Lead Poisoning in 2013 It Aint What It

Lead Poisoning in 2013: It Ain’t What It Used to Be Stanley J. Schaffer, M. D. , M. S. James R. Campbell, M. D. , M. P. H. WNY Lead Poisoning Resource Center Department of Pediatrics University of Rochester

Disclosures Stanley Schaffer, M. D. and James Campbell, M. D. have no conflicts of interest to disclose.

What Have We Known For a Long Time About Lead Poisoning? “Lead makes the mind give way. ” -- Dioscerides – 2 nd Century B. C.

Lead Paint As a Source of the Problem

Deteriorating Painted Surfaces – A Common Source of Lead

It Wasn’t Only Paint Though: Ethyl Isn’t Just a Woman’s Name Tetra-ethyl Lead: “A colorless liquid of sweetish odor, very poisonous if absorbed through the skin, resulting in lead poisoning almost immediately. ” -- Pierre du. Pont, (Chairman of Du. Pont Chemical Company and General Motors), 1922

The Effect of Removing Lead From Gasoline 120 17 110 16 15 100 14 90 13 80 12 70 11 60 10 50 9 40 8 30 7 1976 1977 1978 1979 Year 1980 Average Blood Lead Levels (ug/dl) Total Lead Used in Gasoline Per 6 Month Period (in 1000 tons) Change in Blood Lead Levels in Relation to a Decline in Use of Leaded Gasoline in the U. S. , 1976 -1980

Sources of Lead Past and Present Sources Frequently Encountered in the Past: Paint Air Soil Sources Seen with Increased Frequency Now: Dust Imported Cosmetics Imported Foods & Spices Ceramic Pottery Lead-Containing Toys

Sources of Lead We Have Encountered

Sources of Lead – It’s Not Always Obvious Who How When What Where

Our Knowledge About the Adverse Effects of Lead Has Come a Long Way Blood Lead Level in mcg/d. L Blood Lead Cut-offs As Determined by the CDC 40 35 30 25 20 15 10 5 0 1975 1985 1991 2012

Which Children Are Most At-Risk for Lead Poisoning?

The Conclusion of the National Academy of Sciences’ Review of the Evidence Concerning the Effects of Lead “Lead is toxic wherever it is found … and it is found everywhere. ” National Academy of Sciences, 1993.

What Kind of Harm Does Lead Cause in Children? • Irreversible IQ deficits • Elevated hearing thresholds and associated auditory processing problems • Problems with attention and impulsivity • Poor control of emotions; increased likelihood of aggressive behavior and conduct problems • Significantly increased likelihood of delinquency and incarceration

The Rochester Lead Study

The Effects of Low-Level Lead Exposure on IQ in Young Children From Canfield RL, et al. NEJM. 2003; 348: 1517 -1526

Gender-Specific Effects of Lead on Executive Functioning (Learning How to Solve a Puzzle) Froehlich, et al. , Biological Psychiatry, 2007; 62: 243 -249.

Lead Exposure and SAT Scores Nevin R. Trends in preschool lead exposure, mental retardation and scholastic achievement: association or causation. Env. Research. 2009

Which Children Exposed to Lead Have the Greatest IQ Deficits? Hornung RW, et al. Environmental Health Perspectives, 2009; 117: 1309 -1312.

Lead and ADHD Inattention Hyperkinesis Lead? Impulsivity Lead?

Neurobiological Mechanisms: The Mesocorticolimbic Dopamine (DA) System as a Target of Lead • Mesocorticolimbic system: w Learning, executive function, attention, reward, addiction • Nigrostriatal system: w Motor function, Parkinson’s disease

Brain Function Later in Life After Lead Exposure Functional MRIs showing areas of brain function after tasks requiring impulse control were given to adults Brain of an adult who was exposed to lead as a child Brain of an adult who was not exposed to lead as a child Cecil K. PLOS Medicine, 2008; 5: e 112 Cecil K, PLo. S Medicine. 2008; 5: e 112.

Does Lead Poisoning Cause Antisocial Behavior? Does lead poisoning cause antisocial behavior?

Lead Poisoning and Juvenile Delinquency: Earlier Observations Byers and Lord reported a high prevalence of behavior problems among survivors of lead encephalopathy. “…violent aggressive behavioral difficulties such as attacking teachers with knives and scissors. ” Byers & Lord, Am J Dis Child. 1943 Dr. Randolph Byers

Lead Levels and Aggression, Delinquency and Attention Issues

Delinquency and Bone Lead Levels of Adjudicated Teens Subjects __ African-American White Cases Controls P-value 9. 0 1. 5 0. 05 20. 0 3. 5 0. 008 Needleman HL. Neurotox Teratol. 2002; 24: 711.

