Document Dm8nVv9NGBELZkBjxRJ91knn

ORIGINAL ARTICLES Newark kas tke most serious pediatric lead poisoning problem in the USA. Lead Poisoning in Newark The Situation Prior To a Case Finding and intervention Program Ann'A, Browder, M.D./Newark* positive, a yield of 2.6 per cent. Subsequent blood' lead levels ori the children with posi- Newark recognized an emergency in lead live urine tests are shown in Table I. Forty- poisoning with three deaths in rapid succes- six per cent of the bloods showed lead con ' sion during the spring of 1969. On a popula centrations of 40 mg per. cent or higher. This tion basis, these deaths made the Newark: mor tality greater than any other city in the USA. The problem relates, at least in part, to the inordinate number of deteriorated and dilap-. Mated buildings. According to the I960 cen sus,1 85 per cent of units with nonwhite heads of household were so characterized. It is augmented by the great prevalence of pica* .among the children. Some 30 to 70 per cent . ' . .Table I Blood Lead Levels in Children with Positive Urine Screening Tests No Blood . ; Numberwith Lead .. Number Blood Lead Levels Determl- UrineTest Positiye 6Qmg. 59-40 mg . 40 mg nation Aminolevu linic acid 113 Coproporphyrin 21 Total 134 23 ` 10., .45' 35 26 4 "9 . 25 16 49 44 of all children attending municipal clinic in deprived areas may be expected to have , a means that fifty-four per cent of- the bipods ' history of this oral behavior.2' > Newark is taken because the ALA test was positive were not likely to have a lower prevalence since considered non-diagnostic. In Newark 94 chil pica* often reflects the cultural patterns of', dren were hospitalized for lead poisoning, be the rural south and half of Newark's young tween January 1, 1969 and March 1, 1970, 28 mothers5 were born in southern states. of these as a result of the urine, screening program and the other 66 by direct hospital - Alarmed by the apparent' severity of the admission.' An additional 43 children had problem, the College of Medicine and Dentis-. blood lead levels 60 mg per cent or higher try of New Jersey at Newark established an detected during the. screening program, but Environmental Toxicology unit in the De were not admitted; -Many authorities believe partment of Public Health and Preventive. the -diagnosis of lead poisoning should be Medicine, July 1, 1970, A survey was under made if blood levels exceed 40 mg per cent, taken to assess what has been done and what . If this is used as the upper limit of normal, was known. the number of children with dangerously high levels who were not hospitalized in Situation Prior to July 1970 > creases from 45 tq 65. Thus, the maximum Screening in Newark from January- 1, 1969 number of children recognized as lead poi through March, 1970 was carried out' by soned was 159. In most cases among the 66 urine analysis using the Davis method** for hospitalized, with symptoms of lead poison- detection of 8-aminoIevuiinic (ALA). Dnf-, `The author is Assistant Professor of Public Health at ing this period, 1973 ALA tests were done the College of Medicine and Dentistry o New Jersey with 113 positives, a yield of under- 6 per - at Newark. . cent* Additionally,. 833 coproporphyrin fMany o today's medical students here never heard of "pica"'--a craving for substances not fit for food, (COPR) tests were made of which 21 were *`Bio-Rad, New York City, ... VOL, 69-NUMBER 2-EEBRUARY, 1972 V N 27642 103 .. V. - r. `f- ' .- tU;./ ' ... ! 'u *: x-., it ii . A ing, the diagnosis o lead intoxication was made promptly by the private physician or hospital staff. But in an important minority the correct diagnosis was not made early in the course of the disability. The various presenting manifestations in these children, summarized in Table II, ac count for some of the difficulties in establish ing the diagnosis. Delay in recognition and gm per cent and the blood lead 190 rag per cent. Despite vigorous therapy, the child died on the seventh hospital day.. The children admitted for therapy generally responded favorably. But, on discharge, they usually face the environment m which they had originally been poisoned. One third of the children hospitalized in this 15 month period were suffering second or third episodes of lead intoxication. Table II Mode of Presentation of 94 Cases Subsequently Treated for Lead Poisoning, Neniark 1969 The importance of follow-up of poisoned children is underscored by our cases. Chil Asymptomatic Screening with ALA1 in urine Screening with COPR1 in urine Case of lead poisoning in relative Pica " ' 26 2 7 9 dren with lead poisoning dearly cannot be discharged to be seen only if symptomatic. The next episode, if not fatal, is too likely to be one from which the child does not fully Neurologic symptoms Convulsions- ... Drowsiness .18 . recovert Without a specific focus on the dan 12 gers of repoisoning, this possibility was usual S' ly ignored during the asymptomatic and more Gastrointestinal symptoms 18 reversible stages. When mothers brought a Vomiting ' Anorexia ` " . 