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Introduction
Background
The U.S. Environmental Protection Agency (EPA), Centers for Disease Control and Prevention (CDC), and American Academy of Pediatrics agree that there is no known safe level of lead (Pb) in a child’s blood; even low levels of Pb in the blood can result in behavior and learning problems, lower IQ and hyperactivity, slowed growth, hearing problems, and anemia (www.epa.gov/lead; http://www.cdc.gov/nceh/lead/; Council on Environmental Health 2016). Triantafyllidou et al. (2014) concluded that low levels of Pb in drinking water could pose a human health concern in sensitive population groups (e.g., young children and particularly formula-fed infants). Drinking water and other exposure sources for Pb have recently been the subject of public health concerns around the Flint, Michigan, drinking water (Hanna-Attisha et al. 2016; Laidlaw et al. 2016) and East Chicago, Indiana, Pb in soil (Goodnough 2016) crises. As part of the EPA’s Safe Drinking Water Act assessment of lead in drinking water, the National Drinking Water Advisory Council (NDWAC)’s Lead and Copper Rule (LCR) Working Group was established to provide advice to EPA in considering potential revisions to the LCR. In December 2015, NDWAC recommended establishment of a “health-based, household action level” for Pb in drinking water based on children’s exposure (NDWAC 2015). The NDWAC working group recommended that “water systems would be required to notify the consumer, state drinking water program, and the local public health agency if this level were exceeded. The expectation is that individuals and local officials would use this information to take prompt actions at the household level to mitigate lead risks. …” While the EPA has not yet determined the specific role of a health-based benchmark for Pb in drinking water in the new rule, the agency sees value in providing states with drinking water systems and the public with a greater understanding of the potential health implications for vulnerable populations of specific levels of Pb in drinking water. The EPA anticipates that a health-based benchmark could also help inform other potential elements of a revised LCR, including public education requirements, prioritization of households for lead service line replacement programs or other risk mitigation actions at the household level, and potential requirements related to schools or other priority locations (U.S. EPA 2016a). To guide a potential health-based benchmark for...