A Grand Rounds Presentation for Primary Care Providers Lead ead an - - PowerPoint PPT Presentation

A Grand Rounds Presentation for Primary Care Providers Lead ead an and A Arsen enic E Exposure e Near ear the F e Former er C Colorad ado Smel elter er in n Pueb eblo, C Colorad ado

Lourdes (“Luly”) Rosales-Guevara, M.D. Senior Medical Officer, ATSDR

Agency for Toxic Substances and Disease Registry Division of Community Health Investigations

Agen ency for Toxic Substan ances es an and Diseas ease e Reg egistry (ATSDR) R)

What i is A ATSD SDR? R?

 A fed

eder eral al p public heal ealth ag agen ency

 Bas

ased ed in Atlan anta, a, G Geo eorgia

 Cha

harge ged w with h

• Assessing the presence of environmental health hazards in

communities

• Preventing harmful exposures to contaminants
• Increasing the knowledge about the health effects from chemical

and radiation exposure

Presentation O n Out utline ne

• Lear

earning G Goal als

• Chi

hildren a n and nd Environm nmental Exposur ure

• Lead

ead

• Arse

senic

• ATSDR’s Colorad

ado Smel elter er E Exposure I e Inves estigation

• Quest

stions s

Lear earning G Goal als

Recogni gnize a and nd und understand nd:

1.

• 1. Why children

en ar are m e more e vulner erab able? e? 2.

• 2. CDC’s r

ref efer eren ence e level el for l lead ead 3.

• 3. Sources

es o

• f l

lead ead an and ar arsen enic exposure 4.

• 4. The h

e heal ealth ef effec ects from exposure e to lead ead an and ar arsen enic 5.

• 5. Met

ethods o

• f t

tes esting for l lead ead an and ar arsen enic exposure 6.

• 6. Ways to preven

ent l lead ead an and ar arsen enic exposure e 7.

• 7. The

he f find ndings ngs a and nd recommend ndations ns o

• f A

ATSDR’s Colorad ado S Smel elter er Exposure e Inves estigation (EI)

Children en ar are e at H Higher er Risk t tha han A n Adul ults for Environ

• nment

ntal Expos

• sure t

to C

• Cont
• ntaminant

nts

Children en ar are u e uniquel ely v vulner erab able e to en environmen ental al e exposures es. Child ildren are not just “lit little le adult lts.” Children en’s ag age-specif ific ic ris risk f factors rs for r exposure t to en environmen ental ally rel elated ed illnes ess ar are: e:

• Ex

Exposure

• Absor
• rption
• n
• Met

etab abolism

• Dis

istrib ibutio ion

• Tar

arget et organ an s suscep eptibilities es

Environmen ental al Heal ealth Per erspec ectives es. Sep eptem ember er 1 1995; 103(Supplem emen ent 6):7- 12

• 12. How A

Are D e Differ eren ent f from Adults? Bear earer er, C C F .

Chi hildren n are a at Highe gher Risk t tha han A n Adul ults for Environ

• nment

ntal Expos

• sure t

to C

• Cont
• ntaminant

nts

(cont

• nt…)

…)

 Chi hildren n will b be in d n different environm nments thr hrougho ughout ut t the he day, depend nding ng on a n age ge.  Pr Pre-am ambulating c children en can annot rem emove t e them emsel elves es from an an unsaf afe en e environmen ent.  Y

• ung c

ung chi hildren n ha have ag age-appr ppropr priate ha hand nd-to to-mout uth h behav avior.  The e met etab abolic r rate o e of children en is h higher er than an ad adults b bec ecau ause e

• f t

thei eir lar arger er surfac ace-to to-volu lume r ratio io.  The a amou

• unt

nt of

• f f

food

• od con
• nsumed per b

bod

• dy weight

ht is much hi highe gher in c n chi hildren n tha han n in n adul ults; t the herefore, c chi hildren n ha have hi highe gher exposur ure to i inge ngested toxins ns in f n food.

Environmen ental al Heal ealth Per erspec ectives es. Sep eptem ember er 1 1995; 103( 103(Supplement 6) 6):7-12.

• 12. How

Are C e Children en Differ eren ent from Adults? B Bear earer er, C F F .

LEA EAD

What Is t the P e Problem em?

Ov Over half lf a a m millio illion child ildren (>500,000) ag ages es 1 1 to 5 y year ears in the U e U.S. h have e blood l lead ead levels hi high gh eno nough ugh to affect the heir he health. h.

What i is s Lead

ead Poisoni ning? ng?

Is one e of t the e most s significan ant an and p preval alen ent diseas ease o e of en environmen ental al origin am among chi hildren n living ng in n the he U U.S. a and nd… It is preven entab able! e!

• MMWR. November 2,

2, 2007; 2007; 56( 56(RR08) 08):1-14; 4;16 16.

