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Lead Poisoning in Children and Pregnant Women in 2013: A Persistent Public Health Problem

Lead Poisoning in Children and Pregnant Women in 2013: A Persistent Public Health Problem November 1, 2013 Paromita Hore, PhD, MPH Risk Assessment Coordinator Bureau of Environmental Disease Prevention NYC Department of Health and Mental Hygiene. Non-Paint & Non-Occupational Lead Sources.

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Lead Poisoning in Children and Pregnant Women in 2013: A Persistent Public Health Problem

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  1. Lead Poisoning in Children and Pregnant Women in 2013: A Persistent Public Health Problem November 1, 2013 Paromita Hore, PhD, MPH Risk Assessment Coordinator Bureau of Environmental Disease Prevention NYC Department of Health and Mental Hygiene

  2. Non-Paint & Non-Occupational Lead Sources • Lead paint still primary source of lead poisoning among NYC children but… • Lead paint hazard not identified in 25% of children with BLLs > 15 µg/dL * • Occupational hazards remain the primary source of lead poisoning among adult males but… • 17% of males with BLLs > 10 µg/dL reported only non-occupational sources • 88% of women with BLLs > 10 µg/dL reported non-occupational sources of lead exposure *2012 Estimates

  3. Global Span of NYC’s Lead Poisoned Children From 2002 to 2009, countries shown in red are the birth countries of at least 2 children with lead poisoning in NYC.

  4. Global Span of NYC’s Lead Poisoned Adults Countries shown in blue are the birth countries reported by adult lead poisoning cases interviewed by DOHMH (2009)

  5. Identification of Hazardous Consumer Products • Investigations of lead-poisoned individuals • Poison Control Center reports • National alerts • Reports from other jurisdictions • Media reports • Published literature Intervention Model for Contaminated Consumer Products • Determination of Product Availability in NYC • Check product availability in NYC stores • Target neighborhoods based on product users • Laboratory testing (when necessary) • Public Awareness Activities • Notify consumers and general public, businesses, health care providers, community-based organizations • Press releases • Brochures • Fact sheets • Health advisories • Embargo and Enforcement • Stop sale or distribution of products • Seize and remove products • Order disposal of products • Notify other agencies when applicable

  6. Products From Mexico

  7. Ceramics Associated with Child Poisonings Clay cup From Mexico Used as toy 50,000 ppm BLL 16 ug/dL Ceramic cup From Ecuador Used for drinking 69,000 ppm BLL 20 µg/dL Clay cup From Mexico Used as toy 23,000 ppm BLL 16 µg/dL Ceramic cup From Mexico Used to drink water or milk 6.2 µg/mL BLL 20 µg/dL Clay pan From Mexico Used as toy 26,000 ppm BLL 36 µg/dL Clay cup From Mexico Used as toy 25,000 ppm BLL 36µg/dL Ceramic cup From Mexico Used as toy 860 ppm BLL 36 µg/dL

  8. Ceramics – Federal Limits • FDA Allowable Limits For Food Contact Surfaces • Flatware – 3 µg/mL • Small Hollowware other than cups and mugs – 2 µg/mL • Cups/mugs – 0.5 µg/mL • Large Hollowware other than pitchers – 1 µg/mL • Pitchers – 0.5 µg/mL • Method ASTM C 738-94

  9. Herbs • Pregnant Female • BLL 18 µg/dL • Obtained in Mexico • 1600 ppm lead in herbs • 29 ppm lead in solution

  10. Chapulines • Grasshopper snacks with garlic, salt, lime juice or red chili powder • BLL’s range from 10-52 ug/dL • Lead Levels (380 – 1,100 ppm)

  11. Other Snack Products • Preserved mangoes cooked in clay pot • Obtained in Mexico • Lead poisoning in children • BLLs 19-37 µg/dL • 260-620 ppm lead • Tamarind pulp • Purchased in Mexico • Child BLL 26 µg/dL • 350 ppm lead

