) 18 333 (2.79) 21 018 (3.20) 4891 (0.74) 25 909 (3.94)
2.8-6.9% 666 236 627 939 (94.25) 16 417 (2.46) 17 607 (2.64) 4273 (0.64) 21 880 (3.28)
7.0-13.9% 692 538 658 850 (95.14) 14 352 (2.07) 15 261 (2.20) 4075 (0.59) 19 336 (2.79)
14.0-27.9% 614 839 590 014 (95.96) 10 800 (1.76) 11 198 (1.82) 2827 (0.46) 14 025 (2.28)
$28.0% 637 740 618 030 (96.91) 8633 (1.35) 9010 (1.41) 2067 (0.32) 11 077 (1.74)
HHS region5
1: CT, MA, ME, NH, RI, VT 165 624 151 422 (91.43) 5184 (3.13) 7306 (4.41) 1712 (1.03) 9018 (5.44)
2: NJ, NY 722 385 681 603 (94.35) 19 431 (2.69) 16 950 (2.35) 4401 (0.61) 21 351 (2.96)
3: DE, DC, MD, PA, VA, WV 406 681 374 655 (92.13) 11 407 (2.80) 16 313 (4.01) 4306 (1.06) 20 619 (5.07)
4: AL, FL, GA, KY, MS, NC, SC, TN 509 539 494 543 (97.06) 6637 (1.30) 7085 (1.39) 1274 (0.25) 8359 (1.64)
5: IL, IN, MI, MN, OH, WI 262 144 244 002 (93.08) 6711 (2.56) 8849 (3.38) 2582 (0.98) 11 431 (4.36)
6: AR, LA, NM, OK, TX 264 833 255 900 (96.63) 3549 (1.34) 4240 (1.60) 1144 (0.43) 5384 (2.03)
7: IA, KS, MO, NE 96 232 87 446 (90.87) 3292 (3.42) 4424 (4.60) 1070 (1.11) 5494 (5.71)
8: CO, MT, ND, SD, UT, WY 21 372 20 346 (95.20) 436 (2.04) 503 (2.35) 87 (0.41) 590 (2.76)
9: AZ, CA, HI, NV 874 401 848 895 (97.08) 13 291 (1.52) 10 268 (1.17) 1947 (0.22) 12 215 (1.40)
10: AK, OR, ID, WA 11 700 11 255 (96.20) 212 (1.81) 172 (1.47) 61 (0.52) 233 (1.99)
Time period (Year)
May 2009-April 2010 823 198 770 737 (93.63) 22 217 (2.70) 24 185 (2.94) 6059 (0.74) 30 244 (3.67)
May 2010-April 2011 737 826 698 385 (94.65) 16 847 (2.28) 18 449 (2.50) 4145 (0.56) 22 594 (3.06)
May 2011-April 2012 633 374 602 166 (95.07) 13 522 (2.13) 14 171 (2.24) 3515 (0.55) 17 686 (2.79)
May 2012-April 2013 560 906 534 990 (95.38) 10 955 (1.95) 11 993 (2.14) 2968 (0.53) 14 961 (2.67)
May 2013-April 2014 540 016 516 139 (95.58) 10 184 (1.89) 10 941 (2.03) 2752 (0.51) 13 693 (2.54)
May 2014-April 2015 507 750 485 457 (95.61) 9142 (1.80) 10 353 (2.04) 2798 (0.55) 13 151 (2.59)

PIR, povery income ratio.

Notes:
1 - 12 496 results did not have gender data.
2 - 531 730 results did not have pre-1950 house construction data available.
3 - 368 174 results did not have payer data available.
4 - 534 400 results did not have poverty/wealth data.
5 - 468 159 results did not have state data available.

