1. Environment & Health: Lead investigations
Dr Merav Kliner,
Consultant in communicable Disease Control
Greater Manchester Public Health England

2. History of lead toxicity
Nicander of Colophon, 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

3. 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

4. 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

5. Source Receptor Pathway
Inhalation
Ingestion
Touch
Lead investigations

6. 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

7. Sources of lead
Lead investigations

8. 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

9. Social determinants of health
Lead investigations

10. 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

11. 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 Jul;113(7):894-9.
Lead investigations

12. Significance of 5 point IQ reduction
Lead investigations

13. Other possible impact of lead…
Mean blood lead levels and murder rate United States,
Lead investigations

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

15. INTEGRATED HEALTH PROTECTION RESPONSE
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

16. Case study

17. 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

18. 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

19. 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

20. 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

21. EHO assessment
Lead investigations

22. 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

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

24. Management Treatment of anaemia House was refurbished
Quarterly blood tests:
22/07/ umol/L
01/11/ umol/L
21/01/ umol/L
28/04/ umol/L
1/9/ umol/L
Lead investigations

25. 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

26. 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

27. 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

28. 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

29. 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