1. Lead Poisoning, Not Just for Children: A Characterization of Blood Lead Levels in New Hampshire Adults from 2009-2013 Iha Kaul Public Health Associate Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP 2016 Spring Seminar April 5, 2016 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. LEAD POISONING: AN OVERVIEW What is lead? Where is it found? What effects does it have on health?

3. Leaded Gasoline Lead in Paint Pipes Where is Lead Typically Found? Older Homes Lead Paint was banned for residential use in 1978 75% of New Hampshire’s housing stock is built pre-1978

4. Health Effects of Lead in Adults  Lead has no known use in the body  The body stores lead in the:  Blood – for about a month  Soft Tissues/Organs- for several months  Bones- for decades  High Risk for Pregnant Women  Crosses the placental barrier  Maternal lead may affect child’s neurologic development  Children and pregnant women absorb more lead than others

5. Health Effects of Lead in Adults  Lead impacts:  Cardiovascular (hypertension)  Gastrointestinal (loss of appetite, nausea)  Hematologic (anemia)  Renal (kidney damage)  Neurologic (fatigue, memory, attention)  Reproductive (sperm damage)  For children:  Hearing and nutritional status

6. Health Effects of Lead in Adults  There are no safe levels of lead in the blood  Public health action level in NH is 25 µg/dL  Adverse health effects have been noted as low as 5 µg/dL  New case definition for an elevated blood lead level (BLL) ≥10 μg/dL  Pregnant women should try to maintain lead levels below 10 µg/dL  All blood leads are reported to the state:  BLLs above 10 µg/dL are reported to ABLES  For adults with BLLs above 25 µg/dL HHLPPP sends a letter  For BLLs above 40 µg/dL OSHA is notified Medical removal at around 50 µg/dL  The typical BLL for all adults in the US is less than 3 µg/dL  Yet, 95% of BLLs less than 25 μg/dL in adults are work-related

7. Health Effects of Lead in Adults Symptoms at Associated Blood Lead Levels (BLL) BLLSymptoms 15 µg/dL Increase in blood pressure, harmful to fetus 20 µg/dL Headaches 30 µg/dL Damage to sperm, slower reflexes, tiredness, reproductive problems, kidney damage 40 µg/dL Muscle and joint pains, stomach pain, constipation 50 µg/dL Diarrhea, loss of appetite, anemia, sleep problems 60 µg/dL Memory problems, mood swings, trouble concentrating 80 µg/dL Sharp pains in stomach 100 µg/dL Severe brain damage NIOSH has designated 10 µg/dL of whole blood as the reference blood lead level for action in adults

8. Occupational Lead Exposure TThese activities may expose people to high levels of lead: PPainting, renovating, or remodeling pre- 1978 buildings WWelding FFirearms manufacturing, firing range instructors & cleaners BBatteries & ammunition manufacturing SShooters and shooting competitions MMaking jewelry, ceramic items or stained glass FFoundry work, soldering MMaking cables and cable splicers MManufacturing or “biting” lead fish sinkers WWaste incinerator & metal recycling RRepairing or cleaning automobile radiators

9. OSHA Lead Standard For those exposed to airborne lead at or above the:  OSHA Action Level of 30 µg/m3 for more than 30 days/year:  Medical screening & blood lead testing  Medical removal protection (temporary removal from the job task due to elevated blood lead)  Permissible Exposure Limit (PEL) of 50 µg/m3, employer must:  Post a warning sign  Install ventilation  Provide showers & changing rooms  Provide medical screening & blood lead testing  Provide medical removal protection

10. OSHA Lead Standard  For workplaces with significant risk of lead exposure:  An employer must make blood lead testing available at least:  Every 6 months for employees with an airborne lead exposure above the Action Level for more than 30 days/year.  Every 2 months for anyone who’s last blood lead was > 40 µg/dL.  Monthly for an employee during temporary medical removal due to an elevated blood lead level. Action Steps Blood Lead Monitoring In an environment where worker is exposed to OSHA Action Level (regardless of BLL):  Evaluate blood lead prior to exposure  Test blood lead every month for the first 3 months  Test blood lead every 6 months and at annual exam Worker with a blood lead > 40 µg/dL within the past 12 months or at a level requiring medical removal:  Medical evaluation annually  Monitor every 2 months until 2 consecutive tests < 40 µg/dL Worker with blood lead > 50 µg/dL :  May indicate medical removal  Test blood lead monthly Any symptoms of lead poisoning or worker with difficulty breathing while wearing respirator  Evaluate blood lead immediately The OSHA Lead Standard provides guidelines for protection in workplaces where employees are at risk of being exposed to lead

