title: Effectiveness of interventions to reduce exposure to lead through consumer products and drinking water: A systematic review.
abstract: OBJECTIVE
  The objective of this systematic review is to assess the effectiveness of regulatory, environmental and educational interventions for reducing blood lead levels (BLLs) and associated health outcomes in children, pregnant women and the general population.
  
  
  METHODS
  Searches were run in MEDLINE, EMBASE and the Global Health Library up until August 2015. Studies were eligible for inclusion if they assessed the impact of regulatory, environmental or educational interventions, stand-alone or in combination, on BLLs among children, pregnant women or the general population through randomized controlled trials (RCT), controlled before-after (CBA), interrupted time series (ITS), uncontrolled before-after (UBA) or repeated cross-sectional studies. Studies assessing the impact of interventions to reduce exposure to lead in paint or household dust as well as studies concerned exclusively with environmental concentrations of lead were not included. As documented in a detailed protocol, screening, data extraction and quality appraisal were largely undertaken according to Cochrane standards. Harvest plots were used to graphically summarize evidence of effectiveness.
  
  
  RESULTS
  The searches yielded 6466 unique records, of which five met our eligibility criteria; two additional eligible studies were identified by experts. We did not find any studies regarding the effectiveness of regulatory, educational or environmental interventions targeting exposure to lead in consumer products. Evidence regarding the effectiveness of interventions in reducing BLLs from exposures through drinking water is limited in both quantity and quality. Stand-alone targeted educational interventions showed no statistically significant reductions in children's BLL (two RCT) when compared to general educational interventions. Likewise, instructing women to reduce or eliminate lead-contaminated drinking water showed no effect on BLL (one RCT). Stand-alone environmental interventions appeared more promising in reducing BLL (three UBA). Combining educational and environmental interventions and targeting multiple settings may be effective in reducing BLL, as suggested by one uncontrolled before-after study. No studies examining the effectiveness of regulatory interventions were found.
  
  
  CONCLUSIONS
  The limited quantity and quality of the evidence measuring BLL and associated health outcomes points to an urgent need for more robust research into the effectiveness of interventions to reduce lead exposure from consumer products and drinking water, especially for regulatory interventions.
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany. Electronic address: pfadenh@ibe.med.uni-muenchen.de.
authors.forename: Lisa Maria
authors.initials: LM
authors.lastname: Pfadenhauer
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
authors.forename: Jacob
authors.initials: J
authors.lastname: Burns
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany; Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, 7500, South Africa.
authors.forename: Anke
authors.initials: A
authors.lastname: Rohwer
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
authors.forename: Eva Annette
authors.initials: EA
authors.lastname: Rehfuess
mesh_terms: D003257:Consumer Product Safety / Q000331:legislation & jurisprudence*; D004781:Environmental Exposure / Q000517:prevention & control*; D006801:Humans; D007854:Lead / Q000097:blood*
chemical_list: D007854:Lead
keywords: Blood lead level; Consumer product; Drinking water; Education; Environmental intervention; Harvest plot; Regulation