Commentary: ISEE Call for Action for Global Control of Lead Exposure to Eliminate Lead Poisoning : Epidemiology

Secondary Logo

Journal Logo

From The ISEE


ISEE Call for Action for Global Control of Lead Exposure to Eliminate Lead Poisoning

Author Information
Epidemiology 26(5):p 774-777, September 2015. | DOI: 10.1097/EDE.0000000000000352
  • Free
  • ISEE

Lead poisoning is one of the most pervasive, well-established, and preventable environmental hazards worldwide. We in the International Society for Environmental Epidemiology (ISEE) add, therefore, our voices to the call for a concerted global effort to eliminate lead poisoning.

We specifically call for:

  1. The governments of all nations to:
    • a. Ban the manufacture, import, and export of lead-containing fuels, paints, plumbing fixtures, and plastics;
    • b. Vigorously explore replacements for the lead content, wherever possible, in other consumer and commercial products;
    • c. Implement, to the greatest extent feasible, effective procedures to reduce occupational exposure to lead and its compounds, especially in mining, manufacturing, and construction;
    • d. Implement, to the greatest extent feasible, effective procedures to reduce emissions from smelters and lead battery manufacturing and recycling facilities;
    • e. Implement regulations for safely recycling used batteries containing lead and for preventing the illegal dumping of lead-containing materials and products;
    • f. Implement, to the greatest extent feasible, programs to identify and remediate lead contaminated public and residential areas, and surveillance programs to identify heavily exposed individuals, populations, new sources of lead exposure, and trends in lead exposure;
    • g. Investigate and reduce lead exposures from contamination of food and from hazardous waste sites;
    • h. Increase the training of health professionals in the identification and prevention of lead poisoning;
    • i. Ratify and implement the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Disposal.1
  2. The governments of countries with high-quality blood analytical capacity to provide assistance (expertise, material resources, and training) to other countries in developing this capacity.
  3. The elimination of lead poisoning to be included in the United Nations Sustainable Development Goals, with indicators and targets set accordingly.
  4. Professional organizations to support the efforts of international organizations working for lead poisoning prevention and, in particular, to encourage their members to contribute to the efforts of the Global Alliance to Eliminate Lead Paint.2
  5. WHO and UNEP to take a lead in coordinating and assisting the efforts of all countries in implementation of the above actions.



Lead poisoning is pandemic. Globally, there are an estimated 674,000 deaths annually attributed to lead exposure, including many from cardiovascular diseases, and 600,000 cases of intellectual disability among children.3,4 There is no evidence of a threshold for the effects of low-level lead exposure on cognitive functioning in children.5 Moreover, there is substantial evidence that childhood lead exposure elevates the risk of behavioral problems, like Attention Deficit Hyperactivity Disorder (ADHD)6,7 and antisocial behaviors.8–10 Lead is an established risk factor for hypertension and chronic renal failure, and a potential risk factor for cognitive decline in adults.11–13 Lead is an endocrine disruptor that may delay sexual maturation in children.14–16 Lead is a risk factor for spontaneous abortion, fetal death, and reduced birth weight.17–19 There is no safe level of lead exposure.20

Progress in reducing lead exposures has been achieved over the last four decades, but exposure is still ubiquitous, especially in low- to-middle-income countries.21 Lead exposure continues to be an occupational hazard in manufacturing, mining, and smelting,22 and it is often found in consumer products.23 In addition, the vestiges of past lead use, such as lead-based paint remaining on surfaces on the interior and exterior of housing and schools, provide widespread opportunities for exposures, particularly for children, painters, and construction workers. Use of lead in plumbing fixtures and water supply lines can result in excessive exposure and remains a concern in many countries.24

Lead-containing paint for residential use is available in retail stores in more than 40 countries.25–27 Companies based in countries that have restricted domestic use of leaded paint, such as in the U.S., Canada, and the European Union, continue to export more than 25,000 tons of lead–containing pigments annually.28 Operations for recycling of lead batteries, which can result in substantial exposures to workers and the surrounding community, are largely uncontrolled in many countries.29–31 In the U.S., where there are environmental regulations to control these exposures, companies often export used batteries for recycling to countries where there is less stringent regulation.32

Exposure to lead also occurs from food stored or cooked in ceramics or cans containing lead or aluminum cookware and from proximity to hazardous waste sites.33–36

Reduction in lead exposure across the age spectrum is essential. Lead has a potential half-life in bone of 27 years. Consequently, exposure at any age can result in residual exposures as bone stores are mobilized. This is of particular concern during pregnancy, when mobilization results in fetal exposure.37,38 Children with poorer nutrition (e.g., iron deficiency) may absorb more lead and are at greater risk from exposures.39 Inadequate nutrition (e.g., calcium deficiency) can also exacerbate the release of lead to the fetus during pregnancy.40

