As a  result of this act, the CDC Childhood Lead Poisoning Prevention Program  (CLPPP) was created. While the 2004 MMWR article discussed some  limitations to its findings, it did not discuss other limitations that  addressed how information in the 2004 MMWR article could be used. CDC Has Issued Statements to Address Confusion It Created Related to the 2004 MMWR Article, but Has Not Published an Overview of the Effects of Lead in Tap Water on BLLs in Children

Although CDC does not have a policy to monitor the use of or clarify  information in public health publications, such as the information in the  2004 MMWR article, the agency issued statements to address confusion it  created related to elevated lead levels in the District’s tap water. Specifically, CDC has not published an overview of what is  known and not known about tap water as a source of lead exposure and  the potential health effects on children, as suggested by the CDC internal  incident analysis. In February 2008, a CDC official corresponded with the District’s Water  and Sewer Authority officials about a statement in a February 2008 fact  sheet published by the water authority that incorrectly characterized  information in the 2004 MMWR article. The CDC official  requested that the statement be corrected. CDC Has Not Published an Overview of the Effects of Lead in Tap Water on BLLs in Children

Although CDC has taken actions to address confusion specific to the 2004  MMWR article, as of January 2011, CDC had not taken action to publish an  overview of the current knowledge about the contribution of elevated lead  levels in tap water to BLLs in children and the associated health effects. CDC Has Begun an Initiative and Revised Procedures to Help Ensure That CDC Information Is Accessible and Clear, but These Procedures Do Not Address Confusion after Publication

CDC officials told us they had begun an initiative and revised procedures  to help ensure the accessibility and clarity of CDC public health  communications prior to publication, both agencywide and in NCEH. Specifically, an official from the Office of the Director told us that the CDC  Office of the Associate Director of Science has begun an initiative to revise  existing procedures to help ensure that information that CDC publishes,  such as guidelines and recommendations, is easily accessible by a  common portal on CDC’s Web site. Because CDC does not  have procedures for addressing confusion after publication, the agency  runs the risk that its staff will provide inconsistent responses to  interpretations of its information that differ from what CDC intended. Conclusions

Although CDC has taken some belated actions to clarify confusion related  to the 2004 MMWR article on BLLs of residents in the District, the agency  does not plan to publish a comprehensive review of the role of tap water  as a source of lead exposure that would communicate what is known  about the contribution of lead in water to elevated BLLs in children. CDC’s credibility as the nation’s premier public health agency relies on  presenting accurate, reliable, and timely information to the public. CDC can mitigate  the risk of such misinterpretations as well as the resulting risk to its  credibility by developing procedures that allow it to address confusion in a  timely, consistent manner. Recommendations for Executive Action

We are recommending that the Director of CDC take two actions, the first  to clarify confusion about the contribution of lead in tap water to elevated  BLLs, and the second to improve the clarity of CDC’s published  information on public health issues. 1. 2. CDC agreed with our first recommendation to publish an article in an  MMWR Recommendations and Reports. Appendix I: 2004 Morbidity and Mortality Weekly Report Article about Blood Lead Levels of District Residents

On April 2, 2004, the Centers for Disease Control and Prevention (CDC)  published the following article in the Morbidity and Mortality Weekly  Report, which presented results of the investigation on the effect of lead in  the District’s tap water on the blood lead levels of residents.
Why GAO Did This Study

In February 2004, the Centers for Disease Control and Prevention (CDC) was asked to assess the effects of elevated lead levels in tap water on Washington, D.C., residents. In April 2004, CDC published the results. However, an inaccurate statement and incomplete descriptions of the limitations of the analyses resulted in confusion about CDC's intended message. GAO was asked to examine (1) CDC's actions to clarify its published results and communicate current knowledge about the contribution of lead in tap water to elevated blood lead levels (BLL) in children and (2) CDC's changes to its procedures to improve the clarity of the information in its public health communications. GAO reviewed CDC communication policies and procedures and interviewed CDC officials.

What GAO Found

CDC officials told GAO that although the agency does not have a policy to monitor the use of or clarify information in public health publications, the agency took actions to address confusion it created related to the 2004 Morbidity and Mortality Weekly Report (MMWR) article about elevated lead levels in Washington, D.C., tap water. For example, in 2008, CDC officials contacted District of Columbia Water and Sewer Authority officials requesting corrections to a statement in a fact sheet published by the water authority that incorrectly characterized information from the 2004 MMWR article. In addition, CDC also published articles in the 2010 MMWR intended to clarify the confusion, such as a June 25, 2010, article that discussed limitations about how information in the 2004 article could be used. While CDC took these actions, among others, to clarify confusion about the effect of elevated lead levels in District tap water, as of January 2011, CDC had no plans to publish an overview of the current knowledge about the contribution of elevated lead levels in tap water to BLLs in children, as suggested by a CDC internal incident analysis of issues surrounding the 2004 MMWR article. CDC officials told GAO they had begun an initiative and revised procedures designed to help ensure the accessibility and clarity of CDC public health communications, both agencywide and in the National Center for Environmental Health, the center responsible for lead poisoning prevention programs. For example, under the new initiative, CDC will revise existing procedures to help ensure that information that CDC publishes, such as guidelines and recommendations, is easily accessible by a common portal on CDC's Web site. While the initiative and revised procedures focus on making CDC information more accessible and on preventing errors or unclear statements in CDC communications, they do not include actions to address confusion that may arise after information is published, such as occurred with the 2004 MMWR article. Without agency procedures specifically addressing how and when to take action about confusion after publication, CDC runs the risk of inconsistent responses across the agency when its published information is not interpreted as CDC intended. CDC's mission to promote the nation's public health relies on its credibility in presenting accurate, reliable, and timely information. Communicating the agency's current knowledge about the health effects of lead levels in tap water and developing procedures that allow it to address confusion in a timely, consistent manner could improve the public's understanding of the effect of lead in water and help CDC mitigate the risk of confusion in other situations and protect its credibility.

What GAO Recommends

GAO is making two recommendations to CDC: (1) publish an article providing a comprehensive overview of tap water as a source of lead exposure and communicating the potential health effects on children and (2) develop procedures to address any confusion after information is published. CDC generally concurred with GAO's recommendations. For the second recommendation, while CDC described procedures it is developing, the agency did not explicitly address all components of the recommendation.