Environment & Health: Lead investigations Dr Merav Kliner, Consultant in communicable Disease Control Greater Manchester Public Health England Merav.kliner@phe.gov.uk

History of lead toxicity Nicander of Colophon, 185-135 BC Greek botanist, poet, grammarian 1st described acute lead poisoning Vitruvius, born 80–70 BC, died after 15 BC Julius Caesar’s engineer “Water is much more wholesome from earthenware pipes than from lead pipes. For it seems to be made injurious by lead, because white lead is produced by it, and this is said to be harmful to the human body” The first clear descriptions of lead toxicity dated back to the second century BC, when the Hellenistic physician Nicander of Colophon identified the acute effects associated with high-dose exposure (paralysis and saturnine colic). Lead investigations

Atmospheric lead deposition over time *based on lead analyses of sediment sequences from a large number of lakes and peat from several ombrothrophic bogs. A = first indications of pollution lead, B = Greek–Roman period, C = medieval time, D = Black Death, E = discovery of America, F = Industrial Revolution, G = 1970's peak in lead pollution Lead investigations

Presentation of environmental issues Cancer Birth defects Deaths Unexplained illness Developmental issues Arsenic Lead VOCs Chlorine Radiation Exposure Syndrome Hazard How do environmental issues in particular lead present? VOC = Volatile organic compound Known exposure e.g. in water A hazard with possible exposure which may require further investigation Syndromes – lots of cancer, birth defects etc that may require PH or clinicians to investigate possible cause Leaks, spills & fires Contaminated land Air pollution Lead investigations

Source Receptor Pathway Inhalation Ingestion Touch Lead investigations

Sources of lead Inorganic - Old paint, soil, dust and various consumer products. Lead acetate – tastes sweet white lead (lead carbonate), yellow lead (lead chromate, lead monoxide) , Red lead (lead tetraoxide. Organic - Tetra-ethyl lead (petrol 1930s-1970s) Still in 9 countries Absorbed through the skin Highly neurotoxic Afghanistan Algeria Bosnia-Herzegovina Iraq Montenegro Myanmar North Korea Serbia Yemen Lead investigations

Sources of lead Lead investigations

Source Receptor Pathway in children More susceptible to impact Pregnancy Consuming things they shouldn’t More susceptible to impact – body weight – have to eat/drink/breathe less before it is a problem More time to develop disease Nutritional deficiency can increase chance they will eat things they shouldn’t Not responsible for own environment – often occurs in children from lower socio-economic backgrounds Socioeconomic factors important predictors of exposure Lead investigations

Social determinants of health Lead investigations

Health effects from lead exposure (children) µmol/L µg/dL 7.2 4.8 1.9 0.96 0.48 “When exposure to lead is widespread, low level toxicity can damage health, reduce intelligence, damage economies, incapacitate the future leadership & security of entire countries.” Lead investigations

Impact of lead on IQ *adjusted for maternal education, maternal IQ, and birth weight Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, Canfield RL, Dietrich KN, Bornschein R, Greene T, Rothenberg SJ, Needleman HL, Schnaas L, Wasserman G, Graziano J, Roberts R. Low-level environmental lead exposure and children's intellectual function: an international pooled analysis. Environ Health Perspect. 2005 Jul;113(7):894-9. Lead investigations

Significance of 5 point IQ reduction http://www.psr.org/assets/pdfs/psr-coal-fullreport.pdf Lead investigations

Other possible impact of lead… Mean blood lead levels and murder rate United States, 1978-2006 Lead investigations

Our role Source Receptor Pathway Environmental Health Scientists Public Health Source Receptor Pathway Environmental Scientists Health Lead investigations

INTEGRATED HEALTH PROTECTION RESPONSE http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947331304 Reid et al. Chemical Hazards and Poisons Report, May 2005; 4: 33-35 From Risk to Response SITUATION ANALYSIS e.g. Statutory procedures already underway Local environment Local epidemiology Local investigations being undertaken National pictures Litigation RISK MODEL Hazard analysis Exposure analysis Risk assessment Risk communication STAKEHOLDER POSITION Engagement with Community & Staff Local Authority Councillors & MPs Environment Agency Clinicians Health agencies HSE INTEGRATED HEALTH PROTECTION RESPONSE Lead investigations

Case study

Presentation 5 year old child Medical history Severe autism and developmental delay Long term history of constipation which has been resistant to treatment Social history Lives with mum, and sibling (well, developing well) Dr reports was living in run down old terrace house Food history Very picky eater History of pica - in particular eats paints Lead investigations

Presentation Consultant decides to test for lead in addition to other blood tests - Blood lead levels: 1.05 umol/L - Anaemia 5 year old child Medical history Severe autism and developmental delay Long term history of constipation which has been resistant to treatment Social history Lives with mum, and sibling (well, developing well) Dr reports was living in run down old terrace house Food history Very picky eater History of pica - eats paint and bits of plaster and soil Lead investigations

Health effects from lead exposure (children) µmol/L µg/dL 7.2 4.8 1.9 0.96 0.48 Blood lead levels: 1.05 umol/L Lead investigations

EHO assessment Questionnaire completed Visit to properties Mum works part time in DIY shop, but doesn’t have contact with lead pain No hobbies that may expose to lead Old terraced house, built before 1970 Large amount of social housing stock in the area Built on farmland, not land that was previously used for industry or waste Visit to properties Home has clear areas where child has picked walls Nursery is in a new building, and built after 1970 All toys bought from reputable companies Lead investigations

EHO assessment Lead investigations

United Utility assessment Sampling from property Flushed main and resampled Both samples <0.29umol/L (i.e. level of detection) Excavation of pipe no lead present on the customer’s side or that of United Utilities Lead investigations

Health assessment Discussed with toxicologist regarding lead levels No chelation required at this level Mum and brother had normal lead levels Lead investigations

Management Treatment of anaemia House was refurbished Quarterly blood tests: 22/07/13 1.05umol/L 01/11/13 1.03umol/L 21/01/13 1.04umol/L 28/04/14 0.69umol/L 1/9/14 0.34 umol/L Lead investigations

Summary of management Social setting Poor quality housing, requirement for refurbishment Single mother, complex health needs Likely source Thought to be from paint/plaster – although could not test (££) Garden excluded as previous use was farmland Management Remove source (redecorate) Remove pathway (treat anaemia) Remove receptor (advise to move house if 1st two don’t work) Lead investigations

Approach to management Multi-agency approach Health (primary care and secondary care) Environmental health Water company Public Health ?social services Local authority (housing standards) Lead investigations

Local tools – EHO questionnaire Household contacts Home School attendance Occupational status Possible exposures to lead (food, toys, hobbies, non-food items) Visits away from the home Previous testing for lead Lead investigations

Local tools – clinician questionnaire About the case Lead levels Medical history Eating habits Household contacts Social circumstances Also provided local training to clinicians to raise awareness of testing Lead investigations

Summary Can significantly impact health Likely underdiagnosed Complex multi-agency investigations Source is often not found Implication for child and family can be high Lead investigations