Stanley J Schaffer MD MS James R Campbell MD MPH WNY Lead Poisoning Resource Center Department of Pediatrics University of Rochester Disclosures Stanley Schaffer MD and James Campbell MD have no conflicts of interest to disclose ID: 999348
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1. Lead Poisoning in 2013:It Ain’t What It Used to BeStanley J. Schaffer, M.D., M.S.James R. Campbell, M.D., M.P.H.WNY Lead Poisoning Resource CenterDepartment of PediatricsUniversity of Rochester
2. DisclosuresStanley Schaffer, M.D. and James Campbell, M.D. have no conflicts of interest to disclose.
3. What Have We Known For a Long Time About Lead Poisoning? “Lead makes the mind give way.” -- Dioscerides – 2nd Century B.C.
4. Lead Paint As a Source of the Problem
5. Deteriorating Painted Surfaces – A Common Source of Lead
6. It Wasn’t Only Paint Though:Ethyl Isn’t Just a Woman’s NameTetra-ethyl Lead: “A colorless liquid of sweetish odor, very poisonous if absorbed through the skin, resulting in lead poisoning almost immediately.” -- Pierre duPont, (Chairman of DuPont Chemical Company and General Motors), 1922
7. The Effect of Removing Lead From GasolineChange in Blood Lead Levels in Relation to a Decline in Use of Leaded Gasoline in the U.S., 1976-1980Total Lead Used in Gasoline Per 6 Month Period (in 1000 tons)Average Blood Lead Levels (ug/dl)
8. Sources of Lead Past and PresentSources Frequently Encountered in the Past:PaintAirSoilSources Seen with Increased Frequency Now:DustImported CosmeticsImported Foods & SpicesCeramic PotteryLead-Containing Toys
9. Sources of Lead We Have Encountered
10. Sources of Lead – It’s Not Always Obvious
11. Our Knowledge About the Adverse Effects of Lead Has Come a Long WayBlood Lead Level in mcg/dLBlood Lead Cut-offs As Determined by the CDC
12. Which Children Are Most At-Risk for Lead Poisoning?
13. 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.
14. What Kind of Harm Does Lead Cause in Children?Irreversible IQ deficitsElevated hearing thresholds and associated auditory processing problemsProblems with attention and impulsivityPoor control of emotions; increased likelihood of aggressive behavior and conduct problemsSignificantly increased likelihood of delinquency and incarceration
15. The Rochester Lead Study
16. The Effects of Low-Level Lead Exposure on IQ in Young ChildrenFrom Canfield RL, et al. NEJM. 2003;348:1517-1526
17. Gender-Specific Effects of Lead on Executive Functioning(Learning How to Solve a Puzzle)Froehlich, et al., Biological Psychiatry, 2007;62:243-249.
18. Nevin R. Trends in preschool lead exposure, mental retardation and scholastic achievement: association or causation. Env. Research. 2009Lead Exposure and SAT Scores
19. Which Children Exposed to Lead Have the Greatest IQ Deficits?Hornung RW, et al. Environmental Health Perspectives, 2009; 117:1309-1312.
20. Lead and ADHDInattentionHyperkinesisImpulsivityLead?Lead?Lead?
21. Neurobiological Mechanisms: The Mesocorticolimbic Dopamine (DA) System as a Target of LeadMesocorticolimbic system:Learning, executive function, attention, reward, addictionNigrostriatal system:Motor function, Parkinson’s disease
22. Brain Function Later in Life After Lead ExposureFunctional MRIs showing areas of brain function after tasks requiring impulse control were given to adultsBrain of an adult who was exposed to lead as a childBrain of an adult who was not exposed to lead as a childCecil K. PLOS Medicine,2008;5:e112Cecil K, PLoS Medicine. 2008;5:e112.
23. Does Lead Poisoning Cause Antisocial Behavior?Does lead poisoning cause antisocial behavior?
24. Lead Poisoning and Juvenile Delinquency:Earlier ObservationsByers and Lord reported a high prevalence of behavior problems among survivors of lead encephalopathy.“…violent aggressive behavioral difficulties such asattacking teachers with knives and scissors.”Byers & Lord, Am J Dis Child. 1943Dr. Randolph Byers
25. Lead Levels and Aggression, Delinquency and Attention Issues
26. Delinquency and Bone Lead LevelsBone Lead Levels of Adjudicated TeensSubjects __ Cases Controls P-valueAfrican-American 9.0 1.5 0.05White 20.0 3.5 0.008Needleman HL. Neurotox Teratol. 2002;24:711.
