East Midlands 5 Pack 1 Programme Public

East Midlands 5 Pack + 1 Programme Public Health Lead Surveillance Project Lydia Izon-Cooper Environmental Public Health Scientist 24 th February 2011

Overview • What is the problem? • Surveillance of Lead in Children (SLi. C) project • Public Health response • Legislation and the Environmental Health role • Sampling and Investigation • A case study response

What’s the Problem?

http: //ecohistorical. files. wordpress. com/2009/10/lead-paint-chipyummy. jpg? w=500&h=413

About Lead • Naturally occurring element in the earth’s crust, mostly as the sulphide galena; • Much of lead emitted into the atmosphere is in the form of inorganic salts. http: //geology. com/minerals/photos/galena-argentiferous-545. jpg

About Lead: A long-standing adversary “Water conducted through earthen pipes is more wholesome than that through lead; indeed…from it white lead is obtained, and this is said to be injurious to the human system. . . This may be verified by observing the workers in lead, who are of a pallid colour; for in casting lead, the fumes from it fixing on the different members, and daily burning them, destroy the vigour of the blood; water should therefore on no account be conducted in leaden pipes if we are desirous that it should be wholesome. " Vitruvius: De Architectura (time of Augustus)

Modern Sources of Lead 1. Flaking paint chips; 2. Leaded dust from renovation of older homes; 3. Water from pipes made of lead or with lead soldering; 4. Auto exhaust and industrial pollution; 5. Some folk medicines and cosmetics; 6. Soil or food contaminated with lead; 7. Dust and fumes from hobbies that use lead, such as stained glass; 8. Battery casings, fishing weights, or shotgun pellets; 9. Contaminated work clothes; 10. Antique pewter; 11. Porcelain or pottery with lead glaze.

Lead Paint • 1960 ~ by agreement, lead not used in paints other than primers • 1980 s ~ lead stopped being used in primers • 1992 ~ lead banned by Controls on Injurious Substances Regulations Still used in some specialist industrial paints. Data from the English House Condition Survey shows that: There are 21 million dwellings, occupied by 48 million people 50% of dwellings are over 50 years old, 20% are over 100 years old. There around 10. 5 million dwellings where there could be some lead -based paint

Introduction to Lead Toxicology The main routes of exposure to lead are by: Inhalation (dust, fumes, vapour) • Absorption following inhalation is generally high (50 -90%) depending upon the particle size. Ingestion (dust, food, water) • Absorption following ingestion is approximately 40% in children (approx. 5 -15% in adults). http: //www. answers. com/topic/lead-poisoning

Introduction to Lead Toxicology • Lead is transported primarily in the red blood cells and binds to plasma proteins. • Absorbed lead is distributed by the blood to liver, kidney, bone and teeth and may be excreted in urine and faeces. • Following chronic exposure, lead becomes deposited in the form of insoluble lead phosphate in areas of the skeleton that are rapidly growing, such as the radius, tibia and femur. • Lead accumulates in bone throughout most of the human life span. The majority of the body’s burden of lead is within the bones: approx 94% in adults and 73% in children. • Characteristic ‘lead lines’ may be seen on x-ray and width is related to duration of exposure. • Lead in bone is readily mobilised to blood. The half life of lead is: 36 days in blood 40 days in soft tissue; 27 years in bone

Chronic effects of exposure to lead Lead is most commonly a chronic or cumulative toxin. Health effects of chronic exposure: • Haematological effects, such as anaemia, basophilic stippling; • Neurological disturbances including headache, irritability, lethargy, convulsions, muscle weakness, ataxia, tremors and paralysis; • In children – cognitive deficits, such as decrease in IQ, which does not exhibit a threshold; • Renal and hepatic injury as well as GI disturbances; • Spontaneous abortion, still birth or decreased birth weight, sperm abnormality; • Inorganic lead compounds are classified as probably carcinogenic to humans (group 2 A) IARC (International Agency for Research on Cancer).

How common is lead poisoning in the UK? • Routine hospital statistics, England 1992 -1995 9 hospitalised children / year • Visits to Medical Toxicology Unit, ~20% UK 1991 -1997 125 cases children / year Societal reduction in IQ – 14, 000 DALYs lost in Europe It is not known how common lead poisoning is in the UK.

Surveillance of Lead in Children (SLi. C) A new project is underway involving paediatricians, toxicologists and public health professionals in the UK and Republic of Ireland to investigate how common lead poisoning is among children and what the causes are. Aims: • Investigate blood lead concentration of ≥ 10μg/dl in children aged 0 -15 years in the UK and Republic of Ireland • Report proportion of cases where a lead source was identified and describe these sources • Raise awareness and understanding among clinicians and public health practitioners • Enhance understanding • Estimate prevalence and identify sources and vulnerable populations • Inform health policy and guidance

Surveillance of Lead in Children (SLi. C) Method: • Clinicians will report cases to British Paediatric Surveillance Unit (BPSU) on a monthly notification card for a period of two years (began in July 2010); • BPSU will notify the SLi. C team at the HPA (in R&D) who will send a questionnaire to clinicians; • Clinicians treating children will be encouraged to inform their local HPU and LA EHD for source investigation and remediation. HPA SLi. C team will also inform HPU.