11. Clinical Evaluation of Elevated Blood Leads in Adults  Preventive screening  Exposure History  Age and condition of residences  Home remodeling activities  Occupations and hobbies of family  Unusual medicines or home remedies.  Imported or glazed ceramics or lead crystal  Physical evaluation  Signs and symptoms

12. METHODS New Hampshire Adult Lead Exposure Data

13. Methods  New Hampshire adult blood lead results >10 μg/dL were analyzed for 2009–2013 (n=650)  All blood leads in NH are reported to the Healthy Homes and Lead Poisoning Prevention Program  Adults were defined as anyone 16 years and older  Employment information for 458 of the 650 including patients:  Self-employed  Retired  Unemployed  Deceased  NAICS codes were determined to assess industry of employment

14. OVERVIEW OF LOWER BLOOD LEAD LEVELS FROM 2009-2013 New Hampshire Adult Lead Exposure Data

15. Number of Elevated Blood Lead Levels (>10 μg/dL) in NH Adults, 2009-2013

16. Blood Lead Test Results by Level, 2009 - 2013 OSHA Lead Standard

17. Lead Test Results by Gender and Age, 2009–2013 Age Group (Years) Blood Lead Level Test Result Total No. of Cases for Age Group 10- 24 µg/dL>25 µg/dL No. of Males No. of Females No. of Males No. of Females 16 to 201113015 21 to 30124671138 31 to 401004100114 41 to 501156140135 51 to 6012811220161 61 and up72411087 Total55032671650

18. Average Blood Lead Level of those Adults Tested, by Year, 2009–2013 Known Health Risks at 10 mcg/dL

19. OVERVIEW OF OCCUPATIONAL EXPOSURES FROM 2009-2013 New Hampshire Adult Lead Exposure Data

20. Lead Test Results by General Industry, 2009–2013 NAICS General Industry Blood Lead Level Test Result Total No. of Cases for Industry 10- 24 µg/dL>25 µg/dL No. of cases Manufacturing16114175 Construction10313116 Waste Management and Remediation Services 57461 Repair and Maintenance Services13114 Wholesale Trade6511 Professional, Scientific, and Technical Services 707 Transportation and Warehousing707 Educational Services505 Public Administration303 Retail Trade213 Utilities303 Arts, Entertainment, and Recreation202 Information202 Finance and Insurance101 Real Estate and Rental and Leasing101 Total37338411

21. Lead Test Results by Top 10 Industry Subcategories, 2009–2013 NAICS Industry Text Blood Lead Level Test Result Total No. of Cases for Industry 10- 24 µg/dL>25 µg/dL No. of cases Foundries, Valves and Inline Plumbing and Heating 11713130 Bridge and Highway Painting/Construction401050 Firearms, Ammunition Manufacturing and Wholesale 41647 Environmental remediation services42244 Residential Construction and Renovation150 Waste recovery facilities13114 Antique furniture repair and restoration shops718 Acid plant construction404 Door and Window Installation404 Heating boiler installation404

22. Discussion of Results  The majority of adults in our study had a BLL between 10 and 24 µg/dL  Adults employed in the manufacturing and construction industries, specifically foundries, painting, and firearms represented a large number of these lower EBLLs  The average blood lead for these adults was 5 µg/dL higher than the 10 µg/dL level at which there are known health effects  OSHA rules impact those with BLLs >40 μg/dL, however, no such regulation protects those with lower blood lead levels  Lead at work can impact a worker’s family via “take-home” lead

23. Limitations  Does not represent all workers in New Hampshire with exposure to lead  Large number of cases with unknown occupation and employer information  Employer information collected from labs and providers contained patient self-reported data  Limited staff for data collection and analysis

24. Future Actions  Correlate take-home lead exposure with childhood poisoning data  Educate high-risk industries on effective protection and safety from lead at work  Increase testing for adults with lead exposure risk  Educate providers on health impacts and importance of monitoring lead  Improve surveillance systems to ensure accurate occupational information is included

25. Outreach and Education for Adult Lead Exposure

26. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thanks! For more information please contact: Iha Kaul at ypl9@cdc.govypl9@cdc.gov Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support