Environmental investigation for mass lead poisoning among children in industrial area of Samutsakorn...
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Athipat Athipongarporn, Adisak Plitponkarnpim, Chatchai Im-arom, Ratchaneewan Sinitkul,
Sakda Arj-ong Vallipakorn
Department of Pediatrics Faculty of Medicine Ramathibodi Hospital
Mahidol University
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Lead
Toxic substance
Cognitive impairment
CDC and AAP recommend blood lead levels (BLL) <10 μg/dl among children in the US.
American Academy of Pediatrics. 2005
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Binns HJ, et al 2007 Bornschein et al 1997
Interior paint
Interior dust Exterior soil
and dust
Community sources
Home products •Hands •Toys •Food •Mouthable objects
Exterior paint
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In 2012, Ramathibodi Hospital An 8-m-old girl presented with status epilepticus Her family lived in the recycling factory near Ban
Nong Had Yai school, Samutsakorn Blood lead level (BLL) 166 μg/dl (level of concern
>10 μg/dl)
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August 2012 (N=165)
Kindergarten
Grade1-3
Grade4-6
BLL<10mcg/dl
12 26
35
Children with high BLL 73/165 =44.2%
92 73
BLL≥ 10 μg/dl
BLL< 10 μg/dl
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Primary objective
To identify the environmental risk factors associated with high blood lead level (BLL)
Secondary objective
To study prevalences of low IQ and LD among children with BLL ≥ 15 μg/dl
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Study design Case-control study
Study population Students at Ban Nong Had Yai School ▪ Cases: Students with BLL ≥ 10 μg/dL (High BLL) ▪ Controls: Students with BLL < 10 μg/dL
Matching criteria Classroom: Kindergarten 1-2, Grade 1-3, Grade 4-6 Gender
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Match case and control group (67 pairs)
Environmental investigation
Questionnaire 19 risk factors
6 Specimen collection
2 Paint 2 Dust 2 Soil
Data analysis
Distance from home to factory
BLL ≥ 15 mcg/dl (N=25)
BLL < 10 mcg/dl (N=43)
BLL ≥ 10 mcg/dl (N=43)
Screening IQ,LD
Lose follow up Migration
Case (N=73)
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1st: Rapport. February, 2013
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2nd : Interview by pilot questionnaire. February, 2013
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DELTA Lead Paint Handheld XRF Analyzer (OLYMPUS)
3rd : Record environmental lead level, interview and informed lead intoxication in children for parents and teachers, IQ test & WRAT test
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Demographic data Risk factors
School and Home duration Father’s and mother’s
occupation Home products Interior and exterior paint Playground Industry
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Program STATA 13
Univariate analysis & Multivariate logistic regression analysis
p-value
Odds ratio (95 % Confidence Interval)
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Factors Blood lead levels (mcg/dl) Odds ratio (95%CI)
p-value ≥10, n (%) < 10, n (%)
School duration ≥4 years
31 (65) 17 (35) 3.95 (1.5-10.4)
< 0.01
Home duration ≥6 years
31 (61) 20 (39) 2.97 (1.2-7.6)
0.02
Father’s occupation related to lead
23 (62) 14 (38) 1.91 (0.8-4.9)
0.049
Mother’s occupation related to lead
12 (55)
10 (45)
1.28
(0.5-3.4)
NS
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Factors Blood lead levels (mcg/dl) Odds ratio (95%CI)
p-value ≥10, n (%) < 10, n (%)
Home and Industrial waste < 500 m
10 (67) 5 (33) 2.30
(0.7-7.6)
NS
Home and Industrial factory < 500 m
31 (60) 21 (40) 2.71
(1.1-6.8)
0.03
Home and Garage < 30 m
7 (50) 7 (50) 1.00 (0.3-3.2)
NS
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Interior paints
Enamel wall, window, door frame
Peeled wall, window, door frame
Exterior paints
Enamel wall, gate
Peeled wall, gate
Home product
Peelable items: Toys, Tables, Toothbrushes
Lead containing: Repaired Tank and pot
Metallic odor water
P > 0.05
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Factors Blood lead levels Odds ratio (95%CI)
p-value ≥10*n(%) < 10*n(%)
Paint (≥100 ppm) 22 (51) 18 (42) 1.34 (0.6-2.8)
NS
Dust (≥400 ppm) 12 (28) 14 (33) 0.79 (0.4-1.8)
NS
Soil (≥400 ppm) 2 (5) 1 (2) 1.50 (0.3-9.4)
NS
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Factors
Coefficient
Odds ratio
95% CI
p-value
School duration ≥ 4 years
1.6 4.9 1.8-13.0 <0.01
Father’s occupation related with lead
1.0 2.8 1.0-7.4 0.04
Distance between home and factory < 500 m
1.1 3.00 1.1-7.9 0.03
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OK international.2012
Zhejiang, China 2011
Sichuan, China 2010
Uruguay in 2001 This research
- Poison worker
- Distance 800 meters from factory
- Cottage industries -lead paints - Occupational lead exposure
- Father’s occupation -Distance between home and industry < 500 m.