Public Health Response HPA Lead Action Card The HPA lead action card has been prepared for use by HPUs and provides information and guidance on investigating cases of lead poisoning. The full document can be seen on the HPA website at: HPA Lead Action Card

Lead Action Card Appendix 2 – Lead Action Card Flow Chart. Gives an indication of action to take at different stages in investigation of: • an identified case; or • an identified source / hazard

A Case is Reported • HPA advise clinician to liaise with NPIS re treatment and clinical management of the case; • HPA to liaise with EH to carry out risk assessment (with reference to Lead Action Card questionnaire); • Consider joint visit: LA (EH, Social Services, HPA? ); • Consider incident meeting; • Control hazard (secondary prevention).

A Source or Hazard is Identified – Separate to the SLi. C study • EH to conduct a risk assessment (with assistance HPA); • Advise that people who may have been exposed are considered for blood lead level investigation; • Consider an incident meeting; • Control the hazard: primary prevention with LA as appropriate.

HPA Exposure Questionnaire Appendix 3 – Lead Action Card – Lead Exposure Questionnaire. Guidance on what questions to ask as part of the risk assessment process - where a case of lead poisoning is identified. The questionnaire could be undertaken in conjunction with a site visit involving the HPU, LA and CRCE.

HPA Exposure Questionnaire Appendix 3 – Lead Action Card – Lead Exposure Questionnaire (extracts)

Multi-Agency Response Diagnosis and treatment of individual NHS toxicologists, physicians, GPs, Paediatricians, NPIS Coordination of clinical, health protection with HPU , LA , Health Visitor, CRCE environmental interventions Public health risk assessment HPU, LA , CRCE Test water supply Water Company, LA (Private Water Supply) Sampling of paintwork in domestic households LA , home owner, Consultant, CRCE Remediation of paint work LA , Landlord, home owner Soil sampling / CL risk assessment LA, Consultant Public health campaigns and awareness raising – pro-active HPU, CRCE, LA, NHS

Roles and Relevant Legislation HPA: • Public health assessment: Health Protection Agency Act 2004 (will be different post 2012); • Proper Officer function under: Health and Social Care Act 2008; Health Protection Regulations 2010 (Part 2 A Orders). All in collaboration with the Local Authority

Roles and Relevant Legislation Local Authority: • Proper Officer function under: Health and Social Care Act 2008; Health Protection Regulations 2010 (Part 2 A Orders). • Private water supplies: Water Supply Regulations 2007; Water Act 2003; Private Water Supply Regulations 2010, Part 2 a – Environmental Protection Act 1990. • Investigation and action inside properties: Housing Act 2004 • Investigation and outside of properties (land): Part 2 a of the EPA. Other: Social Services; Building Control; HSE; Trading Standards; FSA.

CURRENT EXPOSURE GUIDELINES AND STANDARDS HPA – Chemical Compendia Incident Management Document Exposure Standards, Guidelines and Regulations

Sampling and Investigation • What is the age of the dwelling? If pre-1992, then possibility of lead-based paint If pre-1960, then lead-based likely • What is condition of paint? If deteriorating (eg, flaking, peeling) then full assessment Sampling: dust wipes; XRF; paint; soil; water

Dust wipes • Samples from floors, painted surfaces (where dust could collect • In all rooms and areas (halls, stairs, etc) to which children have access • There are various companies and labs that supply wipes (cost approximately £ 45 for a kit containing two wipes) Source: http: //www. leadtest. co. uk

XRF Analysers • Projects X-Rays - if lead is present it will emit x-rays at a characteristic frequency, the intensity is then given a qualitative output of ‘positive’, ‘inconclusive’ or ‘negative’; • To be taken where paint is thickest; • Areas where pipes or wiring should be avoided; • It is isotope based, so there are regulatory requirements relating to storage and transport; • Rental is possible.

Paint Sampling • Carried out after dust sampling (avoiding cross-contamination) • Sample should include all paint layers • Sample size - about 25 cm 2 measured to nearest mm • Samples should be sealable rigid containers (not plastic bags possibility of static electricity interfering with analysis) • Results should be given in mg/cm 2 rather than % • Positive ~ 1. 0 mg/cm 2 (or 0. 5%) or more • Approx - £ 50 for two samples Sources David Ormandy, Warwick University and http: //www. leadtest. co. uk

Soil and Water Soil Sampling • Taken from areas where children have access; based on risk assessment and questionnaire. Water Sampling • First visual inspection for lead pipes in and outside of the property. • Sampling from points of consumption. • Water Company involvement.