Per ersonal al Ri Risk Fa Factors for L Lead ead Exp xpos

• sure

Ri Risk f factors Prev evention s strat ategy

Gen enet etics, d does es not

• t cha

hange nge Prev event ex exposure Age o e of o

• rgan

an d devel elopmen ent Prev event ex exposure Y

• ung

ung males <6 year ears o

• f ag

age Su Supervise kids/ s/Prev event ex exposure Pica b a beh ehavior Super ervise k e kids/Discourag age b e beh ehavior Poor

• or n

nutrition

• n

Bala lanced d die iet, ric ich in in I Iron, Calc lciu ium, Vit itamin in C a and Vit itamin in E E Po Poverty-Inco come-Ratio (P (PIR) ) <1.3 Acces ess to WIC p program am /heal ealth c car are Cultural al prac actices es/ Ayurved eda/ a/spices es Avoi

• id use/Prevent

nt expos

• sure

Environ

• nment

ntal Sou

• urces f

for

• r

Lead ead Exp xpos

• sure

Environmen ental al s sources es Prev evention s strat ategy

Y ear ear h house b e built <1978 (lead ead-bas ased ed pai aint) Iden entify/Eval aluate/ e/Rem emed ediate Dust f from lead ead-ba based pa d paint chips ps Cont

• ntrol
• l s

sou

• urces

Soil c il contamin inated wit ith le lead Res estrict play ar area/ ea/cover er source Drink nking ng water Check infor

• rmation
• n from
• m water

dep epar artmen ent Home r e ren enovation Prop

• per c

cont

• ntainment

nt Worker er t tak ake-home e cont

• ntamination
• n

Shower er/Rem emove s e shoes es an and c clothes es Some h e hobbies es Proper er u use/ e/storag age/ e/ven entilation Some i e imported ed toys, cosmet etics/spices es an and c cer eram amic cookwar are Avoid use se

CDC Ref efer eren ence e Val alue e for Lead ead Gui uidanc nce

 Before 2012

2012 “ “Level el of C Concer ern”

• ≥

10 µg/ dL

• All c

ll child ildren

 2012 – to present “Reference Value”

• ≥

5 µ 5 µg/dL dL

• Children

en 1 1 to 5 5 y year ears of ag age e an and preg egnan ant women en

• The r

e ref efer eren ence e val alue e will b be u e updated ed e ever ery 4 4 y year ears as as appr ppropr priate.

• Follo

llow-up r p requ quired d

http:/ ://www.cdc.gov/nceh eh/lead ead/ACCLPP/blood_lead ead_level els.htm

What should b be t e the e blood l lead ead level el (BLL) for c children en 1 t to 5 year ears of ag age an e and for p preg egnan ant women en? No s saf afe b e blood lead ead l level el f for children en has as been een i iden entified ed.

Heal ealth E Effec ects from L Low L Level el Lead ead Exposure

Human an L Lead ead E Exposure

In g gen ener eral al, e exposure e occurs v via o a one e or m more e

• f the

he m main c n compone nents of t the he hum human n en environmen ent:

Inhal aled ed ai air Soil and d du dust o

• f vari

rious t type pes (can be ingested or inhaled) Drink nking w ng water and nd Food

• od

Heal ealth Ef Effects in A n Adul ults (inc nclud uding p ng pregna gnant women) n)

1 GFR Glo

lomerula lar filt iltratio ion rate; 2 BP Blood pressu ssure; 3 HTN H Hyper erten ension National T Tox

• xicology Program (NTP). 2012.

2012.

Blood

• od lead

ead l level el (µg/ g/dL) i in n adul ults Organ sy syst stem Suffic icie ient eviden ence o e of

At At le levels ls belo low 10µ 10µg/dL dL an and ev even at le levels ls b belo low 5µ 5µg/dL dL Ren enal al

• Dec

ecreas eased ed G GFR¹ Car ardiovas ascular ar

• Increas

eased ed B BP²

• Increas

eased ed Risk H HTNᶾ Neurol

• log
• gic
• Increas

eased ed inciden ence e of es essen ential al t trem emors

Heal ealth Effec ects in U Unborn B Bab abies es

Blood L Lead ead Level l in in Preg egnan ant w women en Affects t the he U Unb nborn n Baby’s ’s Sufficien ent Eviden ence e of Even en a at level els bel elow 5µ 5µg/dL dL Devel elopmen ent

• Reduc

uce gr growth h in t n the he unb unborn b n baby by (SGA)

• Red

educed ed p postnatal al grow

• wth

National Toxicology Program. Monograph on Health Effects of Low-level Lead. 2012. US Department of Health and Human Services. June

Heal ealth Effec ects in Children en

BL BLL in n Child ildren Organ sy syst stem Suffic icie ient eviden ence o e of

At At le levels ls bel elow 10µ 10µg/dL dL an and ev even a at le levels ls b belo low 5µ 5µg/dL dL Neurol