  12. Tierra Santa or Panito del Señor • Pregnant woman BLL 34 ug/dL • Lead (13 ppm) and arsenic (11 ppm) • Used to treat stomach problems • Made in Mexico • Purchased in NYC store • Wholesaler not identified • Suppliers were a traveling couple • FDA notified • Outreach to CBOs

  13. Calabash Chalk (Nzu) • West African remedy used to treat morning sickness in pregnant women • Sold as large pellets or in bulk and can resemble balls of clay or mud • Lead (4~7 ppm) and Arsenic (5~10 ppm) • Triggered by FDA and Texas Department of State Health Services

  14. Many Cultures Use Medicinal Clay • Clay marketed in Esquipulas, Guatemala as 5-6 cm wide embossed tablets • Clay in a Nigerian market is sold in a variety of forms. Source: Ray E, Ferrell Jr., Medicinal Clay and Spiritual Health. Clay and Clay Minerals, Vol. 56, No. 6, 751-760, 2008.

  15. Pica and Lead Poisoned Pregnant Women (2001-2009) • ~10% of lead poisoned pregnant women reported pica • 3x more likely to have blood lead levels ≥45 µg/dL • 3x more likely to be born in Mexico • Reported ingestions • 65% soil • 21% ceramics or brick • 8% paint or plaster • 6% other substances including tissue paper, ice, eggshells Source: Thihalolipavan, S. et. al., Examining Pica in NYC Pregnant Women with Elevated Blood Lead Levels

  16. Products From South Asia

  17. Supplements/Remedies Made in India (2004-2012) Adult Case Investigations • Adult female • BLL= 54 µg/dL BLL • 20,000 ppm lead • Obtained in India • Diabetes, blood pressure, asthma, arthritis and thyroid problems • Adult male • BLL = 192 µg/dL BLL • ~89,000 ppm lead • Obtained in India • Diabetes • Adult pregnant female • BLL = 24 µg/dL BLL • 47,000 ppm lead • Obtained in India • Eczema • Adult male • BLL = 33 µg/dL • Obtained in India for diabetes & weakness • Adult male • BLL = 91 µg/dL BLL • ~47,000 ppm lead • 4,800 ppm mercury • 4,300 ppm arsenic • Prescribed & obtained in NYC • Rheumatic pain • 9,400 ppm lead • 70,000 ppm mercury • 1,700 ppm arsenic • 29 ppm lead • 31,000 ppm mercury

  18. Contaminated Supplements Made in IndiaPregnant Women Case Investigations (2011-2012) • Adult pregnant female • BLL = 16 µg/dL • Purchased products in • NYC for skin problems • Adult pregnant female • BLL = 64 µg/dL • Purchased & prescribed in India • Pregnancy-related nausea & vomiting • 12,000 ppm lead • 20,000 ppm lead, • 15,000 ppm mercury • 130 ppm arsenic • 12 ppm lead • 35 ppm mercury • 9.5 ppm arsenic • Adult pregnant female • BLL = 49 µg/dL • Purchased & prescribed in India • Keep pregnancy and fetus healthy • 22,000 ppm lead • 19,000 mercury • 410 ppm arsenic • Adult pregnant female • BLL = 42 µg/dL • Purchased & prescribed in India • Promote fertility • 12,000 ppm lead • 18,000 ppm mercury • 1,000 ppm arsenic • CDC MMWR/ August 24, 2012/ Vol. 61/ No. 33

  19. Contaminated Supplements Made in India (2012) • Adult pregnant female • BLL = 51 µg/dL • Purchased and prescribed in India • Adult pregnant female • BLL = 24 µg/dL • Purchased and prescribed in India • Ovarin • Reproductive health • 24,000 ppm lead • 70,000 ppm mercury • 100 ppm arsenic • Reproductive health • 110 ppm lead • 100,000 ppm mercury • 140 ppm arsenic • Reproductive health • 120 ppm lead • 52,000 ppm arsenic • Improve skin complexion • 7 ppm lead • 29,000 ppm mercury • 27 ppm arsenic • Reproductive health • 180 ppm lead • 120 ppm mercury • 12 ppm arsenic • “Having a male baby” • 15,000 ppm lead • 4,400 ppm mercury • 81 ppm arsenic • CDC MMWR/ August 24, 2012/ Vol. 61/ No. 33

