Transcript Lead Poisoning - Lancaster General

LEAD POISONING
in the 21st Century
Jerome A. Paulson, MD, FAAP
Professor of Pediatrics & Environmental & Occupational Health
George Washington University
Medical Director for National & Global Affairs
Mid-Atlantic Center for Children’s Health & the Environment
Child Health Advocacy Institute
Children’s National Medical Center
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Disclosures
• This material was developed by the Mid-Atlantic Center for
Children’s Health & the Environment and funded under the
cooperative agreement award number 1U61TS000118-03
from the Agency for Toxic Substances and Disease Registry
(ATSDR).
• Acknowledgement: The U.S. Environmental Protection
Agency (EPA) supports the PEHSU by providing funds to
ATSDR under Inter-Agency Agreement number DW-7592301301-0. Neither EPA nor ATSDR endorse the purchase
of any commercial products or services mentioned in PEHSU
publications.
• Dr. Paulson has consulted with lawyers in lead poisoning cases
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
OBJECTIVES
• After attending this session the participant will
 be able to discuss why lead poisoning is still a problem
 be able to discuss the extent of lead poisoning in the US
 be able to explain the disproportionate impact of lead
poisoning on minority populations
 be able to explain the importance of primary prevention
 be able to utilize pediatric environmental health specialty
units as a clinical and educational aid.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
LEAD POISONING
Very common, very significant
environmental health problem for children
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Scope of the Problem
• Have the potential to eliminate childhood lead
poisoning
least 4 million households have children living in
them that are being exposed to lead
About 500,000 children with blood lead levels over 5
µg/dL
http://www.cdc.gov/nceh/lead/
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Primary Prevention is the Only Appropriate
Approach to the Resolution of the Lead
Poisoning Problem
• Screening of children may have been
appropriate in the past & must continue until…
• Making housing lead-safe is what is appropriate
now and in the future
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Historical Perspective
• Use of lead in ancient times
for water pipes and utensils
• Late 19th century –
recognition of problem in
some parts of world
• Early 20th century - banning
residential use of lead-based
paint in some parts of the
world
• Throughout the 20th century
– obfuscation on the part of
the lead industry about the
hazards of lead
Lead Pipe in the Ruins of Pompeii
Eruption 79 CE
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Historical Perspective
• 1920’s introduction of
tetraethyl lead as octane
booster in gasoline –
subsequent obfuscation on
the part of industry about the
hazards of tetraethyl lead
• 1940’s recognition by Byers
and Lord that lead poisoning
created long-term sequela in
survivors
• 1960’s introduction of
chelation by Julian Chisolm
as a means of preventing
seizures, coma and death
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Historical Perspective
• 1970’s and beyond - decrease in average blood
lead level in children in the US
• 1980’s and beyond – recognition that “low lead
levels” are harmful to children
• Marked decrease in average blood lead levels in
kids in the US
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Change in Blood Lead Level
in US Over Time
• 1976-1980
 88% of children 5
and under with BLL
≥ 10 μg/dL
 Geometric mean
BLL in children 5
and under = 14.9
μg/dL
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Blood Lead Level for Children
Aged 1-5 Years by Year of
NHANES, US
Centers for Disease Control. (2012). Fourth National Report on Human Exposure to Environmental Chemicals: Updated Tables September 2012. Accessed at: http://www.cdc.gov/exposurereport/
Jones, R., Homa, D., Meyer, P., Brody, D., Caldwell, K., Pirkle, J., & Brown, M. (2009). Trends in blood lead levels and blood lead testing among US children aged 1 to 5 years, 1988-2004.
Pediatrics, 123(3), e376-e385. doi:10.1542/peds.2007-3608
Mahaffey KR, Annest JL, Roberts J, Murphy RS. National estimates of blood lead levels: United States, 1976-1980. N Engl J Med 1982;307:573-9.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Where Did Success In
Lowering Lead Levels Come
From?
•
•
•
•
•
Gasoline
Paint
Cans
Water
Ceramics
http://www.epa.gov/bns/lead/Fig_01.gif
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
How Do Children
Get Lead Poisoned Today?
• Old paint
• Lead on the ground
From paint
From past use of leaded gasoline
Industrial sources – smelters
Solder
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Other
• As lead paint becomes less common, “Other”
becomes proportionately more important
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Other Potential Sources Of
Lead In The Environment
•
•
•
•
•
•
•
•
Lead glazed pottery
Brass fittings in well pumps
Lead water pipes
Home remedies or cosmetics
Firing ranges
Automotive repair
Casting ammunition, fishing weights or sinkers
Burning lead painted wood or lead batteries
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Who Are the
Children at Greatest Risk?