Daniel Renfrew1.2009
Compare risk factors mass lead poisoning
-Home duration ≥ 6 Y -School duration ≥ 4 Y
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IQ test (N=25)
Mean IQ This group 99.6
Samutsakorn 103.7
BKK & perimeter 119.7±14.7
IQ N (%)
< 90 Low normal Borderline MR
5 (20) 4 (16) 0 (0) 1 (4)
Duangduan Chinrungrat.2009 สถาบนัสขภาพจติเด็กและวยัรุน่ราชนครนิทร.์2010
LD ≥ grade3 (N=17)
Prevalence of LD in Thailand 5 - 29.3%
Group N (%)
Learning disability Reading Writing Mathematic
9 (53) 6 (35) 9 (53) 7 (41)
Lieven Lagae.2008
Duangduan Chinrungrat. 2009
Winadda Piyasil. 2006
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High blood lead level among children associated with
School duration
Father’s occupation
Distance between home and factory
Prevalences of low IQ and LD were higher than average of Thai children
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Different time of collection
Blood sampling
Environmental sampling
Insufficient information of manufacturing in the study area
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Screening BLL among children in industrial area
Raise community awareness in lead poisoning by the research evidences for Thailand policy and future researches
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All students and teachers in Ban Nong Hat Yai School
The psychologists Boonrananives Foundation Olympus Company, Lead Paint Handheld XRF
Analyzer
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Factory
School
100m
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The major pathway of exposure for children is from deteriorated lead-based paint and lead-contaminated dust in the home that is ingested during normal hand-to-mouth behavior.
Binns HJ, et al. Interpreting and managing blood lead levels. Pediatrics 2007; 120:e1285–e1298. Bornschein et al. Lanphear, Pathways of Lead Exp Residential Env, 1997
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Low IQ, Hearing, Growth
Encephalopathy Nephrotoxic
Encephalopathy Anemia
DEAD
www.aafp.com
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Neurological disorder that difficult to reading, writing or calculate
The children cannot do it more than 2 levels of classroom
Reading disabilty
Writing disability
Calculate disability
www.rcpsycht.org
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Factors Group Odds ratio (95%CI) p-value
Blood lead level ≥10 μg/dl n(%)
Blood lead level < 10 μg/dl n(%)
Age < 5 years old 5 – 10 years old > 10 years old
8 (38.1)
16 (57.1) 19 (51.4)
13 (61.9) 12 (42.9) 18 (48.6)
1
2.16 (0.66-7.12) 1.72 (0.57-5.21)
NS
Education Preschool Primary school
4 (57.1)
39 (49.4)
3 (42.9)
40 (50.6)
1
1.37 (0.28-6.58)
NS
Class (2013) grade 1 grade 2 grade 3 grade 4 grade 5 grade 6
2 (40.0) 3 (30.0) 4 (40.0) 9 (75.0)
13 (76.4) 8 (32.0)
3 (60.0) 7 (40.0) 6 (60.0) 3 (25.0) 4 (23.6)
17 (68.0)
1
1.05 (0.13-8.41) 1.00 (0.10-9.66)
4.50 (0.40-50.74) 3.90 (0.43-35.16) 0.75 (0.10-5.64)
NS
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Interior paint and exterior paint Factors Group Odds ratio
(95%CI) p-value
Blood lead level ≥10 μg/dl n(%)
Blood lead level < 10 μg/dl n(%)
Interior paint
Enamel wall paints 6 (75.0) 2 (25.0) 0.30 (0.06-1.63) NS
Enamel window/door frame
31 (52.5) 28 (47.5) 0.72 (0.29-1.82) NS
Peeled wall 5 (62.5) 3 (37.5) 1.75 (0.39-7.96) NS
Peeled window/door frame
4 (66.7) 2 (33.3) 2.10(0.36-12.35) NS
Exterior paint
Enamel wall 15 (53.6) 13 (46.4) 1.24 (0.50-3.07) NS
Enamel gate 23 (60.5) 15 (39.5) 2.15 (0.88-5.22) NS
Peeled wall 16 (48.5) 17 (51.5) 0.91 (0.38-2.17) NS
Peeled gate 2 (50.0) 2 (50.0) 1.00 (0.13-7.53) NS
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Factors BLL Odds ratio (95%CI)
p-value
≥10 μg/dl n(%) < 10 μg/dl n(%)
Toy* 19 (55.9) 15 (44.1) 1.48 (0.61-3.56) NS
Table* 6 (60.0) 4 (40.0) 1.58 (0.41-6.12) NS
Toothbrush* 3 (50.0) 3 (50.0) 1.00 (0.19-5.31) NS
Plate* 38 (50.7) 37 (49.3) 1.23 (0.34-4.43) NS
Repaired Tank** 0 (0.0) 0.00 ** **
Repaired Pot** 1 (50.0) 1 (50.0) 2.00(0.35-11.55) NS
Metallic odor Water 3 (42.7) 4 (57.1) 0.73 (0.15-3.52) NS
* Peelable color ** Lead containing