• log
• gic
• Dec

ecreas eased ed ac acad adem emic ac achievem emen ent

• Dec

ecreas eased ed I IQ / /spec ecific c cognitive m e meas easures es

• Increas

eased ed i inciden ence e of a atten ention-rel elated ed beh ehavior an and

• Increas

eased ed b beh ehavioral al problem em Repr produ ductive

• Del

elayed ed puber erty

Nation

• nal Toxicol
• log
• gy Prog
• gram. Mon
• nog
• graph on
• n H

Health E Effects of

• f Low-level L
• Lead. 2012.
• 2012. US

Dep epar artmen ent of H Heal ealth an and H Human an S Ser ervices

• es. June

Pea earls o

• f

Lead ad E Exposure

Women o n of C Chi hildbearing ng Age ge (17 17 – 44 y year ears)

 Over 40 % 40 % of the U U.S. pop

• pulation
• n c

con

• nsists of
• f wom
• men of
• f

chi hildbearing ng age. e.  El Eleven out ut o

• f o
• ne

ne hund hundred-thousand ( (11/ 11/100, 100,000) 000) women en o

• f c

childbear earing ag age e have e BLLs >5 µ 5 µg/dL.  In a a study conducted i in 2006, 2006, 50% 50% of pregna gnanc ncies i in n women en of c childbear earing ag age e wer ere e uni nint ntend nded ( (no not pl planned) d)  Wo Women of c child ild-bear earing ag age e should n not be e e exposed ed to lead ead.

• Contraception. N

November 2011; 2011; 84( 84(5) 5): 478 478-485.

• 485. Uni

nintend nded p pregna gnanc ncy in t n the he U.S: i inciden ence e an and d dispar arities es, 2 2006.

Risk Fac actors o

• f Lead

ead Ex Exposure for

• r

Preg egnan ant Wo Women

Recent migra gration, n, Pi Pica, Occup upationa nal e exposur ures, Nutritional status, Cultural ally spec ecific pract actices es such as as t the u e use o e of some t e trad aditional al med edicines es or i imported ed cosm smetics s The u e use o e of trad aditional al lead ead-glaz azed ed p potter ery for cook

• oking and s

stor

• ring food
• od.

Maternal Child Health J. 2013 January ; 17(1): 172–179.

Lead ead i in Bone

A w wom

• man who
• has

as h had ad increas eased ed b blood lead ead lev evels (BLLs LLs) in in t the p past (as a a c child ild) w will ill have ab about 90% 90% of

• f the l

e lead ead stor

• red in b

bon

• ne.

. Lead ead stored ed in b bone e may be be mobi bilized d du during preg egnan ancy an and l lact actation (source e of

• f

end ndoge geno nous us exposur ure), exposing ng the he f fetus us a and nd breas eastfed ed infan ants.

• MMWR. November 2,

2, 2007; 2007; 56( 56(RR08) 08):1-14, 4,16 16

Lead ead i in B Breas eastmilk

 In a l a lead ead e exposed ed mother er, lead ead in h her er b breas eastmilk c can an expose t the he nur nursing i ng inf nfant.  In a study o

• f 255 m

255 mother–infan ant pai airs, infan ant B BLL a at 1 1 mont

• nth p

pos

• st-par

artum sig ignif ific icantly ly c correla lated w wit ith le lead level els in breas eastmilk an and ac accounted ed f for 3 30% o

• f the

e variation n in n the he i inf nfant B BLLs.  Infant exposure to le lead in in b breastmilk ilk is is in in a addit itio ion t to en environmen ental al an and in in-uter ero e exposures es.  Longe nger d dur uration n of b breastfeeding ng was a s asso ssociated with hi highe gher BLLS i in t n the he i inf nfant.

Environmen ental al Heal ealth P Per erspec ectives

• es. Jan

anuar ary 2 2014; 122(1). Mater ernal al B Blood, Plas asma, a, an and B Breas east Milk Lead ead: Lac actational al Transfer and C Cont

• ntribution
• n to I
• Infant

nt Ex Exposure”

Lead ead i in B Breas eastmilk (cont…) …)

 The t e tran ansfer er of lead ead f from plasm sma to b breastmilk ilk is is sub ubstantially hi highe gher t tha han n previous usly r reported ( (0.1 ± 0. 0.1 µ 1 µg/Li Liter), an and it m may b be h e higher er at lower er l level els of plas asma l a lead ead.  The t e tran ansfer er of lead ead f from plasm sma to b breas eastmilk has as im implic licatio ions f for p polic licy decis isio ions r regardin ing c counselin ling the l e lead ead-exposed ed w woman an o

• n breas

eastfeed eeding.

Environmen ental al H Heal ealth Per erspec

• ective. January 2014

2014; ; 122( 122(1) 1). “Mater ernal al B Blood, Plas asma, a, an and B Breas east Milk Lead ead: Lac actation T Tran ansfer er and C Cont

• ntribution
• n to I
• Infant

nt Ex Exposure”

Diagno gnosis

Who hom and nd W Whe hen n to Tes est for L Lead ead?