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
One And 2 Year-old
Children
• Increased mobility during second year of life,
resulting in more access to lead hazards
• Normal hand to mouth activity
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Minority Children
• Traits associated with higher BLLs
Black
Hispanic
Poverty (% on Medicaid)
Increased crowding
Older housing
Lanphear: Pediatrics, Volume 101(2).February 1998.264-271
Bernard SM. McGeehin MA. Pediatrics. 112(6 Pt 1):1308-13, 2003
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Impact of Lead on the Body
• Maternal lead levels may effect pregnancy
Preterm labor
Lead in mothers body, even from her childhood,
may cross placenta and enter the baby
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Impact of Lead on the Body
• Blood lead levels in children
20 μg/dL – decreased nerve conduction velocity
40 μg/dL – decreased hemoglobin synthesis
80 μg/dL – encephalopathy: seizures, coma
> 100 μg/dL – death
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
The Impact of Low
Blood Lead Levels
•
•
•
•
•
Learning disabilities
Hyperactivity
Aggression and other behavior problems
Decreased IQ
Decreased linear growth
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Neurobehavioral Effects of
“Low” Lead Levels
• Lowers IQ
Individual impact small - about 4 IQ points for
blood lead levels of 2.4-10 mcg/dL
Population impact very significant
– Quadruple risk of IQ < 80: 16% vs. 4%
– 5% of low leads with IQ > 125, O% of high leads.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Small Individual Effects Can
Have Large Population Effects
57% increase
in
“Intellectually
Impaired
“Population
Weiss B. Neurotoxicology. 1997;18:581–6.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Childhood lead exposure has a significant and
persistent impact on brain organization associated with
language function
High Lifetime Mean Blood
Lead (26 g/dL)
Low Lifetime Mean Blood
Lead (7.6 g/dL)
activation in left frontal cortex, adjacent to Broca's area, and left middle temporal gyrus, including Wernicke's area, were
found to be significantly associated with diminished activation in subjects with higher mean childhood blood lead levels,
whereas the compensatory activation in the right hemisphere homolog of Wernicke's area was enhanced in subjects with
higher blood lead levels.
Yuan, et al. 2006
What Is The Current Blood
Lead Reference Value?
5 µg/dL
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
What Is A Normal
Blood Lead Level?
UNKNOWN
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
What Is A Safe
Blood Lead Level?
UNKNOWN
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Case 1
• This is a 2-year old Hispanic male who had a
blood lead level of 42 mcg/dL on a routine
screening test.
• What do you want to know?
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Case 1
•
•
•
•
Where does he live?
How old is the home?
Is there any lead in the water?
What other exposures could there be?
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Case 1
• Possible exposure sources in Hispanic families
candy produced in Mexico (tamarind candy)
pottery
folk remedies used in some Hispanic households to
treat "empacho,"
– lead oxide, a yellow-orange powder (greta),
– lead tetroxide, a bright orange powder (azarcon(also
known as reuda, liga, coral, alarcon and maria luisa)
CDC. Lead Poisoning Associated with Ayurvedic Medications---Five States, 2000--2003. MMWR. July 9, 2004; 53(26):582-584.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
General Principles
for Disease Screening
AAP Textbook of Pediatric Care. Chapter 36 Screening: General Considerations.
Paul H Dworkin, MD
1. The condition must have significant morbidity or
mortality, with serious consequences if not detected and
remediated early.
2. The condition must be sufficiently prevalent to justify
the cost of screening programs.
3. The screening program must include the entire
population, especially those at particular risk for the
condition.
4. Diagnostic tests must allow affected individuals to be
distinguished from nonaffected persons or those who
are borderline. Screening should be performed only for
conditions that can be diagnosed with certainty
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
General Principles
for Disease Screening
AAP Textbook of Pediatric Care. Chapter 36 Screening: General Considerations.
Paul H Dworkin, MD
5. The condition, after detection, must be treatable or
controllable.
6. Detection and treatment during the asymptomatic stage
must improve prognosis, and early treatment must have
significant advantage
7. Adequate resources must be available for the definitive
diagnosis and treatment of disorders identified by screening
8. The cost of screening must be outweighed by the savings
in suffering and alternative expenditure that would occur if
the condition were not diagnosed until the symptomatic
stage
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Criteria 4: Do We Have
an Accurate & Reliable Test?
• Current regulations for allowable laboratory error
permitted in BLL proficiency testing programs is ±4
μg/dL
• How does one intelligently interpret today’s BLL results if
they are all ±4 μg/dL?
• How does one interpret the results of a post-intervention
BLL level; i.e., BLL of 4 μg/dL before intervention and
now 2 μg/dL. Is the child at lower risk?
• How does one interpret the results of a post-intervention
BLL level; i.e., BLL of 4 μg/dL before intervention and
now 8 μg/dL. Has the child’s BLL “doubled” as a result
of the home intervention?
Criteria 5: Is the condition
treatable or controllable?
• There is no data to indicate that interventions of
any sort in children with the blood lead levels of
today are effective in treating or controlling the
condition. The damage may well have already
been done and is, by all indications, irreversible.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Criteria 6: Early
detection and treatment
must improve outcome
• The term "asymptomatic phase" does not really
apply to blood lead levels that are common
today
• There is no treatment that can be offered by a
health professional that can demonstratively
improve prognosis.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Criteria 8:
Cost of early treatment
must be less than late
• Since there is no asymptomatic phase, this
criteria cannot be fulfilled.