14 3 previously poisoned child for care of acute Abdominal pain I and unrelated conditions, only infrequently Bone abnormality on x-ray Anemia' * 2 was the opportunity used to Obtain a blood for lead level determination. The child's frac 2 :. ture, lacerations, abscess, hernia, or common Other, including combinations of symptoms 10 cold was the sole focus of the emergency Total 94 room physician's attention. 'aminolevulinic add VoproporpUymi To provide adequate follow-up, the Depart treatment of this chameleon disease, which masquerades as a common illness of the ner vous system, the gastrointestinal system, and/or the bone marrow, can be most seri ous as is illustrated in the following cases. ment pf Pediatrics of the New Jersey College of Medicine and Dentistry at Newark estab lished in March 1970 a weekly "Dead Clinic'' for children discharged from Martland Medi cal Unit after admissions for lead poisoning. (Three-fourths of the cases in Newark are cared for in phis insitution.) This clinic ar A 3 ycar-oid girl had been followed for tuberculous adenitis regularly during the year before her death. ranges for ihese children (together with all During that year she had shown no weight gain. One week before her terminal admission she was . members of their household under age 5) to treated symptomatically' in the emergency ward for be -sjsiert every' three months. This is likely to persistent vomiting. Four days later an infiltrate was found on a chest x-ray and she was hospitalized for be an .interval within which asymptomatic presumed tuberculosis. Tab vomiting suggested lead rises in blood lead levels could be appreciated intoxication and blood for lead levels was obtained. Treatment was not initiated pending return of the before more serious reactions developed. The laboratory studies. Throe days later she convulsed, follow-up includes review of growth and de- and, despite reduction of blood lead concentration, from 100 mg per cent to 20 per cent, she died. velopment, analysis of current symptoms, and determination of hematocrit, hemoglobin, The other patient was first admitted for lead poison ing in September 1968, He was treated successfully serum iron, and total iron-binding capacity, and discharged. In June 1969 he was seen again urinary ALA, and blood lead levels. Pica, past with a two-week history of lethargy and convulsions. Medical attention had not been sought during this or present, is sought for in the mother and fa 14 day period. On admission, hemoglobin was 56 ther a? welt as all children. We made a pre- 102 THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY DUP040009045 Iiminary study in Newark of the association proaches is shown in Table IV. More than a of pica in parents and children, of 25 cases third of the children had blood leads above and 25 control families. Forty-two per cent of 40 mg per cent; over 7 per cent exceeded 59 the case mothers had pica whereas only 24 per mg per cent. *. cent of the controls gave this history. Three of the case fathers had pica; none of the .Although a substantial number of lead poi- control families described this symptom. Al soned children have been identified, the' though this trend appears interesting, the figure for" those actually poisoned is presuma .numbers were small and the differences are bly much higher. It is estimated2' 4. T>8 that 3 not statistically significant. ' to 8 per cent of children under age 5 residing . Siblings of lead poisoned children were usual ly ignored. Of the children hospitalized for lead poisonings or. with blood lead levels 60 mg per cent and over, 60 per cent of the potentially involved siblings (born 1963 in city slums have blood leads 50 mg per cent or higher. Newark has a major problem with ji housing, with 85 per cent of families with nonwhite headsof household living in deteri orated or dilapidated housing- in 1960. Since 1960, the ratio of blacks- in the population- through 1968) had neither blood lead nor has almost doubled. Currently over 8500 in ALA urine screening done (Table III). fants are born each year to Newark residents creating a population of children between table IH ` Remits in Known Siblings Born 1963 through 1968 of Children with Blood Leads over-60 mg per cent or Hospital Admissions for Poisoning, January l, 1969 ' through March 31, 1970. Number of Children No blood or urine test performed 54 age 1 and 5 of over 40,000. . According lo preliminary screening, the number with ex cessive body'burdens of lead is likely to be in the 13,000 range, constituting a public health problem of the first magnitude. Children with evidence of iricreased body lead . 