 R ecom

• mmenda

dation

• ns f

for

• r Preventive P

P ediat atric Heal alth C Car are . T ab # 2. (Brigh ght Fut utur ures b by A American n Acad adem emy of P Ped ediatrics [AAP AAP]), 2014. 2014.  R ecom

• mmenda

dation

• ns on
• n Medical

al Man anage agement of

• f Childhood
• od Lead

ad E xpos

• sur

ure an and P

• i
• ison
• ning. T

ab # 10. (Pedia iatric ic E Envir ironmental l Heal ealth S Spec ecial alty Units [PEHSUs]/AAP/AOEC/ATSDR), 2014. 2014.  Interpr preting g an and Man anagi aging g Low Blood

• od L

Lead ad L Levels. . Tab # # 15. 15. (PEHSU S Supplem emen ental al I Information for

• r Clin

linic icia ians) . .

Blood Lead ead T Tes esting Met ethods

 Con

• nfirmator
• ry m

y method

• d
• Venous sa

s sample

Screeni ning m ng metho hods

• Cap

apillar ary, an anal alyzed ed b by trad adition

• nal labor
• rator
• ry.
• Cap

apillar ary, an anal alyzed ed by LEAD CARE II i instrumen ent;

• The

e rep eportab able e ran ange i e is from 3 3.3 to 65 µ µg/dL dL

• Clinical

al L Lab aboratory Improvem emen ent A Amen endmen ents (CLIA) w wai aived ed.

Follo llow-up BLLs ≥ 5 µg/ dL

Re Re-tes est p patien ent

At B BLLs 5 5 to 14 14 µg/dL, within 1 1 – 3 mont

• nths

At B BLLs 15 15 to 44 44 µg/dL, within 1 1 – 4 w week eeks At B BLLs LLs > > 44 µg/dL L , withi hin 4 n 48 ho hour urs

Ped ediatric Environmen ental al H Heal ealth Spec ecial alty Units (PEHSU). U Updated ed, J June e 2013. Lo Loca cated in Tab # 1 10

Prevent ntion

• n

Pr Primary Prevent ntion

• n

Sin ince n no safe b blo lood le lead le level in l in child ildren has as b been een iden entified ed, C CDC an and ATSDR rec ecommen end p primar ary p preven ention o

• f l

lead ead exposu sure w wherever possi ssible.

CD CDC' C's Advisor

• ry Com
• mmittee on
• n C

Childhood

• od Lead P

Poi

• ison
• ning Prevention, 2007.

2007.

Why Pr Primary Pr Prevention?

 Adver

erse e ef effec ects of lead ead ar are d e dan anger erous.  Adver erse e ef effec ects ar are s e system emic.  Adver erse ef e effec ects ar are p e per ersisten ent.  Che helation n does es n not r res esult i in i improved ed neu eurobeh ehavioral al o

• utcomes

es.  No d dis iscernib ible le thr hresho hold exist sts f s for ad adver erse e ef effec ects.  Prevent ntion

• n is

s cost st-ben enef eficial al.

http ttp://www.cdc.go gov/nc nceh/ h/lead/pub ublications ns/PrimaryPreventionD nDocu men ent.pdf

Dec ecline e in C Children en’s B Blood L Lead ead L Lev evel els d due e to

• Regul

gulations ns

2 4 6 8 10 12 14 16 18 20 Blood Lead ead L Level els ( (µg/dL)

Lead-Based Paint Poisoning Prevention Act Begin phase-

• ut of leaded

gasoline Residential lead paint ban (1978) Lead-Based Paint Hazard Reduction Act (1992) Ban on lead in plumbing (1986) Ban on lead solder in canned foods (1995)

Bruce Lanphear. 2008. PowerPoint presentation: The CDC Should Lower the Level of Concern to Protect Children from Lead Toxicity .

Preven enting L Lead ead E Exposure

Primar ary c car are e provide ders rs:

 Tes est c children en for l lead ead b bas ased ed on risk f fac actors an and t the e state o e of C Colorad ado Lead ead Screeni ning ng Rec ecommen endations,. (Tab # # 13) 13).

https://www.colorad ado.gov/pac acific/sites es/def efau ault/files es/DC_Env_Exposure_ e_Le ad ad_Colorad ado-Lead ead-Screen eening-Guide delines.pdf pdf

 Mak ake e P edia iatric ic E xpos

• sur

ure History ( (T ab # # 6) 6) part of

• f y

you

• ur

patie ient’s m medic ical l his istory.  Recommend nd freque uent nut nutritious us m meals rich i h in c n calcium um, iron, , zin inc, v vit itamin in C, C, a and vitam amin E E t to p preven ent ab absorption o

• f l

lead ead.  Sta tay c current t ab about s sources es of l lead ead i in y your ar area ea that may poten ential ally af affec ect y your patien ents.

Preven enting L Lead ead E Exposure ac according t to B Bruce e Lan anphear ear M.D.