  20. Supplements Made in India (2012)Child Case Investigations • 2 ½ yr old • BLL 42 µg/dL • 4 yr old • BLL 16 µg/dL • Swarna Malini Vasant • Overall well-being • As needed • 32,000 ppm mercury • 1,300 ppm arsenic • 31,000 ppm lead • Purchased in India • Unknown powder • Asthma • 1x/month • 8,300 ppm mercury • Purchased in India • Laxmi Vilas Ras • Cold & influenza • As needed • 59,000 ppm mercury • Purchased in India • “Probal Pishti” • Using for pervasive developmental delay • 1x/week • 17,000 ppm lead • Purchased in India

  21. SindoorPregnant Woman & Child Case Investigations • BLLs range 16-25 µg/dL • Lead levels as high as 330,000 ppm • Red or orange powder used for religious purposes • Worn by married Hindu women as a symbol of marriage • Used during prayers • Brought from abroad or purchased in NYC • Lead poisoning cases in which Sindoor used as food coloring Sometimes lead tetroxide or “red lead” is added as a pigment to Sindoor

  22. South Asian Spices • Turmeric, Chili, Coriander, Saffron • Obtained in South Asia • Not uniformly contaminated • Levels as high as 2,000 ppm • Saffron • Obtained in Pakistan • 567 ppm lead • BLL 16 µg/dL • Turmeric • Obtained in India • 690 ppm lead • BLL 18 µg/dL • Turmeric • Obtained in Bangladesh • 2000 ppm lead • BLL 49 µg/dL

  23. Products From Georgia

  24. Spices from Georgia ….but the country Not the state……

  25. Georgian SpicesChild and Adult Case Investigations • Variety of spices including paprika, sunely or suneli alone or in mixtures (i.e., hmeli sunely, utsho sunely), Svanuri marili • Obtained in Georgia • Lead level as high as 27,000 ppm • Not uniformly contaminated • Zaprana (saffron) • 27,000 ppm lead • BLL 15 µg/dL • Unknown spice • 18,000 ppm lead • BLL 19 µg/dL • Suneli • 14,000 ppm lead • BLL 24 µg/dL

  26. Products From China

  27. Supplements Made in China (2006)Adult Case Investigation • Adult male • BLL 27 µg/dL • Prescribed and purchased in NYC 5,900 ppm lead 5,100 ppm mercury Promote healthy liver & maintain regularity 24 pills/day 5,100 ppm lead 3,200 ppm mercury Natural balance 24 pills/day

  28. Product From The United States

  29. Supplement Made in USA (2010)Adult Case Investigation • Adult female • BLL 22 ug/dL • Lead Levels (380 – 1,100 ppm) • Herbal Supplement manufactured in California • Purchased at a Holistic Expo in NYC • DOHMH notified FDA • FDA issues consumer alert and mfg issued recall • Letters to holistic practitioners • Expo organizer ordered to stop selling & post signs • DOHMH inspectors verified compliance by EXPO

  30. Cross Cultural Products Jewelry, Charms, Amulets Cosmetics

  31. Cosmetics - Kohl, Kajal, Surma, Tiro • Used for many reasons – cosmetic, cultural significance, medicinal purpose • Prohibited by FDA • Lead poisoning cases in NYC associated with lead levels as high as ~90% • Brought from abroad or purchased in NYC • Imported eye cosmetics from South Asia, Africa and the Middle East Made by grinding galena (mineral form of lead sulfide)