In 49 3-digit ZIP codes, <1.0% of specimens had high blood
lead levels. Eighteen of these 3-digit ZIP codes were found
in California, including San Jose (0.61%), which had the
lowest proportion in the study. Eight were found in
Florida, with South Florida (0.65%) having the lowest pro-
portion in Florida.
Yearly Changes in Blood Lead Level Distribution
The distributions of patient blood lead levels showed year-
over-year percentage increases in blood lead level groups
#3.0 mg/dL (Table I). This increase outpaced the decrease
in the 3.1-4.9 mg/dL blood lead group, resulting in a net
decrease of those below the 2012 CDC 5 mg/dL threshold:
176
from 3.67% for May 2009-April 2010 to 2.59% for May
2014-April 2015. For the 5.0-9.9 mg/dL blood lead level
group and the very high blood lead level group, the patient
distributions showed year-over-year decreases during the
same period (Table I). May 2014-April 2015 showed a
slight reversal of these trends. The top 2.5% blood lead
level threshold (97.5th percentile) was 5.1 mg/dL every year
of the study.
Yearly Changes in High Blood Lead Level for
Various Risk Factors
Table III illustrates the trends in high blood lead levels for all
the risk factors mentioned previously across the 6 years of the
McClure, Niles, and Kaufman
Blood Lead Levels in Young Children: US, 2009-2015