28 Spanish-speaking families with lead poisoning have been infrequently noted in Newark. admitted for chelation blood lead 60 mg per cent and over, no admission blood lead 40-59 mg per cent ALA urine positive, no blood lead determinations made Cliild.ren without evidence of in creased body lead (blood lead under 40 mg per cent) 14 4 7. ' - 3- 9 Total . 91 Few children with Spanish family names ap pear among the 94 hospitalized despite the fact that in 1967 Newark wa$ estimated to have a Spanish-speaking population of 12 per cent.5 This probably does not: reflect differ ences in housing. It may reflect a lesser amount of pica in this group. The most likely explanation, however, is that few Spanishspeaking children have been hospitalized be Preliminary Study of Groups of Potentially Lead-Poisoned Children cause this group receives even- .less medical attention than the rest of Newark. Under the Division of Epidemiology a sum mer project to screen children by blood lead levels used two approaches. Initially, a target area was defined by its poor housing condi tions and randomly sampled blocks were re-' viewed systematically by doorTtd-door search for children age 1 through 5, Subsequently, four "Lead Days" were held in community storefronts; open as a screening service to all who came. The distribution of blood leadlevels in children tested by these two ap The screening program conducted 'by the . Newark Division of Health during 1969 and into 1970 was based on aminolevulinic'acid determination. The low yield of true posi tives, and the high rate pf false positives among these urine' tests (compared to blood lead levels. as standards) reflect both the lim its of the procedure and the difficulty of car rying out suitable collections. The specimens should be from the first voiding of the day corrected to proper pH and either stored fro- VOL. 69-NUMBER 2-FEBRUARY, 1972 , 103 DUP04G009046 s.,/ a zen or studied promptly. None of these re* lead level obtained. Sometimes the failure of quiiements is met easily either by the average further investigation related to difficulties in household or the usual screening programs. herent in locating families. In other cases the Large-scale programs in Chicago and New family could not be persuaded to have addi York City have not used urine ALA as the tional tests made. In still others, lack of fol K-;- screening procedure, but have instead focused low-up was due to inadequate .communica on blood concentrations. tion among various interested groups. For ex % ample, the public health nurses and sanitari ); r The small proportion of those a.t risk who ans, on whom the identification of the source did receive screening (less than 7 per cent) of poisoning currently depends, did not have ;L ..' .* - emphasizes the need for wider educational all names of positive ALA determinations or efforts. Clearly, - the delay- in recognition is; of all children with bloods over 60 mg per not only due to a lack of awareness on the cent. Failure to follow siblings is all the more part of physicians but also on the part of distressing in the light of the data showing P, parents as illustrated by our second case and that one-third of siblings9 of children with t by another child not yet two years of age who vomited daily for three weeks before he was brought to medical attention. At that time, lead poisoning may be expected to show in creased body burdens of lead. These studies are supported by our own data. .In siblings the blood lead concentration was found to be who were tested, almost half required treat 290 mg per cent. Parental ignorance can also ment. create the problem. Some mothers in Newark Ik have used lead-containing plaster as pacifiers. Inadequate housing has been a major obsta One well-intentioned mother collected paint cle to protection of families with! lead- flakes for the child to eat "like potato chips" poisoned children. During or Shortly after while watching television. hospitalization, the home is usually visited by the Newark public health purse and the sani tarian. The latter reports on both the condi Public education can help bring the child tion of the paint-bearing surfaces and the per with pica, or suspicious symptoms, to medical cent lead by weight in a sample paint chip. attention. | An article on dead poisoning made Chips of paint were tested from 64 houses in one father recognize his child's pica for the which a lead poisoned child lived. Only one- danger it wasi The child's blood lead was third were reported to contain over 1 per found to ibe 260 mg per cent. In six other cent lead. From studies in other