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Abstract The USEPA (United States Environmental Protection Agency) Lead and Copper Rule Revisions allow the use of distributed treatment approaches such as point‐of‐use (POU) and point‐of‐entry (POE) treatment for systems with 10,000 connections or less as a compliance strategy. However, this poses an opportunity for the USEPA to reevaluate system size recommendations for distributed treatment. The current research uses online surveys and semi‐structured interviews (SSIs) to highlight the general sentiment of state regulators managing POU/POE devices and inquiries. Analysis of the 43 survey responses and 13 SSIs revealed that most state regulators described systems of approximately 30–50 connections as the most successful. Resident cooperation, operation and maintenance, monitoring, and the actual implementation of distributed treatment approaches were repeatedly listed as the greatest concerns. As the use of distributed treatment continues to expand, the water sector must devote research efforts to quantitatively determining the drivers of success as well as highlighting clear indicators of potential failure. 

One in three children globally is estimated to have blood lead levels (BLL) at or above the BLL reference value of 5 μg/dL with increased burden falling on low- and middle-income countries (LMIC). Within developed countries, aqueous lead is the predominant exposure route. However, aqueous lead exposure is rarely examined in the LMIC, leaving a gap in the literature that ignores a potentially significant route of exposure. Furthermore, limited lead-based remediation efforts around consumer products have been examined. This study investigates the importance of lead exposure from the water supply through a case study in Toamasina, Madagascar. The project measured aqueous lead and BLL of children pre- and postremediation efforts (i.e., removal of leaded pump components in hand pumps) to verify the impact of aqueous lead exposure within this community. Removal of the leaded pump components (i.e., piston and foot valves) and replacement with nonleaded components decreased aqueous lead levels below the World Health Organization provisional guideline of 10 μg/L in all but 4% of pumps tested. Measured BLL concentrations indicated a statistically significant decrease in BLL from pre- to postremediation. Furthermore, the remediation resulted in a decrease in BLL for 87% of children with the greatest changes in BLL observed for children with the highest preremediation concentrations. These findings point to a need for greater consideration of lead in drinking and cooking waters as an important exposure route in LMIC. 

One-third of children globally have blood lead levels (BLLs) exceeding the (former) US CDC reference value of 5 μg/dL; this value may be as high as one-half for children in low- and middle-income countries (LMICs). Lead exposure occurs through a variety of routes (e.g., water, dust, air), and in LMICs specifically, informal economies (e.g., battery recycling) can drive lead exposures due, in part, to absent regulation. Previous work by our team identified a ubiquitous source of lead (Pb), in the form of Pb-containing components used in manually operated pumps, in Toamasina, Madagascar. Characterization of BLLs of children exposed to this drinking water, and identification of additional exposure routes were needed. BLLs were measured for 362 children (aged 6 months to 6 years) in parallel with surveying to assess 14 risk factors related to demographics/socioeconomics, diet, use of pitcher pumps, and parental occupations. BLL data were also compared against a recent meta-review of BLLs for LMICs. Median childhood BLL (7.1 μg/dL) was consistent with those of other Sub-Saharan African LMICs (6.8 μg/dL) and generally higher than LMICs in other continents. Risk factors significantly associated (p < 0.05, univariate logistic regression) with elevated BLL (at ≥ 5 μg/dL) included male gender, living near a railway or major roadway (owing potentially to legacy lead pollution), having lower-cost flooring, daily consumption of foods (beans, vegetables, rice) commonly cooked in recycled aluminum pots (a previously identified lead source for this community), and a maternal occupation (laundry-person) associated with lower socioeconomic status (SES). Findings were similar at the ≥ 10 μg/dL BLL status. Our methods and findings may be appropriate in identifying and reducing lead exposures for children in other urbanizing cities, particularly in Sub-Saharan Africa, where lead exposure routes are complex and varied owing to informal economics and substantial legacy pollution.