August 2016
Table II. Blood lead levels in children < 6 years old by state
May 2009-April 2015 May 2009-April 2010 May 2014-April 2015
>3.0 and
Total 3.0 mg/dL <5.0 mg/dL 5.0 and <10.0 mg/dL 10.0 mg/dL 5.0 mg/dL Total 5.0 mg/dL Total 5.0 mg/dL
State Number (Percent) Absolute
% change
MN 2345 2030 (86.57) 74 (3.16) 184 (7.85) 57 (2.43) 241 (10.28) 638 60 (9.40) 345 26 (7.54) 1.86
PA 190 843 168 214 (88.14) 7728 (4.05) 11 633 (6.10) 3268 (1.71) 14 901 (7.81) 41 568 4444 (10.69) 21 782 1644 (7.55) 3.14
KY 8530 7598 (89.07) 324 (3.80) 461 (5.40) 147 (1.72) 608 (7.13) 1291 125 (9.68) 1727 70 (4.05) 5.63
OH 35 703 31 715 (88.83) 1501 (4.20) 1889 (5.29) 598 (1.67) 2487 (6.97) 6420 575 (8.96) 3668 209 (5.70) 3.26
CT 76 520 68 697 (89.78) 2705 (3.54) 4099 (5.36) 1019 (1.33) 5118 (6.69) 16 095 1324 (8.23) 10 250 639 (6.23) 2.00
WI 5216 4700 (90.11) 170 (3.26) 255 (4.89) 91 (1.74) 346 (6.63) 2275 165 (7.25) 284 19 (6.69) 0.56
MO 82 200 74 375 (90.48) 2976 (3.62) 3931 (4.78) 918 (1.12) 4849 (5.90) 20 109 1450 (7.21) 9918 474 (4.78) 2.43
NH 10 571 9616 (90.97) 344 (3.25) 474 (4.48) 137 (1.30) 611 (5.78) 1236 120 (9.71) 1792 47 (2.62) 7.09
MI 30 132 27 427 (91.02) 967 (3.21) 1411 (4.68) 327 (1.09) 1738 (5.77) 7650 502 (6.56) 4163 208 (5.00) 1.56
LA 17 891 16 491 (92.17) 524 (2.93) 647 (3.62) 229 (1.28) 876 (4.90) 4180 249 (5.96) 2470 89 (3.60) 2.36
MS 9869 9044 (91.64) 362 (3.67) 388 (3.93) 75 (0.76) 463 (4.69) 1140 35 (3.07) 572 36 (6.29) 3.22
SC 7114 6611 (92.93) 179 (2.52) 261 (3.67) 63 (0.89) 324 (4.55) 1011 36 (3.56) 801 54 (6.74) 3.18
IN 20 645 19 295 (93.46) 479 (2.32) 663 (3.21) 208 (1.01) 871 (4.22) 2277 115 (5.05) 3282 106 (3.23) 1.82
MA 78 016 72 651 (93.12) 2123 (2.72) 2698 (3.46) 544 (0.70) 3242 (4.16) 7564 374 (4.94) 20 969 777 (3.71) 1.23
WV 11 315 10 561 (93.34) 318 (2.81) 338 (2.99) 98 (0.87) 436 (3.85) 1611 95 (5.90) 1965 55 (2.80) 3.10
IL 168 103 158 835 (94.49) 3520 (2.09) 4447 (2.65) 1301 (0.77) 5748 (3.42) 37 675 1815 (4.82) 23 036 644 (2.80) 2.02
OK 23 605 22 356 (94.71) 467 (1.98) 616 (2.61) 166 (0.70) 782 (3.31) 3468 96 (2.77) 3909 116 (2.97) 0.20
TN 15 204 14 372 (94.53) 331 (2.18) 417 (2.74) 84 (0.55) 501 (3.30) 1727 49 (2.84) 3368 95 (2.82) 0.02
NY 598 685 562 660 (93.98) 17 291 (2.89) 14 880 (2.49) 3854 (0.64) 18 734 (3.13) 140 558 5448 (3.88) 72 265 1799 (2.49) 1.39
NC 15 731 14 995 (95.32) 270 (1.72) 371 (2.36) 95 (0.60) 466 (2.96) 1818 43 (2.37) 7517 264 (3.51) 1.14
AL 9484 8990 (94.79) 222 (2.34) 225 (2.37) 47 (0.50) 272 (2.87) 1670 58 (3.47) 1616 40 (2.48) 0.99
UT 2375 2243 (94.44) 64 (2.69) 56 (2.36) 12 (0.51) 68 (2.86) 458 20 (4.37) 352 19 (5.40) 1.03
MD 157 736 150 431 (95.37) 2849 (1.81) 3713 (2.35) 743 (0.47) 4456 (2.82) 30 589 1179 (3.85) 23 340 512 (2.19) 1.66
AR 7865 7518 (95.59) 129 (1.64) 171 (2.17) 47 (0.60) 218 (2.77) 1593 33 (2.07) 805 23 (2.86) 0.79
KS 11 859 11 332 (95.56) 205 (1.73) 265 (2.23) 57 (0.48) 322 (2.72) 2376 84 (3.54) 1772 34 (1.92) 1.62
GA 56 864 54 194 (95.30) 1147 (2.02) 1309 (2.30) 214 (0.38) 1523 (2.68) 10 445 257 (2.46) 7952 226 (2.84) 0.38
CO 18 528 17 674 (95.39) 359 (1.94) 423 (2.28) 72 (0.39) 495 (2.67) 3395 126 (3.71) 3750 85 (2.27) 1.44
NM 2621 2520 (96.15) 35 (1.34) 53 (2.02) 13 (0.50) 66 (2.52) 296 4 (1.35) 964 26 (2.70) 1.35
OR 6562 6302 (96.04) 114 (1.74) 105 (1.60) 41 (0.62) 146 (2.22) 1242 32 (2.58) 956 30 (3.14) 0.56
NJ 123 700 118 943 (96.15) 2140 (1.73) 2070 (1.67) 547 (0.44) 2617 (2.12) 29 570 810 (2.74) 13 706 251 (1.83) 0.91
VA 26 911 26 088 (96.94) 309 (1.15) 381 (1.42) 133 (0.49) 514 (1.91) 7343 125 (1.70) 3031 70 (2.31) 0.61
DE 8647 8415 (97.32) 80 (0.93) 117 (1.35) 35 (0.40) 152 (1.76) 1969 31 (1.57) 1101 22 (2.00) 0.43
TX 212 851 207 015 (97.26) 2394 (1.12) 2753 (1.29) 689 (0.32) 3442 (1.62) 38 871 699 (1.80) 31 439 519 (1.65) 0.15