 Elim limin inate all n ll non-es essen ential al u uses es o

• f lead

ead w worldwide an e and strengt ngthe hen n regul gulations ns t to c control lead e emissions ns.  Screen een h housing u units for l lead ead haz azar ards bef efore e purchas ase e

• r occupan

ancy an and af after er r ren enovation an and ab abatem emen ent.  Lower er ref efer eren ence l e level el to <1µg/dL as as a p a public h heal ealth goal al--

• -not as a

a c clin linic ical l “actio ion le level. l.”  Begi gin n environm nmental interventions ns i in hi n high gh-risk sk communi unities.

• Pres

esen entation Summar ary : : The C e CDC S Should Lower er the L e Level el of C Concer ern to Protec ect Children en f from Lead ead Toxicity B Bruce e P . Lan anphear ear, MD, M MPH C Cinc ncinna nnati Children en’s H Hospital al Med edical al Cen enter er

Diets s Ric ich in in C Calc lciu ium Preven ent I Increas eased ed BLLs

Cal alcium d dec ecreas eases es t the m e mobilization of bone l e lead ead to blo lood, especia ially lly d durin ring hig igh metabolic lic a activ ivit ity of the he b bone ne s suc uch h as in

Pregna gnanc ncy Lactati tion Chi hildho hood gr growth h and nd d development Men enopau ause

Calc lciu ium s supple lementatio ion m may pla lay a a role le in in

 Dec ecreas easing intes estinal al lead ead ab absorption  Inc ncreasing ng lead e excretion f n from t the he c circul ulation n and nd  Red educing bone r e reab eabsorption.

National T

• xicology Program. Monograph on Health E

ffects of Low-level Lead.

• 2012. US

Department of Health and Human Services. June

Cal alcium an and Lead ead dur uring ng Pregna gnanc ncy

Dur uring ng pregna gnanc ncy, the he fetus us ne needs 100 100-140 140 mg/ g/kg/ kg/day accr ccretion o

• f ca

calci cium for

• r skel

elet etal al for

• rmation
• n and gr

growth. h. Preg egnan ant an and l lact actating women en req equire ab e about 1, 1,200 200-1,500 mg/ g/day of c calcium um, d depend nding ng on n thei eir ag age. Lead ead compet etes es with cal alcium absorption; n; t thus hus, intak ake o e of a c a cal alcium-rich diet et hel elps dec ecreas ease e lead a d abs bsorpt rption.

• Pediatrics. O

October 1, 1, 2005; 2005; 116( 116(4) 4):1036 1036 -1046 1046

Nutrit itio ional D l Defic icie iencie ies that Increas ease L e Lead ead Absorption

 Most lead up uptake o

• ccur

urs thr hrough ugh the he ga gastrointestina nal tract. .  Increas eased ed ab absorption occurs w with diet etar ary def eficien ency of

• f
• Calc

lciu ium

• Ir

Iron

• Vit

itamin in C C

• Zi

Zinc  The ab e absorption of i inges ested ed lead ead ran anges es from 20 20% % – 70% 70% unless ss a good nutrit itio ional d l die iet is is in in place ce. Brit

itis ish Journal of Nutrition. 2001; 2001; 85( 85(Suppl. 2) 2):S181 181- S185 185

Arse senic

Forms o s of A Arse senic

 Orga gani nic

• No

Non-tox

• xic
• Exposure

e is m mai ainly from fish an and s seaf eafood

 Ino norga gani nic

• Very t

toxi xic

• Mainl

nly f from gr ground und w water and nd d dietary produc ucts s suc uch h as as rice ( e (es espec ecial ally b brown rice) e) an and ap apple e juice.

• Carcino

noge geni nic, affecting a ng almost e every orga gan i n in t n the he body y (skin, lungs, s stomac ach, liver er, b blad adder er an and car ardio- vas ascular ar)

• Asso

ssociated w with diab abet etes es mellitus: > 150µ > 150µg/L a arsenic in d n drink nking ng water.

Arse senic E Exposu sure

Sou

• urces of
• f

Ino norga gani nic Arseni nic Ex Exposure

 Some e foods (e.g. , , ap apple e juice an e and rice) e)  Water er ( (e.g., ar arsen enic i is n natural ally-occur urring ng in n groundwater er i in man any ar areas eas of t the e U.S. )  Soil; arseni nic compound unds can a n accum umul ulate i in s n soil bec ecau ause e they ar are e not b biodeg egrad adab able.  Ai Air

Heal ealth E Effec ects

Arsen enic af affec ects man any b biologic sy syst stems, somet etimes es year ears or dec ecad ades es af after er exposure e reduc uctions ns.

Nau aujokas as M MF , Ander erson B B, A Ahsan an H, et et al

• al. The B

e Broad ad Scope o e of Heal ealth E Effec ects from Chronic A Arsen enic Expo posure: U Upda pdate on Worldw dwide de Publ blic Health P Probl blem. Environmental Health P

• Perspectives. March 2013;

2013; 121( 121(3) 3).