Sampling Protocols • No official UK protocols. • British Coatings Federation (2005). • Defra leaflet (2005). • HPA website. • Laboratory accreditation. • Consultants? • USA – Guidelines issued by Department of Housing & Urban Development 2007.

Indiana State Department of Health – Indiana Lead and Healthy Homes Program http: //www. in. gov/isdh/19124. htm

Public Information – HPA Sources HPA website includes a number of information sources on lead: Chemical compendia: http: //www. hpa. org. uk/web/HPAweb. File/HPAweb_C/1194947319565 Lead Action Card: http: //www. hpa. org. uk/web/HPAweb. File/HPAweb_C/1274092896741 Public information pages: Information for members of the public who may be worried about sources of lead in their home.

Thank you for listening Any Questions?

Case Study A case of lead poisoning Lydia Izon-Cooper Environmental Public Health Scientist 24 th February 2011

Case Study This case is based on the experience of the HPA managing incidents of chronic lead exposure, but it is not an accurate account of any particular incident. • The local HPU receives a call from a GP. • The GP organised blood lead level testing for a 2 year old child suffering with lethargy, reduced appetite and paleness of the skin. • The GP has now received the results which indicate a blood lead concentration of 56 µg/d. L.

Case Study – continued • On the advice of NPIS, the GP referred the child to the local paediatrician who liaised directly with the clinical toxicologist. • The child was anaemic but was otherwise fit and well. Their diet was thought to be generally poor, and there was a history of eating paint flakes. A diagnosis of chronic lead poisoning was made. • The Consultant is concerned that the child is at continuing risk of exposure to lead.

Case Study – continued What are the potential sources of lead in? • Soil, paint, water, toys, jewellery, dust, crockery etc. • Home, nursery What are the next steps in the investigation and management? • Complete exposure questionnaire • Consider a multi-partner meeting • Consider a site visit Who are the key partners and what are their roles? • GP, HPU, LA, CRCE

Case Study – continued The Environmental Health Practitioner and the HPU decide to undertake the questionnaire contained within the Lead Action Card together with the family. The questionnaire reveals that: • the child is an only child who lives with their mother (non-pregnant) and father in a council owned flat • the child stays with their grandparents (in a neighbouring borough) 2 nights a week in their private residence • the child also attends a council run nursery 3 mornings a week • the family do not use any traditional remedies or cosmetics • the parents report that they have seen the child eat flakes of paint from the walls at home occasionally • the parents have not seen the child eat any soil.

Case Study – continued What are the potential sources and pathways? What are the potential receptors? Who could be involved in the incident meeting? HPU, GP, CRCE, Health Visitor, EHO from resident LA and possibly grandparents LA. Settings Home Nursery Grandparents SOURCE Paint Water Toys Jewellery Soil Dust Crockery PATHWAY Ingestion Inhalation RECEPTOR Case Parents Children at nursery Grandparents

Case Study - continued During the incident meeting a decision is made to conduct a site visit to the parents’ residence, with appropriate environmental sampling based on the findings. If no source is found here then further site visits, with sampling, will take place at the grandparents’ home and the nursery. The results of the environmental sampling at the parents’ home: Drinking water - 8μg. L-1 Soil from garden – 40 mg. kg-1 dry weight soil Paint chips – not detected Therefore a site visit and environmental sampling was also conducted at the grandparents’ home: Drinking water - 10μg. L-1 Soil from garden – 375 mg. kg-1 dry weight soil Paint chips – 3 mg. cm-2

Case Study - continued What are the next steps in the management of this case? HPU LA Inform parents/grandparents of identified source of lead exposure Education about the potential and actual harm from paint ingestion HPU / LA may seek advice on remediation / sampling strategy from CRCE Work with grandparents to carry out remediation

Case Study - continued The family are reluctant to co-operate with the planned remediation, what powers / authority can be used to assist you to protect public health? Housing Act 2004 – Housing Health and Safety Rating System • System for assessing hazards in the home • 29 hazards – lead is a specific hazard • Category 1 hazard – council has duty to act • Category 2 hazard – council has power to act • Action – require the hazard be removed or minimised • Hazard awareness notice; Improvement notice (can be suspended), Prohibition notice, Emergency notice in case of immediate risk. • Council can prosecute for non-compliance • Council can carry out work in default

Case Study - continued Part 2 a of the Environmental Protection Act 1990 (inserted by Environment Act 1995): • Contaminated land investigation and remediation – Defra Circular 01/2006. Private Water Supply Regulations 2009: • Enforcement powers Part III of the Environmental Protection Act 1990 – Nuisance: • Prejudicial to health or a nuisance

Thank you for listening Any Questions?