Globally, there are inadequate resources and insufficient government infrastructure for managing and reducing lead poisoning. Many countries have little or no laboratory capacity for blood lead tests.41 Moreover, funding for lead poisoning screening and prevention programs is often inadequate.21


Various methods are available to reduce exposure to lead. Safer alternatives exist for most products that contain lead.42 Methods exist to reduce industrial emissions and control occupational exposures, and techniques exist to safely remediate homes that are contaminated with lead paint and lead-contaminated house dust.43 Because of the widespread historic and current use of lead compounds as paint additives, many dwellings and other structures contain lead hazards. It is important to identify residential lead hazards and take measures to prevent exposures before children are exposed. Lead paint remediation, if done incorrectly, can actually increase exposures; remediation must be properly guided by scientific methods and clearance dust measurements following cleanup. Some remediation methods such as abrasive blasting, power sanding, and burning off lead paint have been shown to be dangerous.43


The burden of disease and disability due to lead poisoning falls disproportionately on low-income and minority communities globally. Acute fatalities in children due to lead poisoning have largely been eliminated in high-income countries but still occur in low- and middle-income countries.44,45 It has been estimated that, worldwide, 240 million people have blood lead levels >5 μg/dL (>50 μg/L), including 40% of the world’s children. Of these children, 90% live in “developing regions.”46 In the U.S., African-American children are more than twice as likely to have blood lead levels >5 μg/dL (>50 μg/L) than white children. Children in families whose income is less than 130% of the poverty line have been shown to have more than three times the likelihood of having elevated blood lead levels compared to other children, and their homes are nearly twice as likely to contain lead-based paint hazards.47,48

The economic cost of lead poisoning is substantial, primarily due to lost lifetime economic productivity. The economic cost for low- and middle-income countries is estimated to be $977 billion annually.49 The cost in the U.S. is estimated to be $50 billion annually.50

Lead poisoning prevention is cost-beneficial; it has been estimated that for every dollar spent in controlling residential lead hazards, there will be a return of $17 to $221 in societal benefits.51 This compares favorably with the most widely accepted form of public health intervention, childhood vaccination, which is estimated to return $5.30 to $16.50 for every dollar spent.51

In summary, lead exposures cause death and disability that are almost entirely preventable with a very high benefit-to-cost ratio.


Considerable progress has been made over the last few decades to reduce the health burdens due to lead exposure. Virtually all countries restrict the use of tetraethyl lead in gasoline but most have not banned the use of lead in paint and other products. Average blood lead levels have declined in many countries.52,53 The U.S. CDC has reduced the level at which actions should be taken to reduce childhood lead exposure, from 10 μg/dL (100 μg/L) to 5 μg/dL (50 μg/L).54 An international treaty (The Basel Convention) places restrictions on the transfer of lead-containing waste between countries and makes recommendations for the proper handling of lead containing waste.55 However, the Convention has not been ratified by the U.S., which is a large exporter of lead-containing waste, and has failed to eliminate widespread transfers of this waste to low- and middle-income countries.32,56 In addition, the enforcement and compliance provisions of the convention are unevenly implemented and lack effectiveness.57


Many organizations and agencies have advocated for increased efforts to eliminate the lead poisoning pandemic. Examples of some of these are given in the Appendix.


This Call for Action was written by Frank S. Rosenthal, Bruce P. Lanphear, Perry Gottesfeld, and Michal Krzyzanowski, who take responsibility for the text. Further input was provided by David E. Jacobs, Wael Al-Delaimy, and Colin L. Soskolne, as well as by members of the ISEE Ethics and Philosophy Committee and members of the ISEE Policy Committee.