Arse senic Heal ealth Effect cts

No Non-Can ancer er H Heal ealth Effect ects:

• The chemical form of arsenic (organic, versus inorganic)
• E

xposure route,

• Duration (acute versus chronic exposure)
• Dose and
• The health of the person at the time of exposure

Can ancer er:

• S

kin, (synergistic action with sunlight for causing skin cancer??)

• Lung (smoking may increase the risk for mortality from lung cancer)
• Bladder

Arsen enic H Heal ealth Effec ects i in Preg egnan ant W Women en/Fet etus an and Children en

In n Pregna gnant Women/ n/Fetus us at v very hi high l gh levels:

• Increas

eased ed spontan aneo eous ab abortions, & stillbirths In n Chi hildren n at very hi high gh levels:

• Increas

eased ed i infan ant mortal ality an and al alter ered ed;

• developing

ng immune une system in n ne newborn

• mot
• tor
• r func

unction n

• ver

erbal al and nd ful ull-scal ale I e IQ in gir irls ls

• ne

neur urologi gical im impair irments in in child ildren

Nau aujokas as MF , Ander erson B, Ahsan an H, H, et et al

• al. The

e Broad ad Scope e of Heal Health Effec ects from Chronic Arsen enic E Exposure: e: U Update e on Worldwide e Public Heal Health P Problem em. Environmen ental al Health P

• Perspectives. March 2013;

2013; 121( 121(3) 3).

Prevent ntion

• n

Preventing A ng Arseni nic E Exposur ure

Primar ary c car are e provide ders rs:

 Mak ake e P edia iatric ic E xpos

• sur

ure History ( (T ab # # 6) 6) part of

• f y

you

• ur

patie ient’s m medic ical l his istory.  Rec ecommen end nutritious m meal eals ap appropriate e for ag age an e and gr growth, h, r rich h in n Fo Folate (Vit itamin in B B9) f found und in c n cornm nmeal, spag aghet etti, bag agel els, p pita an a and s sourdough bread eads an and more. .  Sta tay c current t ab about s sources es of ar arsen enic i in y your ar area t ea that may poten ential ally af affec ect y your patien ents.

Fol

• late for
• r

Prevent ntion

• n of
• f A

Arsenic P Poi

• ison
• ning

 Low folate e in d diet et i increas eases es blood ar arsen enic ab absorption, allowing ng accum umul ulation i n in t n the he b body and nd i inc ncreasing t ng the he risk sk o

• f
• Arsenic

ic s skin in le lesio ions

• Skin

n an and b blad adder er can ancer ers an and

• Per

eripher eral al vas ascular ar d diseas ease.  Sugge uggest th that t folic lic a acid id supplem emen entation may r red educe e the r risk sk of ino norga gani nic-ar arsen enic-rel elated ed heal ealth o

• utcomes

es.

Nau aujokas as MF , A Ander erson B, A Ahsan an H, A Aposhian an HV, et et al

• al. The B

e Broad ad Scope e of H Heal ealth Effect ects from Chronic Ars rsenic ic E Exposure: Update on a a World rldwid ide Public lic H Healt lth P

• Program. EHP Volu

lume 1 121/Number 3 r 3/March 2013.

Diagno gnosis

Met ethods t to Meas easure e Urinar ary A Arsen enic

 A A 24 24-ho hour ur ur urine ne collection n is the m e most rel eliab able e met ethod t to cor

• rrect f

for

• r fluctuation
• ns in e

n excretion n rates. .

Biom

• mon
• nitor
• ring for
• r Environ
• nment

ntal Expos

• sures to
• Arsenic. Jou
• urnal of
• f Toxicol
• log
• gy and

Environmen ental al Heal Health, Par art B: Critical al Reviews. 12:7 :7, 509-524.

• 524. O

Orloff K, Met etcal alf S, Mistry

• K. 2009

2009

 In the e Colorad ado S Smel elter er Exposure e Inves estigation, w we e collec ected ed a “ a “spot” urine e sam ample,

– that is why, t the e urine e spec ecimen ens wer ere c e crea eatinine-correc ected ed, t to adjus ust for d dilut ution n and nd – for d det eter ermining w whet ether er a a spot urine e sam ample w e was as val alid for asse ssessi ssing a arse senic exposu sure.

Environmental Health P

• Perspectives. Jul 2005;

2005; 113( 113(7) 7): 192 192-200. 200.

Colorad ado S Smel elter er Exposu sure I Invest stigation

Colorad ado S Smel elter er Exp xpos

• sure Investigation
• n (EI)

 PCCHD req eques ested ed an an exposure i e inves estigation f from ATSDR. R. A b bio iolo logic ic EI (blo lood le lead and urin rinary a ars rsenic ic) w was conducted ed during S Sep eptem ember er an and Novem ember er 2 2013.  The p e purpose o e of the e EI w was as to i inves estigate e whet ether er peo eople e liv livin ing wit ithin in half lf a mile ile o

• f t

the smelt lter a r at higher er r risk f for h heal ealth ef effec ects h had ad el elevated ed le levels ls o

• f

lead ead in in blo lood a and/or r ars rsenic ic in in ur urine ne.