ORIGINAL ARTICLES
WA 2474 2391 (96.65) 45 (1.82) 30 (1.21) 8 (0.32) 38 (1.54) 636 15 (2.36) 193 5 (2.59) 0.23
DC 11 229 10 946 (97.48) 123 (1.10) 131 (1.17) 29 (0.26) 160 (1.42) 2518 41 (1.63) 1749 17 (0.97) 0.66
CA 873 944 848 450 (97.08) 13 285 (1.52) 10 262 (1.17) 1947 (0.22) 12 209 (1.40) 200 413 3538 (1.77) 107 443 1448 (1.35) 0.42
FL 386 743 378 739 (97.93) 3802 (0.98) 3653 (0.94) 549 (0.14) 4202 (1.09) 72 951 1070 (1.47) 59 019 513 (0.87) 0.60

Absolute change reflects the difference in >5.0 mg/dL from the first to the second time periods.
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Table III. Trends in high blood lead levels of children <6 years old
May 2009- May 2009- May 2010- May 2011- May 2012- May 2013- May 2014-
April 2015 April 2010 April 2011 April 2012 April 2013 April 2014 April 2015
Significant
3 803 070 823 198 737 826 633 374 560 906 540 016 507 750 trend
Number (Percent)
Gender1
Male 1 947 693 60 219 (3.09) 16 216 (3.86) 12 079 (3.20) 9357 (2.89) 8063 (2.81) 7379 (2.66) 7125 (2.72) *
Female 1 842 881 51 622 (2.80) 13 856 (3.47) 10 417 (2.91) 8245 (2.68) 6828 (2.51) 6277 (2.40) 5999 (2.44) *
Pre-1950 housing quintile2
<3.6% 660 387 7065 (1.07) 1555 (1.21) 1295 (1.05) 1097 (0.99) 1015 (1.01) 855 (0.89) 1248 (1.23) P = .0446
3.6-12.9% 662 327 9866 (1.49) 2124 (1.50) 1993 (1.52) 1785 (1.59) 1411 (1.42) 1262 (1.37) 1291 (1.51) P = .0290
13.0-29.9% 661 936 13 763 (2.08) 3587 (2.50) 2725 (2.13) 2288 (2.05) 1923 (1.95) 1642 (1.78) 1598 (1.82) *


30.0-50.9% 659 314 24 269 (3.68) 6706 (4.74) 4743 (3.77) 3817 (3.51) 3310 (3.34) 2966 (3.09) 2727 (3.10) *

