l ead s ources from amulets to zaprana lead poisoning in children and pregnant women in 2013: a...

Lead Poisoning in Children and Pregnant Women in 2013: A Persistent Public Health ProblemNovember 1, 2013

Paromita Hore, PhD, MPHRisk Assessment CoordinatorBureau of Environmental Disease PreventionNYC Department of Health and Mental Hygiene

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

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.

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)

Identification of Hazardous Consumer Products•Investigations of lead-poisoned individuals•Poison Control Center reports•National alerts•Reports from other jurisdictions•Media reports•Published literature

Identification of Hazardous Consumer Products•Investigations of lead-poisoned individuals•Poison Control Center reports•National alerts•Reports from other jurisdictions•Media reports•Published literature

Embargo and Enforcement•Stop sale or distribution of products •Seize and remove products•Order disposal of products•Notify other agencies when applicable

Embargo and Enforcement•Stop sale or distribution of products •Seize and remove products•Order disposal of products•Notify other agencies when applicable

Public Awareness Activities•Notify consumers and general public, businesses, health care providers, community-based organizations

₋ Press releases₋ Brochures₋ Fact sheets₋ Health advisories

Public Awareness Activities•Notify consumers and general public, businesses, health care providers, community-based organizations

₋ Press releases₋ Brochures₋ Fact sheets₋ Health advisories

Determination of Product Availability in NYC•Check product availability in NYC stores•Target neighborhoods based on product users•Laboratory testing (when necessary)

Determination of Product Availability in NYC•Check product availability in NYC stores•Target neighborhoods based on product users•Laboratory testing (when necessary)

Intervention Model for Contaminated Consumer Products

Products From Products From MexicoMexico

Ceramics Associated with Child Poisonings

Ceramic cupFrom EcuadorUsed for drinking69,000 ppmBLL 20 µg/dL

Clay cup From MexicoUsed as toy23,000 ppmBLL 16 µg/dL

Clay panFrom MexicoUsed as toy26,000 ppmBLL 36 µg/dL

Clay cupFrom MexicoUsed as toy25,000 ppmBLL 36µg/dL

Ceramic cupFrom MexicoUsed as toy860 ppmBLL 36 µg/dL

Clay cupFrom MexicoUsed as toy50,000 ppmBLL 16 ug/dL

Ceramic cupFrom MexicoUsed to drink water or milk6.2 µg/mLBLL 20 µg/dL

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

Herbs

Pregnant Female BLL 18 µg/dL Obtained in Mexico 1600 ppm lead in

herbs 29 ppm lead in

solution

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)

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

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

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

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.

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, eggshellsSource: Thihalolipavan, S. et. al., Examining Pica in NYC Pregnant Women with Elevated Blood Lead Levels

Products FromProducts FromSouth AsiaSouth Asia

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 pregnant female

• BLL = 24 µg/dL BLL

• 47,000 ppm lead• Obtained in India• Eczema

• Adult male• BLL = 192 µg/dL

BLL• ~89,000 ppm lead• Obtained in India• Diabetes


BLL• ~47,000 ppm

lead• 4,800 ppm

mercury• 4,300 ppm

arsenic• Prescribed &

obtained in NYC• Rheumatic pain

• 29 ppm lead• 31,000 ppm

mercury

• 9,400 ppm lead• 70,000 ppm mercury• 1,700 ppm arsenic


• Obtained in India for diabetes & weakness

Contaminated Supplements Made in IndiaPregnant Women Case Investigations (2011-2012)

• Adult pregnant female • BLL = 64 µg/dL• Purchased & prescribed

in India• Pregnancy-related

nausea & vomiting• 12,000 ppm lead

• Adult pregnant female • BLL = 16 µg/dL

• Purchased products in NYC for skin problems

• 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

Contaminated Supplements Made in India (2012)

• Adult pregnant female • BLL = 51 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


• 180 ppm lead• 120 ppm



• 120 ppm lead• 52,000 ppm

arsenic

• Improve skin complexion

• 7 ppm lead• 29,000 ppm


CDC MMWR/ August 24, 2012/ Vol. 61/ No. 33

• Adult pregnant female

• BLL = 24 µg/dL• Purchased and prescribed in India

• “Having a male baby”

• 15,000 ppm lead• 4,400 ppm mercury• 81 ppm arsenic

Supplements Made in India (2012)Child Case Investigations

• “Probal Pishti”• Using for

pervasive developmental delay

• 1x/week• 17,000 ppm lead• Purchased in

India

• 2 ½ yr old• BLL 42 µg/dL

• 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

• Swarna Malini Vasant

• Overall well-being

• As needed• 32,000 ppm

mercury• 1,300 ppm

arsenic• 31,000 ppm lead• Purchased in

India

• 4 yr old • BLL 16

µg/dL

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

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

Products FromGeorgia

Spices from Georgia

Not the state…… ….but the country

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

• Unknown spice• 18,000 ppm lead• BLL 19 µg/dL

• Zaprana (saffron)• 27,000 ppm lead• BLL 15 µg/dL

• Suneli• 14,000 ppm lead• BLL 24 µg/dL

Products From China

Supplements Made in China (2006)Adult Case Investigation

5,900 ppm lead5,100 ppm

mercuryPromote healthy liver & maintain

regularity24 pills/day

5,100 ppm lead3,200 ppm mercuryNatural balance24 pills/day

Adult male BLL 27 µg/dL Prescribed and purchased in NYC

Product From The United States

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

Cross Cultural Products

Cosmetics

Jewelry, Charms, Amulets

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)

Cosmetics - Kohl, Kajal, Surma

Hashmi Surma Special

468,708 ppm leadMade in Pakistan

“Pure Kohl from the Waters of ZamZam”362,419 ppm lead

Manufacturer info not listed

Hashmi Kohl Aswad272,353 ppm leadMade in Pakistan

Hashmi Kajal41,298 ppm leadMade in Pakistan

Cosmetics - Tiro

82.6 % PbCDC MMWR/ August 3, 2012/ Vol. 61/

No. 30

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

0

5

10

15

20

25

Le

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Test Dates

CDC MMWR/ January 28, 2011/ Vol. 60/ No. 3

Tabeez:1 year old childBLL 19 µg/dLUsed to stop child from cryingFrom BangladeshContained 580,000 ppm lead

Charms from Bangladesh

Sheesha:4 year old childBLL 26 µg/dLUsed for speech therapyGrandparents sent from BangladeshContained 880,000 ppm lead

Jewelry from the United States

500,000 ppm lead 330,000 ppm lead

870,000 ppm lead

530,000 ppm lead

• 2 year old child• BLL 43 µg/dL

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

Products From D.R.Products From D.R.

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

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

McKelvey et al.

Products From Products From EcuadorEcuador

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

Risk Communication

Know your population

Identify potential risk factors

Develop health risk messages

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)

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

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

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

Educational Materials

Also available in Arabic, Bengali, Chinese, French, Hindi, Spanish, and Urdu

Special thanks to staff from: Bureau of Environmental Disease Prevention

Lead Poisoning Prevention ProgramEnvironmental and Occupational Disease

EpidemiologyBureau of Environmental Surveillance & Policy

Poison Control Center

Contact Info:E: [email protected]

l ead s ources from amulets to zaprana lead poisoning in children and pregnant women in 2013: a...

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