1. Secretariat of the Basel Convention. Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal. Available at: Accessed May 12, 2015
2. United Nations Environment Program. Global Alliance to Eliminate Lead Paint (GAELP). Available at: Accessed May 12, 2015
3. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224–2260
4. World Health Organization International Programme on Chemical Safety: Lead. Available at: Accessed May 16, 2014
5. Lanphear BP, Hornung R, Khoury J, et al. Low-level environmental lead exposure and children’s intellectual function: an international pooled analysis. Environ Health Perspect. 2005;113:894–899
6. Nigg JT, Nikolas M, Mark Knottnerus G, Cavanagh K, Friderici K. Confirmation and extension of association of blood lead with attention-deficit/hyperactivity disorder (ADHD) and ADHD symptom domains at population-typical exposure levels. J Child Psychol Psychiatry. 2010;51:58–65
7. Froehlich TE, Lanphear BP, Auinger P, et al. Association of tobacco and lead exposures with attention-deficit/hyperactivity disorder. Pediatrics. 2009;124:e1054–e1063
8. Needleman HL, Riess JA, Tobin MJ, Biesecker GE, Greenhouse JB. Bone lead levels and delinquent behavior. JAMA. 1996;275:363–369
9. Fergusson DM, Boden JM, Horwood LJ. Dentine lead levels in childhood and criminal behaviour in late adolescence and early adulthood. J Epidemiol Community Health. 2008;62:1045–1050
10. Wright JP, Dietrich KN, Ris MD, et al. Association of prenatal and childhood blood lead concentrations with criminal arrests in early adulthood. PLoS Med. 2008;5:e101
11. Marcus DK, Fulton JJ, Clarke EJ. Lead and conduct problems: a meta-analysis. J Clin Child Adolesc Psychol. 2010;39:234–241
12. National Toxicology Program (2012) NTP Monograph on the Health Effects of Low-level Lead; 2012. Available at: Accessed May 16, 2014
13. Ekong EB, Jaar BG, Weaver VM. Lead-related nephrotoxicity: a review of the epidemiologic evidence. Kidney Int. 2006;70:2074–2084
14. Bellinger DC. The protean toxicities of lead: new chapters in a familiar story. Int J Environ Res Public Health. 2011;8:2593–2628
15. Iavicoli I, Fontana L, Bergamaschi A. The effects of metals as endocrine disruptors. J Toxicol Environ Health B Crit Rev. 2009;12:206–223
16. Rana SV. Perspectives in endocrine toxicity of heavy metals–a review. Biol Trace Elem Res. 2014;160:1–14
17. Borja-Aburto VH, Hertz-Picciotto I, Rojas Lopez M, Farias P, Rios C, Blanco J. Blood lead levels measured prospectively and risk of spontaneous abortion. Am J Epidemiol. 1999;150:590–597
18. Edwards M. Fetal death and reduced birth rates associated with exposure to lead-contaminated drinking water. Environ Sci Technol. 2014;48:739–746
19. Zhu M, Fitzgerald EF, Gelberg KH, Lin S, Druschel CM. Maternal low-level lead exposure and fetal growth. Environ Health Perspect. 2010;118:1471–1475
20. Centers for Disease Control and Prevention. National Biomonitoring Program Factsheet Lead. 2013 Available at: Accessed May 12, 2015
21. Meyer PA, McGeehin MA, Falk H. A global approach to childhood lead poisoning prevention. Int J Hyg Environ Health. 2003;206:363–369
22. van Geen A, Bravo C, Gil V, Sherpa S, Jack D. Lead exposure from soil in Peruvian mining towns: a national assessment supported by two contrasting examples. Bull World Health Organ. 2012;90:878–886
23. Meyer PA, Brown MJ, Falk H. Global approach to reducing lead exposure and poisoning. Mutat Res. 2008;659:166–175
24. Elfland C, Scardina P, Edwards M. Lead-Contaminated Water from Brass Plumbing Devices in New Buildings (PDF). J Am Water Works Assoc. 2010;102:66–76
25. Clark CS, Rampal KG, Thuppil V, et al. Lead levels in new enamel household paints from Asia, Africa and South America. Environ Res. 2009;109:930–936
26. Clark S, Weinberg J Lead in enamel decorative paints, national paint testing results in a nine-country study. United Nations Environment Program and IPEN. 2013 Available at: Accessed May 12, 2015
27. Occupational Knowledge International. Lead Paint Background. 2014 Available at: Accessed May 25, 2015
28. Gottesfeld P. The West’s toxic hypocrisy over lead paint. New Scientist. 2013;218:26–27
29. Haider MJ, Qureshi N. Studies on battery repair and recycling workers occupationally exposed to lead in Karachi. Rocz Panstw Zakl Hig. 2013;64:37–42
30. Romieu I, Lacasana M, McConnell R. Lead exposure in Latin America and the Caribbean. Lead Research Group of the Pan-American Health Organization. Environ Health Perspect. 1997;105:398–405
31. Vishwanath P, Devegowda D, Prashant A, et al. Environmental lead levels in a coastal city of India: the lead burden continues. Indian J Med Sci. 2012;66:260–266