www.jpeds.com
51.0% + 627 376 37 382 (5.96) 10 766 (7.59) 7573 (6.27) 5615 (5.54) 4669 (5.25) 4550 (4.94) 4209 (5.13) *
Payer type3
Private 2 665 330 76 338 (2.86) 22 060 (3.53) 15 933 (2.94) 11 504 (2.74) 9531 (2.53) 8899 (2.49) 8411 (2.45) *
Medicaid/Medicare 769 566 20 224 (2.63) 4371 (3.35) 3492 (2.80) 3583 (2.50) 3092 (2.44) 2869 (2.11) 2817 (2.60) *
Low income (PIR <1.25) quintile4
<16.0% 703 782 12 213 (1.74) 2993 (2.02) 2266 (1.70) 2005 (1.73) 1610 (1.54) 1528 (1.54) 1811 (1.78) *
16.0-28.9% 624 981 12 270 (1.96) 3116 (2.34) 2586 (2.10) 1947 (1.88) 1633 (1.75) 1566 (1.75) 1422 (1.73) *
29.0-39.9% 643 452 16 374 (2.54) 4327 (3.19) 3334 (2.65) 2531 (2.35) 2100 (2.19) 2034 (2.20) 2048 (2.37) *
40.0-51.9% 698 627 22 743 (3.26) 6424 (4.19) 4433 (3.35) 3476 (2.99) 3067 (2.97) 2752 (2.74) 2591 (2.78) *
52.0% + 597 828 28 627 (4.79) 7842 (6.25) 5684 (4.98) 4632 (4.58) 3899 (4.38) 3383 (3.91) 3187 (3.92) *
High income (PIR >5) quintile4
<2.8% 657 317 25 909 (3.94) 7241 (5.06) 5045 (4.03) 4156 (3.78) 3487 (3.58) 3063 (3.28) 2917 (3.31) *
2.8-6.8% 666 236 21 880 (3.28) 6152 (4.31) 4346 (3.46) 3359 (3.05) 2886 (2.91) 2631 (2.69) 2506 (2.77) *
6.9-13.9% 692 538 19 336 (2.79) 4894 (3.37) 3883 (2.87) 3046 (2.62) 2672 (2.56) 2513 (2.53) 2328 (2.52) *
14.0-27.9% 614 839 14 025 (2.28) 3605 (2.77) 2863 (2.38) 2183 (2.12) 1843 (2.05) 1673 (1.95) 1858 (2.17) *
28.0% + 637 740 11 077 (1.74) 2810 (2.08) 2166 (1.76) 1847 (1.76) 1421 (1.49) 1383 (1.51) 1450 (1.65) *
HHS region5
1: CT, MA, ME, NH, RI, VT 165 624 9018 (5.44) 1824 (7.30) 1636 (7.39) 1330 (5.06) 1147 (4.45) 1607 (4.82) 1474 (4.46) *
2: NJ, NY 722 385 21 351 (2.96) 6258 (3.68) 4997 (3.25) 3342 (2.84) 2393 (2.42) 2311 (2.41) 2050 (2.38) *
3: DE, DC, MD, PA, VA, WV 406 681 20 619 (5.07) 5915 (6.91) 4128 (5.23) 2941 (4.35) 2822 (4.52) 2439 (4.22) 2320 (4.38) *
4: AL, FL, GA, KY, MS, NC, SC, TN 509 539 8359 (1.64) 1673 (1.82) 1598 (1.75) 1368 (1.57) 1376 (1.68) 1046 (1.40) 1298 (1.57) *
5: IL, IN, MI, MN, OH, WI 262 144 11 431 (4.36) 3232 (5.68) 1974 (4.41) 1942 (4.15) 1740 (4.20) 1331 (3.55) 1212 (3.48) *
6: AR, LA, NM, OK, TX 264 833 5384 (2.03) 1081 (2.23) 1012 (1.96) 1041 (2.18) 816 (2.08) 661 (1.73) 773 (1.95) *
7: IA, KS, MO, NE 96 232 5494 (5.71) 1610 (7.02) 1010 (5.55) 866 (5.55) 774 (5.56) 654 (4.93) 580 (4.72) *
McClure, Niles, and Kaufman

8: CO, MT, ND, SD, UT, WY 21 372 590 (2.76) 156 (3.92) 138 (3.69) 63 (1.98) 57 (1.95) 69 (2.03) 107 (2.58) *
9: AZ, CA, HI, NV 874 401 12 215 (1.40) 3540 (1.77) 2328 (1.32) 2004 (1.41) 1574 (1.24) 1320 (1.09) 1449 (1.35) *
10: AK, OR, ID, WA 11 700 233 (1.99) 58 (2.51) 51 (1.87) 24 (1.07) 34 (1.87) 28 (2.11) 38 (2.96) P = .2356

All values Number (Percent) reflect results of $5.0 mg/dL; CDC changed threshold to 5.0 mg/dL in May 2012.
Notes:
1 - chi2 P < .01 for all years; 12 496 results did not have gender data.
2 - Cochran Armitage test for trend P < .01 for all years; 531 730 results did not have pre-1950 house construction data available.
3 - 368 174 results did not have payer data available.

Volume 175
4 - Cochran Armitage test for trend P < .01 for all years; 534 400 results did not have poverty data.
5 - 468 159 results did not have state data available.
August 2016 ORIGINAL ARTICLES