27. Conduct Disorders and Blood Lead LevelsRisk of Conduct Disorder by Blood Lead Level in US Children, 8 to 15 years, NHANES 2001-2004 Quartiles of Blood Lead Concentration (µg/dL) Adjusted Odds RatioBraun JM. Environ Health Perspect. 2008;116:956–962
28. Number of Convictions by Dentine Lead LevelFergusson DM. J Epidemiol Community Health 2008;62:1045–1050
29. The Cincinnati Lead StudyProspective, 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.
30. Association of Blood Lead Levels and Delinquent Behaviors in AdolescentsDietrich KN. Neurotox Teratol 2001;23; 511-518.
31. Number of Criminal Arrests by Blood Lead Levels and SexBlood Lead Level (mcg/dL) at Age 6 YearsWright JP. PLoS Medicine 2008;5:e101 Average number of Arrests
32. Lead-Associated Grey Matter Loss in the Adult BrainCecil K, PLoS Medicine. 2008;5:e112.
33. Lead-Associated Grey Matter Loss in the Adult BrainCecil K, PLoS Medicine. 2008;5:e112.Average Childhood Blood Lead Six-Year Blood Lead
34. Lead, IQ and Anti-Social BehaviorCanfield R. NEJM 2003;348:1517
35. U.S. Air Lead Concentrations and Murder Rates21 Years LaterNevin R. Env Research 2000; 83:1-22
36. Air Lead Concentrations and Aggravated Assault Rates
37. A Recent Magazine Feature ArticleAmerica’s Real Criminal Element: LeadMother Jones Magazine Jan/Feb 2013 Issue
38. Identifying Children with Lead PoisoningWhy test children for lead?Is doing risk assessment sufficient?Since there is no effective treatment for lead poisoning, why bother testing children?
39. Blood Lead Testing Rates for 2 Year Olds Lag Rates for 1 Year OldsBirth Year9-<18 Months Old Tested, %18-<36 Months Olds Tested, %% Tested 2x by 36 Months200366.343.332.6200469.151.739.3200572.652.842.6Monroe County DataSource: NYSDOH
40. Community Action Can Increase Awareness About Testing for Lead
41. Prevention vs. Treatment
42. What Did the CDC’s Childhood Lead Poisoning Prevention Advisory Committee Do in 2012?
43. National Trends in Blood Lead LevelsCDC 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:> 5mcg/dL> 10mcg/dL1988-199131.4%8.6%1991-199420.9%4.4%1999-2004 7.4%1.4%2010 2.5%0.6%
44. New Areas of Emphasis Recommended Primary preventionEducation of medical providers so that they can educate familiesEncouragement of home inspections for at-risk children prior to determining that children have blood lead levelsClose follow-up of children with blood lead levels > 5mcg/dL and communication of blood lead testing results to parentsData sharing between health and housing authoritiesFinancing for lead hazard controlInspections for all residential units in a property when a lead hazard is found in any unit of the property
45. One Major Impediment to Implementation of the Recommendations
46. Another Major Impediment to Implementation of the New CDC Recommendations
47. Rochester As a National Model for Collaboration to End Childhood Lead Poisoning
48. What’s Needed Going ForwardTo successfully eradicate lead poisoning there needs to be a community focus:GovernmentHousing authoritiesMedical providers and insurersEducatorsMediaCommunity leadersLocal successes:Rochester’s lead lawMCDPH environmental inspections for children with BLLs as low as 5 mcg/dL
49. Services Provided by the WNY Lead Poisoning Resource CenterTelephone consultations for providersChelation for children with BLLs > 45 mcg/dLConsultations for familiesCollaboration with county health departments and NYSDOHInformation clearinghouseSite visits to practices to improve lead testing effortsStaff in-services for medical practicesPresentations to community groups
50. The Message That We Want to Send