Col

• lor
• rado
• Smelter E

EI ( (cont

• nt…)

…)

Th The Col

• lor
• rado
• Smel

elter er oper erated ed in n the E e Eiler ers and d Bessemer n neighbo borhoods ds for 2 25 year

• ears. The

e smel elter er c closed ed 117 117 year ears ag ago. Smel elter er o

• per

erations res esulted ed i in t the s e slag ag pile e an and soil il contamin inatio ion wit ith le lead and arsenic ic.

Slag Pile Unrestricted access and evidence of children riding bikes

Criter eria a for

• r Partic

icip ipatio ion/ Targe get Popul ulation n

People le liv livin ing withi hin n hal alf a a mile e of t the e form rmer s r smelt lter r and nd belongi nging t ng to o

• ne

ne o

• f the

he following ng gr group ups:

Chi hildren f n from 9 months hs t to younge unger t tha han 6 n 6 years ( (blood lead ead t tes esting only) Children en from 6 t to 1 16 y year ears (blood lead ead an and u urine ar e arsen enic testing) ng) Preg egnan ant women en an and women en o

• f childbear

earing ag age ( e (blood lead ead an and urine ar e arsen enic t tes esting)

Blood L Lead ead Res esults Exceeding ng 5µg/ g/dL b by A Age ge G Group up

Ag Age n* #≥ 5 µg/ dL Speci cific c resu sult (µg/dL) L)

9 mont

• nths t

to

• <6 year

ears

33¹ 33¹ 3 18. 18.9, 8. 8.87, 87, 6. 6.77 77

6 t 6 to <12 y year ears

47 47 1 5. 5.32 32

12 t 12 to < <20 20 years

23 23 _

20 t 20 to < <45 45 years

32 32 _

*On One vial al ar arrived ed at the e lab aboratory em empty

Blood L Lead ead Res esults

Blood

• od Lead

ead Level els b by H Househ ehold

Colorad ado S Smel elter er Exposur ure I Investiga gation ( n (EI)

Arsen enic l level el ATSDR used ed

 We We compar ared ed the t e total al c crea eatinine e correc ected ed urinar ary ar arsen enic r res esults to the ag e age s e spec ecific 9 95th

th per

ercen entile e of t the e NHANES 2009 2009 – 2010 ( 2010 (Feb 2015) 2015).  The 9 e 95th per ercen entile f e for t the v e var arious ag age-gr group ups

• 6

6 t to < 12 12 years: 60. 60.8 8 µg/g c creatinine

• 12 t

12 to < 20 y 20 years: 28. 28.4 4 µg/ g/g g creatini nine ne

• 20

20 < 45 y 45 years: 87. 87.3 3 µg/ g/g c g creatini nine ne  Only one e el elevated ed total al u urinar ary ar arsen enic was as f found in the he first r round und, but ut i it w was o

• f dietary o
• rigi

gin, n, no non n toxic ar arsen enic.

Fourth Rep eport of t the e National al R Rep eport on H Human an Exposure e to Environmen ental al Chem emical als , U Updated ed Tab ables es, Feb ebruar ary 2015.

Arsen enic G Grap aph

10/15/2015 60

Why T Two Urinary Arse senic T Test sts? s?

 ATSDR conducted 2 rounds of urinary arsenic testing

to increase the likelihood of finding arsenic exposure.

 Arsenic is rapidly metabolized and excreted from

the body within 2 – 3 days of exposure; thus, urinary arsenic testing measures only recent exposures.

 Therefore, a urine sample needs to be collected

soon after exposure has occurred.

Numbe ber r of

• f P

Participant nts b by A y Age G Grou

• ups

Arse senic t test sting

Par articipan ants Ages es 1st R Round und September 2013 2013 (n=99) 99) 2nd

nd Round

und November 2013 2013 (n=65) 65) 6 to <12 year ears² 45 T 45 Total¹ 33 T 33 Total 12 t 12 to < <20 20 years 22 T 22 Total 13 T 13 Total 20 t 20 to < <45 45 year ears 32 T 32 Total 19 T 19 Total ¹ There were two 5 years old included ²Males and Females participants

Lead F Find ndings ngs of the he E EI

Blood L Lead L Lev evels (BLLs LLs) Find ndings ngs

 Y

• ung

ung child ildren liv livin ing wit ithin in h half lf a a m mile ile of the form rmer r smel elter er an and w who wer ere e at increas eased ed risk of l lead ead exposur ure ha had hi highe gher BLLs; t the hese exposu sure level els c can an har arm children en’s h heal ealth.  Blood

• od lead

ead level els for t the y e younges est ag age e gr group ups (9 (9 months s to l less ss than 6 6 years s ol

• ld an

and 6 t to l les ess than an 1 12 year ears o

• ld)

) are hi highe gher t tha han n correspond nding na ng nationa nal levels from NHA NHANE NES 2009-10 ( 10 (February 2013) 2013).