Table IV. Logistic models: Factors associated with high blood lead levels and very high blood lead levels
Factors associated with high BLL (5.0 mg/dL) Factors associated with very high BLL (10.0 mg/dL)
Unadjusted OR 95% CI aOR 95% CI Unadjusted OR 95% CI aOR 95% CI
Study year 0.93 (0.92-0.93) 0.92 (0.91-0.92) 0.94 (0.93-0.95) 0.93 (0.92-0.94)
Private payer 1.09 (1.08-1.11) 0.84 (0.82-0.85) 1.06 (1.02-1.10) 0.80 (0.77-0.83)
Male 1.11 (1.09-1.12) 1.11 (1.09-1.13) 1.10 (1.07-1.13) 1.08 (1.04-1.11)
Top housing quintile 2.99 (2.94-3.02) 2.50 (2.46-2.54) 2.96 (2.87-3.04) 2.58 (2.50-2.68)
Top 3 HHS regions (1,3,7) 2.43 (2.40-2.46) 2.23 (2.20-2.26) 2.48 (2.40-2.55) 2.21 (2.13-2.29)
Top poverty quintile 2.06 (2.03-2.09) 1.64 (1.61-1.67) 1.95 (1.88-2.01) 1.55 (1.50-1.61)
Top wealth quintile 0.56 (0.54-0.57) 0.65 (0.64-0.67) 0.53 (0.51-0.55) 0.62 (0.59-0.65)

BLL, blood lead level; CI, confidence interval; OR, odds ratio.