Conduct Disorders and Blood Lead Levels Adjusted Odds Ratio Risk of Conduct Disorder by Blood Lead Level in US Children, 8 to 15 years, NHANES 2001 -2004 Quartiles of Blood Lead Concentration (µg/d. L) Braun JM. Environ Health Perspect. 2008; 116: 956– 962

Number of Convictions by Dentine Lead Level Fergusson DM. J Epidemiol Community Health 2008; 62: 1045– 1050

The Cincinnati Lead Study • Prospective, longitudinal study initiated in 1979 is examining the effects of childhood lead exposure on growth and development with a particular emphasis on central nervous system outcomes. • Data collected on exposure (blood lead levels), neurobehavior, child health, environment, and sociodemographic variables on a quarterly to yearly basis since its inception.

Association of Blood Lead Levels and Delinquent Behaviors in Adolescents Dietrich KN. Neurotox Teratol 2001; 23; 511 -518.

Number of Criminal Arrests by Blood Lead Levels and Sex 8 Average number of Arrests 7 Females 6 Males 5 4 3 2 1 0 <5 5 to 7 7 to 10 > 10 Blood Lead Level (mcg/d. L) at Age 6 Years Wright JP. PLo. S Medicine 2008; 5: e 101

Lead-Associated Grey Matter Loss in the Adult Brain Cecil K, PLo. S Medicine. 2008; 5: e 112.

Lead-Associated Grey Matter Loss in the Adult Brain Average Childhood Blood Lead Six-Year Blood Lead Cecil K, PLo. S Medicine. 2008; 5: e 112.

Lead, IQ and Anti-Social Behavior Canfield R. NEJM 2003; 348: 1517

U. S. Air Lead Concentrations and Murder Rates 21 Years Later Nevin R. Env Research 2000; 83: 1 -22

Air Lead Concentrations and Aggravated Assault Rates

A Recent Magazine Feature Article America’s Real Criminal Element: Lead Mother Jones Magazine Jan/Feb 2013 Issue

Identifying Children with Lead Poisoning Why test children for lead? Is doing risk assessment sufficient? Since there is no effective treatment for lead poisoning, why bother testing children?

Blood Lead Testing Rates for 2 Year Olds Lag Rates for 1 Year Olds Monroe County Data Birth Year 9 -<18 Months Old Tested, % 18 -<36 Months Olds Tested, % % Tested 2 x by 36 Months 2003 66. 3 43. 3 32. 6 2004 69. 1 51. 7 39. 3 2005 72. 6 52. 8 42. 6 Source: NYSDOH

Community Action Can Increase Awareness About Testing for Lead

Prevention vs. Treatment

What Did the CDC’s Childhood Lead Poisoning Prevention Advisory Committee Do in 2012?

National Trends in Blood Lead Levels CDC replaces use of the term “Lead Level of Concern” with the new term “Reference Level” which is the cut-off below which 97. 5% of children’s lead levels fall. Percent of Children with Lead Levels: > 5 mcg/d. L > 10 mcg/d. L 1988 -1991 31. 4% 8. 6% 1991 -1994 20. 9% 4. 4% 1999 -2004 7. 4% 1. 4% 2010 2. 5% 0. 6%

New Areas of Emphasis Recommended §Primary prevention §Education of medical providers so that they can educate families §Encouragement of home inspections for at-risk children prior to determining that children have blood lead levels §Close follow-up of children with blood lead levels > 5 mcg/d. L and communication of blood lead testing results to parents §Data sharing between health and housing authorities §Financing for lead hazard control §Inspections for all residential units in a property when a lead hazard is found in any unit of the property

One Major Impediment to Implementation of the Recommendations

Another Major Impediment to Implementation of the New CDC Recommendations

Rochester As a National Model for Collaboration to End Childhood Lead Poisoning

What’s Needed Going Forward To successfully eradicate lead poisoning there needs to be a community focus: § Government § Housing authorities § Medical providers and insurers § Educators § Media § Community leaders Local successes: § Rochester’s lead law § MCDPH environmental inspections for children with BLLs as low as 5 mcg/d. L

Services Provided by the WNY Lead Poisoning Resource Center § Telephone consultations for providers § Chelation for children with BLLs > 45 mcg/d. L § Consultations for families § Collaboration with county health departments and NYSDOH § Information clearinghouse § Site visits to practices to improve lead testing efforts § Staff in-services for medical practices § Presentations to community groups

The Message That We Want to Send