Blood L Lead ead Level el R Res esults -Y

• unge

ungest A Age ge Group ups

Arseni nic Find ndings ngs of t the he E EI

Urinar ary A Arsen enic

 Th The con

• ncent

ntration

• n of
• f tot
• tal ur

urina nary ar arsen enic i in al all but one e par articipan ant w was as b bel elow t the e 95 95th

th % o

% of the e NHA NHANE NES.  The e spec eciation of t the e total al ar arsen enic found t the el e elevated ed ar arsen enic t to be ar e arsen enobet etai aine, a d a diet etar ary f form of ar arsen enic mostly f found und i in n se seafood that i is s rela lativ ively ly n nontoxic ic.

 ATSDR did no

not find nd e evidenc nce of e elevated ino norga gani nic arseni nic i in n the he p popul ulation l n living ng withi hin n hal alf a m a mile e of t the e former er Smel elter er tes ested ed in S Sep eptem ember er 2013 or i in November 2013. 2013.

ATSDR Re R Recommendations

1.

• 1. Continue b

e blood l lead ead tes esting for ar area ea res esiden ents: chi hildren, n, p pregna gnant women, n, an and women en of c child ild- bear earing age. e. 2.

• 2. Instruct ar

area ea primar ary c car are e provider ers on l lead ead/ar arsen enic so sources a s and r risk sks s of e exposu sures, diagnosi sis, and more. 3.

• 3. Char

arac acter erize e the he na natur ure an and exten ent of l lead ead an and ar arsen enic cont

• ntamination
• n.

4.

• 4. Stop/red

educe e exposure e to mining w was astes es in r res esiden ential al soil il an and sla lag p pile ile. 5.

• 5. Dev

evelop a s a sustai ainab able e heal ealth ed education p program am in the ar e area. ea.

Public lic H Healt lth Actio ion P Pla lan

• 1. P

PCCHD r rec ecei eived ed a 5 a 5 year ear E EPA gran ant to

• Cond

nduc uct he health e h educ ucation a n and nd BLL screeni ning ng

• Assis

ist in in c coordin dinatin ing de develo lopm pmental l and c d cognit itiv ive eval aluations in af affec ected ed children en

• Cond

nduc uct othe her p pub ublic he health a h actions ns/investiga gations ns

2.

• 2. In 2014,

2014, EPA listed ed t the e Colorad ado Smel elter er s site o e on the e Natio ional l P Prio iorit ity ”Sup uperfund und F Fund und” list for c clean-up. p. 3. ATSDR p publis lished it its E EI report a and is is hold ldin ing public lic availa ilabilit ility meetin ings in in t the c communit ity.

“It is is essentia ial l to guid ide clin linic icia ians and communit ity lead eader ers i in ad advocating to protect ect children en f from har armful level els o

• f lead

ead exposure; e; i it provides es a a goal al for the l e local al, state e an and fed eder eral al heal ealth ag agen encies es t to set policy and nd p provi vide fund unding t ng to protect chi hildren n from t the ad e adver erse c e conseq equen ences es of lead ead t toxicity.” Bruce e P L Lan anphear ear, M MD, M MPH

* Cit ti f d dit

Acknowled edgem emen ents

ATSDR ap apprec eciates es the e Pueb eblo City County Heal ealth Dep epar artmen ent (PCCHD)’s s as assistan ance e with the e Exposure e Inves

• estigation. PCCHD was

as instrumen ental al in t n the he recruit itment, im imple lementatio ion, notif ific icatio ion of infor

• rmation
• n, an

and Heal ealthy H Home e Inspec ections conducted ed for the e par articipan ants of the e Colorad ado Smel elter er EI. Especia ially lly we e wan ant to t than ank Syl ylvia P Proud, MS MS, IPMA MA-CP . Public lic Healt lth Dir irector, PCCHD.

• Dr. C

Chr hristine ne Nev evins-Wood

• ods, D.O. Med

edical al O Officer er, , PCCHD. . Ken Willia illiams, B

• BS. ,

,Dir irector Envir ironmental l Healt lth Div ivis isio ion, PCC CCHD. ATSDR al also ap apprec eciates es t the e Reg egional al O Offices es o

• f t

the E e Environmen ental al P Protec ection Age genc ncy (EPA) f for t the heir ha hard w work a and nd strong ng collaboration n with o h our ur E Exposur ure Inves estigation for the e ar area ea within 0.5 mile e from the e former er smel elter er in Pueb eblo. Last b but ut no not l least, ATSDR a appreciates the he c communi unity whi hich s h so gr gracious usly par articipated ed in this Exposure e Inves estigation, we e wan ant to than ank them em for thei eir partic icip ipatio ion a and c colla llaboratio ion wit ith t the EI!

Thanks for your attention Any Questions?

For more information please contact Agency for Toxic Substances and Disease Registry 4770 Buford Hwy, NE Chamblee, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.atsdr.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Agency for Toxic Substances and Disease Registry Division of Community Health Investigations