study. Male subjects maintained a greater proportion of high

blood lead level than female subjects during each year of the
study, and this difference remained similar over the years
(0.21%-0.39%). The statistically significant trend among
ZIP codes with increasing proportions of pre-1950s housing
quintiles and PIR <1.25 remained when we examined data
from each year of the study individually. Patients with
private payer insurance had larger rates of high blood lead
levels than patients with Centers for Medicare and Medicaid
Services payers each year from May 2009-April 2014 but
exhibited a lower rate of high blood lead levels than those
with Centers for Medicare and Medicaid Services payers
during the final year of the study. HHS Regions 1, 3, and 7
all exhibited a substantial decline in high blood lead level
proportion during the study period but were the only
regions with >4.0% high blood lead levels during the final
year of the study. HHS Region 10 was the only region that
had an increase in high blood lead levels during the study
period and was the only factor examined that did not
demonstrate a statistically significant (P < .05) downward
trend in high blood lead level over the study period.
High Blood Lead Level and Very High Blood Lead
Level Models
Logistic regression models were used to analyze the impact of
the factors examined in Table I on high blood lead levels and
very high blood lead levels. In unadjusted models, the
strongest measures of association with high blood lead levels
were being in the greatest pre-1950s housing quintile (OR
2.99, 95% CI 2.95-3.03) and living in HHS Region 1, 3, or 7
(OR 2.43, 95% CI 2.40-2.46). Living in a region in the
lowest income quintile also was associated with high blood
lead level (OR 2.06, 95% CI 2.03-2.09), whereas living in a
region in the top income quintile had a significant
protective effect (OR for high blood lead level = 0.56, 95%
CI 0.54-0.57). The measures of association for these factors
were similar in the adjusted multivariable model (Table IV).
Private payer status had a small but significant association
with high blood lead levels in the unadjusted model (OR
1.09, 95% CI 1.08-1.11) but had a significant protective
effect in the adjusted model (aOR 0.84, 95% CI 0.82-0.85).
Measures of association in the very high blood lead level
models (both adjusted and unadjusted) were similar to
those in the high blood lead level models (Table IV).
Blood Lead Levels in Young Children: US, 2009-2015
Discussion
Reducing blood lead levels in children has been and con-
tinues to be a major public health success. The declining
blood lead levels are the result of public health initiatives
that include the removal of leaded gasoline, the banning of
lead paint, effective treatment of potable water supplies,
and remediation of homes found to be contaminated with
lead. Studies conducted by the CDC3,19 have provided valu-
able insight into the changing lead levels in children and asso-
ciated risk factors. The millions of test results reported by
individual states have allowed the CDC to track the changes
in lead levels over time.19 The demographic factors associated
with high blood lead levels, however, come from a much
smaller set: n = 793 from 2007-2010 for ages 1-2 years19
and n = 1653 from 2007-2010 for ages 1-5 years.13 The study
presented here examines similar factors in a much larger data
set of 3.8 million children. The CDC studies also were unable
to look at factors associated with blood lead level $10.0 mg/dL
because of small numbers (9 children in 2007-2008; 6 chil-
dren in 2009- 2010).3 In contrast, our study was able to
examine factors associated with very high venous blood
lead level results (n = 22 237).
Our study provides insights for the time period through
mid-2015, 4.5 years after the end of data collection in the
most recent NHANES report, which included data through
the end of 2010. This timeframe extension enabled the exam-
ination of the continuing decline in high blood lead level and
very high blood lead level levels. This was true for the popu-
lation as whole (from 3.67% to 2.59% high blood lead levels
and from 0.74% to 0.55% very high blood lead levels) and for
most demographic groups and geographic regions. The re-
sults also demonstrate a slight increase in the incidence of
high blood lead levels and very high blood lead levels in the
final year of the study. After years of consecutive decline,
the rise was unexpected, especially given that there was no
major observable change in demographic proportions during
the final year. Future studies are needed to evaluate the evo-
lution of high blood lead levels and very high blood lead
levels.
To a large extent, the results presented here confirm the
significance of factors examined by the CDC3,19 and exhibit
similar measures of association. Our study, using a different
methodology, confirms the findings in NHANES associating
179
THE JOURNAL OF PEDIATRICS  www.jpeds.com
pre-1950s housing data and low PIR with high blood lead
level. Examining PIR and housing construction data by ZIP
code instead of direct patient data is a limiting factor but
also highlights the ability of physicians to identify geographic
regions with increased risk, particularly in the event that in-
dividual patient risk factors are unavailable or difficult to
obtain. Using data available on the US Census Bureau web-
site, health care experts can determine the proportion of
housing constructed before 1950 and PIR of the ZIP codes
they serve to help assess the level of risk in their patients,
even if individual factors are not available.
All previously reported NHANES cycles found increased
levels of high blood lead level in Medicaid patients (the dif-
ferences in 1999-2002 and in 2003-2006 were statistically sig-
nificant). The current Quest Diagnostics Health Trends study
found that children with private payers had a significantly
larger rate of high blood lead level than those with
Medicaid/Medicare payers. In the adjusted model, however,
private payer status had a significant protective effect.
Thus, with all factors explored in the study considered
together, the private payer results seem to indicate the
same relationship found in the NHANES studies.
There were also some differences between our findings and
those of the NHANES studies. The 2003-2006 and 2007-2010
NHANES cycles both found female participants to have
slightly greater proportions of high blood lead level than
male participants (although these differences were not found
to be statistically significant). In the present study, male par-
ticipants exhibited a small but statistically significantly larger
proportion of high blood lead levels than female participants.
Our study examined results from patients living in all 50
states and the District of Columbia; however, analyses by