  32. Cosmetics - Kohl, Kajal, Surma • Hashmi Surma Special • 468,708 ppm lead • Made in Pakistan • “Pure Kohl from the Waters of ZamZam” • 362,419 ppm lead • Manufacturer info not listed • Hashmi Kohl Aswad • 272,353 ppm lead • Made in Pakistan • Hashmi Kajal • 41,298 ppm lead • Made in Pakistan

  33. Cosmetics - Tiro • 82.6 % Pb • CDC MMWR/ August 3, 2012/ Vol. 61/ No. 30

  34. Amulet from Cambodia • 1 year old child - BLL 20 µg/dL • Several interviews • During interviews father: • Answers “no” to child wearing “jewelry” or “charm” • Answers "yes" to child wearing “amulet” or “something to protect him” • Mentions that child “puts it in mouth” • Amulet worn around child’s neck since age 3 months for blessing • Contained 450,000 ppm lead • Child”s BLL drops after ID of source • CDC MMWR/ January 28, 2011/ Vol. 60/ No. 3

  35. Charms from Bangladesh Tabeez: • 1 year old child • BLL 19 µg/dL • Used to stop child from crying • From Bangladesh • Contained 580,000 ppm lead Sheesha: • 4 year old child • BLL 26 µg/dL • Used for speech therapy • Grandparents sent from Bangladesh • Contained 880,000 ppm lead

  36. 500,000 ppm lead • 330,000 ppm lead • 530,000 ppm lead • 870,000 ppm lead Jewelry from the United States • 2 year old child • BLL 43 µg/dL

  37. Children’s Products • CPSC Allowable Limits: • Total lead content – 100 ppm • Lead in Paint and Similar Surface Coatings – 90 ppm • What is a children’s product? • Consumer product primarily intended for a child 12 years of age or younger

  38. Products From D.R.

  39. Litargirio • Rhode Island alert • BLLs 26-42 µg/dL • 790,000 ppm lead • Yellow powder used as antiperspirant, fungicide, burn treatment • Found in NYC botanicas • Local Law 49 adopted in NYC in May 2005 • Prohibits the sale of litargirio

  40. Mercury-Containing Skin Lightening Products • Dermal exposure • FDA requirements: • Mercury level < 1 ppm • Must list active ingredients • 10 skin-lightening creams (2004): • Most imported from Dominican Republic • Up to 41,600 ppm mercury • 6 listed mercury as ingredient • Stop use of “skin-lightening” or other products with no ingredients listed or labeled as containing mercury

  41. McKelvey et al.

  42. Products From Ecuador • Chocolates • BLL 15-23 µg/dL • Obtained in Ecuador • 14-190 ppm lead

  43. Risk Communication • Know your population • Identify potential risk factors • Develop health risk messages

  44. Challenges Investigation of the Non-Paint Lead Hazard Language barriers during case interviews Products hard to identify (familiar terminology e.g. amulet vs. jewelry; remedies vs. medicine) Suppliers and retailers hard to locate Sampling and analytic issues Collection of representative sample Batch variability Appropriate methods used to prepare and analyze samples Interpretation of sampling results Program resources (staff, training)

  45. Challenges Enforcement Assessing the policy infrastructure Lack of Federal Standards Informal Distribution/Products purchased abroad Outreach and Education Cultural/religious practices and customs Using effective and clear messages to increase awareness Culturally appropriate messages Finding acceptable substitutes (e.g. spices) Language barriers Cross-cultural use of products

  46. Successes Expanded our organizational capacity to address non-paint hazards Improve our understanding and identification of non-paint exposures Risk assessment tool Staff development to improve interviewing and risk assessment skills Staff alerts Environmental sampling protocols Strengthened relationships with high-risk immigrant communities Reduced exposures Identified potential new lead hazards and informed providers and target community members

  47. Continued Efforts • Increase awareness among public • Identify and learn about other products • Program resources (staff, training, protocols) • Collaborate with other agencies • Build partnerships to develop better interventions

  48. Educational Materials Also available in Arabic, Bengali, Chinese, French, Hindi, Spanish, and Urdu

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