32. Commission for Environmental Cooperation. Hazardous trade? An examination of US-generated spent lead-acid battery exports and secondary lead recycling in Mexico, the United States and Canada. Montreal. 2013 Available at: Accessed May 12, 2015
33. Romieu I, Palazuelos E, Hernandez Avila M, et al. Sources of lead exposure in Mexico City. Environ Health Perspect. 1994;102:384–389
34. World Health Organization (2013) Lead Poisoning and Health. Available at: Accessed July 20, 2014
35. Weidenhamer JD, Kobunski PA, Kuepouo G, Corbin RW, Gottesfeld P. Lead exposure from aluminum cookware in Cameroon. Sci Total Environ. 2014;496:339–347
36. Caravanos J, Chatham-Stephens K, Ericson B, Landrigan PJ, Fuller R. The burden of disease from pediatric lead exposure at hazardous waste sites in 7 Asian countries. Environ Res. 2013;120:119–125
37. Gulson BL, Jameson CW, Mahaffey KR, Mizon KJ, Korsch MJ, Vimpani G. Pregnancy increases mobilization of lead from maternal skeleton. J Lab Clin Med. 1997;130:51–62
38. Riess ML, Halm JK. Lead poisoning in an adult: lead mobilization by pregnancy? J Gen Intern Med. 2007;22:1212–1215
39. Cunningham E. What role does nutrition play in the prevention or treatment of childhood lead poisoning? J Acad Nutr Diet. 2012;112:1916
40. Gulson BL, Mizon KJ, Korsch MJ, Palmer JM, Donnelly JB. Mobilization of lead from human bone tissue during pregnancy and lactation–a summary of long-term research. Sci Total Environ. 2003;303:79–104
41. Falk H. International environmental health for the pediatrician: case study of lead poisoning. Pediatrics. 2003;112:259–264
42. Massachusetts Toxics Use Reduction Institute (2006) Five Chemicals Alternatives Assessment Study. Lowell University of Massachusetts Available at: Accessed April 3, 2014
43. U.S Department of Housing and Urban Development. Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing (2012 Edition). 2012 Available at: Accessed May 12, 2015
44. Haefliger P, Mathieu-Nolf M, Lociciro S, et al. Mass lead intoxication from informal used lead-acid battery recycling in Dakar, Senegal. Environ Health Perspect. 2009;117:1535–1540
45. Lo YC, Dooyema CA, Neri A, et al. Childhood lead poisoning associated with gold ore processing: a village-level investigation-Zamfara State, Nigeria, October-November 2010. Environ Health Perspect. 2012;120:1450–1455
46. Fewtrell LJ, Prüss-Ustün A, Landrigan P, Ayuso-Mateos JL. Estimating the global burden of disease of mild mental retardation and cardiovascular diseases from environmental lead exposure. Environ Res. 2004;94:120–133
47. Centers for Disease Control and Prevention. . Blood lead levels in children, aged 1-5, United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:245–248
48. Jacobs DE, Clickner RP, Zhou JY, et al. The prevalence of lead-based paint hazards in U.S. housing. Environ Health Perspect. 2002;110:A599–A606
49. Attina TM, Trasande L. Economic costs of childhood lead exposure in low- and middle-income countries. Environ Health Perspect. 2013;121:1097–1102
50. Trasande L, Liu Y. Reducing the staggering costs of environmental disease in children, estimated at $76.6 billion in 2008. Health Aff (Millwood). 2011;30:863–870
51. Gould E. Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control. Environ Health Perspect. 2009;117:1162–1167
52. Koller K, Brown T, Spurgeon A, Levy L. Recent developments in low-level lead exposure and intellectual impairment in children. Environ Health Perspect. 2004;112:987–994
53. Centers for Disease Control and Prevention. . Very high blood lead levels among adults - United States, 2002–2011. MMWR Morb Mortal Wkly Rep. 2013;62:967–971
54. Centers for Disease Control and Prevention Lead. Available at: Accessed May 11, 2015
55. Secretariat of the Basel Convention (2003). Technical guidelines for the Environmentally Sound Management of Waste Lead-Acid Batteries. Available at: Accessed March 5, 2015
56. Man M, Naidu R, Wong MH. Persistent toxic substances released from uncontrolled e-waste recycling and actions for the future. Sci Total Environ. 2013;463-464:1133–1137
57. Andrews A. Beyond the ban – Can the Basel Convention adequately safeguard the interests of the world’s poor in the international trade of hazardous waste? Law, Environment and Development Journal. 2009;5/2:167–184 Available at: Accessed May 12, 2015


Examples of Organizations Advocating for Increased Efforts to Eliminate Lead Poisoning

World Health Organization: (accessed March 5, 2015)

United Nations Environmental Program: (accessed March 5, 2015)

International Labour Organization: (accessed March 5, 2015)

Public Health Association of Australia: (accessed March 5, 2015)

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.