state were limited to the 36 states and the District of
Columbia with more than 2000 specimens during the study
period. Our results for high blood lead level at the state level
are often similar (within 3%) to the results reported by the
CDC in their national surveillance data (2010-2014),20 but
there are also interesting differences. The rates of high blood
lead level in our study were considerably lower than those re-
ported by the CDC for New Hampshire (6.2% vs 12.0%),
Mississippi (4.5% vs 9.2%), and Illinois (4.5% vs 7.9%).
Only Minnesota showed a considerably larger rate of high
blood lead level in our study than in the CDC report
(10.3% vs 2.9%). At the national level, we found a virtually
identical rate of very high blood lead level (0.58%) as the
CDC (0.57%) over a similar 5-year period, but the rate of
high blood lead level was lower in our study (2.95% vs
5.48%). The reasons for these differences are unclear but
could reflect the inclusion of capillary blood results in the
CDC data.
According to the CDC, houses built before 1950 pose the
greatest hazard to children because they are much more likely
to contain lead-based paint than newer houses.16 Lead-
contaminated dust on floors, windowsills, and window wells
is associated with elevated blood lead levels in children.21 Our
findings showed that, in general, the regions with the greatest
adjusted level of pre-1950s housing construction had the
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Volume 175
greatest proportions of patients with high blood lead levels.
HHS Region 2 (New York and New Jersey) was an interesting
deviation from this trend. Despite having the greatest level of
housing built before 1950 (based on study participant ZIP
codes), the overall levels of high blood lead level were below
average for the study. It is also interesting that New York
State (3.1%) was near the national average (3.0%) for high
blood lead level while having several 3-digit ZIP codes with
the largest proportions of high blood lead levels and very
high blood lead levels found in the study. The impact of
abatement and active lead surveillance in these states is also
unclear. In general, southern regions had lower proportions
of high blood lead levels. This includes Florida, with more
than 386 000 specimens and 1.1% with high blood lead levels,
and California, with more than 873 000 specimens and 1.4%
with high blood lead levels. We have no easy explanation why
12 of the 36 states and the District of Columbia, with suffi-
cient number of results, had an increase in the proportion
of high blood lead levels between the first year and the final
year of the study.
We found that living in ZIP codes with greater percentages
of residents <1.25 PIR exhibited a stronger association with
high blood lead levels than individual payer type. The reasons
for this perplexing difference are unclear. One possibility may
be that ZIP codes with greater levels of low income also have
greater proportions of housing built before 1950 or other
associated factors. Although this relationship may exist, the
multivariable models indicate that it is not reason for the as-
sociation, because both variables maintain significant associ-
ations with high blood lead levels and very high blood lead
levels in the adjusted multivariable models.
All risk factors associated with high blood lead levels also
were associated with very high blood lead levels. In both un-
adjusted and adjusted models, the measures of association
were remarkably similar. This finding is reassuring because
the risk factors identified in previous studies were not only
confirmed for the most part in this larger study but found
to be associated with very high blood lead levels as well.
The major strengths of this study are its large size, national
representation with data from 50 states and the District of
Columbia, and the inclusion of data through mid-2015. An-
alyses were conducted on more than 5 million results for chil-
dren <6 years of age. The analyses focused on more than 3.8
million results of venous blood draws from children <6 years
of age, consistent with the CDC definition of confirmed
elevated blood lead level. This study also examined demo-
graphics for the vast majority of participants. Having demo-
graphics available for so many participants enabled analysis
of factors associated with very high blood lead levels.
This study also had limitations. The 3.0 mg/dL reporting
threshold precluded our ability to estimate the mean blood
lead level for the study population. Some blood lead level
groups are narrower than the range of instrument variability,
but we assume there is no bias in the data set. It is also
possible that some patients were tested as a follow-up to prior
blood lead level results at another laboratory or because
healthcare providers suspected a high probability of elevated
McClure, Niles, and Kaufman
August 2016
blood lead level. It also may be possible that population seg-
ments or regional populations deemed to be at risk are being
tested more frequently. Sociological, familial, and environ-
mental factors also may play a role in determining who is
tested for lead; however, with our 97.5th percentile being
the same as found in NHANES, we feel the selection bias is
minimal. Quest Diagnostics does not perform all lead testing
in the country, and these data should only be seen as a large
sample of national data. These data do not necessarily reflect
the population as a whole but reflect those tested in medical
practices in the US.
In summary, progress in reducing the burden of lead
toxicity is a public health success story that is incomplete.
This analysis of more than 5 million blood lead level results
over a 6-year period, extending through April 2015, includes
3.8 million venous blood lead level results for infants and
children <6 years of age. This allowed for a robust, detailed
analysis of results by geography and other criteria that are
impossible with the narrower NHANES approach. Unique
observations include the correlation of results for patients
with blood lead level results of $10.0 mg/dL to those with re-
sults of 5.1-10.0 mg/dL. Many of the 3-digit ZIP code regions
with high blood lead levels and very high blood lead levels are
in New York, Pennsylvania, and Ohio. Additional study will
be necessary to assure that the improvements reported will
continue and that specific state and local efforts achieve the
desired goals. n
Submitted for publication Jan 26, 2016; last revision received Mar 29, 2016;
accepted May 3, 2016.
Reprint requests: Leland F. McClure, PhD, Director, Medical Science Liaison,
Medical Affairs - Quest Diagnostics, 11636 Administration Drive, St Louis, MO
63146. E-mail: Leland.F.McClure@QuestDiagnostics.com
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