Primary Prevention
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Residential Lead-Based Paint
Hazard Reduction Act of 1992
• Required EPA to set health-based regulatory
standards for levels of lead in paint, dust and soil
• Required EPA to identify cost-effective methods
for identifying and controlling lead hazards in
housing
• Required EPA to establish a new program for
training and certifying lead hazard control
professionals.
Public Law 102-550. http://www.epa.gov/opptintr/lead/titleten.html
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Residential Lead-Based Paint
Hazard Reduction Act of 1992
• Required notification of new buyers or renters
of pre-1978 housing that lead hazards may be
present.
• Expanded efforts to identify and control lead
hazards in federal low-income housing through
federal and local housing programs.
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Eliminating Childhood Lead
Poisoning: A Federal Strategy
Targeting Lead Paint Hazards – 2000
• Goals
By 2010, eliminate lead paint hazards in housing
where children under 6 live
By 2010 elevated blood levels in children will be
eliminated
http://www.hud.gov/offices/lead/reports/fedstrategy2000.pdf
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Eliminating Childhood Lead
Poisoning: A Federal Strategy
Targeting Lead Paint Hazards –
2000
• Objectives
Increase federal funding of HUD’s lead hazard
control program and leverage private and other nonfederal funding
Increase compliance, monitoring and enforcement
of lead paint regulations
Outreach and public education
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
Federal Agencies with Lead
Poisoning Prevention Activities
• Department of Housing &
Urban Development
• EPA
• CPSC
• Department of Justice
• Occupational Safety &
Health Administration
• Department of Treasury
• Department of Energy
• Department of Defense
• Department of Health &
Human Services
 CDC
– ATSDR
 CMS (HCFA)
 NIH
– NICHD
– NIEHS
 HRSA
 FDA
Bernard SM. Am J Public Health. 93(8):1253-60, 2003
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
The Home Environment
• Evolution to Healthy Homes approach
• Lead remediation +
Weatherization
Dampness reduction
Mold remediation
Carbon monoxide prevention
Radon hazard reduction
QUESTIONS?
Mid-Atlantic Center for Children’s Health & the Environment - MACCHE
PEDIATRIC ENVIRONMENTAL
HEALTH SPECIALTY
UNITS (PEHSUs)
The Mid-Atlantic Center for Children’s Health & the Environment
PEHSUs
• Pediatricians with expertise in environmental
health
• Occupational and environmental health specialty
physicians
• Medical toxicologists, pulmonologists, etc
• National and international network of
collaborators
The Mid-Atlantic Center for Children’s Health & the Environment
The Pediatric Environmental Health
Specialty Unit (PEHSU) Program
is funded by:
&
The Association of Occupational and Environmental
Clinic is responsible for programmatic and financial
management.
The Mid-Atlantic Center for Children’s Health & the Environment
PEHSU Regions
The Mid-Atlantic Center for Children’s Health & the Environment
PEHSUs –
Resource for Education
•
•
•
•
For primary care providers
For occupational health providers
For public health officials
For community organization concerned about
children and the environment
The Mid-Atlantic Center for Children’s Health & the Environment
PEHSUs –
Resource for Services
•
•
•
•
Consultation with community providers
Consultation with departments of public health
Consultation with parents
Consultation with community organizations, schools
and others
• Multidisciplinary evaluation of children with known or
suspected exposure to environmental toxicants
The Mid-Atlantic Center for Children’s Health & the Environment
PEHSUs
Evaluation and Management of
•
•
•
•
•
•
Lead poisoning
Pesticide exposures
Sick building problems
Water pollution
Air pollution
Job related exposures in
adolescents
• Volatile Organic
Compounds
• Exposure to hazardous
waste sites
• Environmentally related
asthma
• Agricultural pollutants
• Solvents
• Carbon monoxide
• Arsenic
• Mercury
The Mid-Atlantic Center for Children’s Health & the Environment
THE MID-ATLANTIC CENTER
FOR CHILDREN’S HEALTH &
THE ENVIRONMENT
(MACCHE)
A PEDIATRIC ENVIRONMENTAL
HEALTH SPECIALTY UNIT
(PEHSU)
The Mid-Atlantic Center for Children’s Health & the Environment
MACCHE
• The Children’s National
Medical Center
 Washington, DC
• The Children’s Hospital
of Philadelphia
The Mid-Atlantic Center for Children’s Health & the Environment
MACCHE
• Director
Jerome Paulson, MD, FAAP
• Pediatrician/Toxicologist
Kevin Osterhoudt, MD, MS, FAAP, FACMT,
FAACT
• Coordinator
Veronica Tinney, MPH(c)
The Mid-Atlantic Center for Children’s Health & the Environment
MACCHE
• Region 3
• Pennsylvania, Delaware, Maryland, Virginia,
West Virginia, & the District of Columbia
• 1-866-622-2431
• 202-476-4829
• www.childrensnational.org/MACCHE
The Mid-Atlantic Center for Children’s Health & the Environment
QUESTIONS?