slum areas,10 families,- lead intoxication was found because the rate of positives should be 60 to 70 per the parents brought their children in for re cent or higher. The low yield, in the Newark view after learning that pica could lead to experience may be explained by the paucity lead poisoning. Ah additional seven families of samples submitted from each dwelling had first been concerned for their own chil unit, in many instances only one chip. dren because of a case of lead poisoning known to them. Table V ` Failure to Continue Indicated Investigation for Lead Poisoning Among Children in Newark The necessity of following children once % identified as having excessive body burdens of COPR urines positive with no sub- Sequent blood lead , 99/21 43 i",' lead is obvious. The children who were iden tified at any stage as requiring further investi ALA urine positive with no sub sequent blood lead 38/113 3.1 gation. but who failed to obtain it are sum Total blood leads with values 40 to 59 hr marized in Table V. Most disturbing were the.. mg per cent without subsequent blood 22/169 13 W 43 cases with blood ieads 60 mg per cent or. Total blood leads with values 60 mg higher in which there was neither a subse per cent or higher without treatment 43/172 25 quent hospital admission nor another blood 'Total 109 'i-V 104 THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY DUP040009047 Some 5a notices were served on the dwellings involved in these cases for violation of the city. code. Not more than three landlords have actually been fined although code com pliance was rare. In few instances was any definitive action taken during the child's hos pitalization either to relocate the family or redecorate the dwelling. With half the families known to be on welfare, few could: afford to repair the apartments with their own resources. Children had to be dis charged, on the average, after six or seven days, the need for acute care pediatric beds making longer hospital stays impossible. Then the children returned to the environ ments in which they had originally been poi soned. . Newark may have the most serious lead prob lem in the nation: over 7 per cent of the blood concentrations were found to be 60 mg per cent and higher. Another 32 per cent, of the sample'had'blood lead levels of 40 to.58 mg per cent. This is considerably higher than the most recent New York figures showing three-fourths of the values under 40 mg per cent, 19 per cent between 40 and 59 mg per cent, arid 5 per cent 63 mg per cent' and higher (Table IV). The samples may not be vestigation of themselves, their siblings, and their environment. Screening by blood levels in the summer of 1970 sharpened the sense of urgency about lead poisoiUtig in Newark. The inadequacy of present resources as well as the inefficiency in their deployment be came a community concern. It then became clear to parents, community leaders, pro fessional workers in health and health admin istration, the city administration., and the medical college that the results of phases 1. (the evaluation of the 15 month preblood screening period) and 2 (the preliminary blood screening) mandated that the entire estimated at-risk population in Newark have lead determinations made in 1971. The out come of the planned phase 3 (total screen ing) and'4 (remedial and preventive efforts) will be the subject of a second report in 1972. Sumrttpry Assessment of lead poisoning in Newark dur ing the 15 months January !, 1969 through March 31, 1970 showed that tlie number of children screened, treated, .and followed were. far below the number projected at ..risk of lead poisoning. The estimates of the severity of the problem were based on two types of Table IV. 'Bipod Lead Levels by Type pf Screening, Summer .1970. " mg% Newark Block study Lead Days ' ; Total . New York City '' less than 40 10-59 60 and over Total N 81 44 13 - 138 % 58.7 ' 31.9 9.4 ; 100 N. 282 ' - 144 30 456 % 61.8 31.6 6.6 ioo N 363 188. 43 594 -% ' 61.1 ' 31.5 ' 7.4 .100 N 27,184 6,991 1.896 36,071 % 75.4 19,1 5.2 100 N = number similar in their relevant characteristics- but screening with blood lead level determina the gravity of Newark's problem is em tions which showed that.7.4 per cent of the phasized by the comparison. children had blood lead levels 60 mg per cent or higher,' while another 32 per cent had Thus, in Newark until late 1970, screening blood leads 40 to 59. mg per pent. Community involved too few children, the ALA test was, interest and resources have been mobilized by found not to be reliable, evaluation of siblings the definition of the gap between the needs was inadequate, and children oiice suspected of the city's children and the amount of con of lead poisoning often had inadequate .in trol achieved. - VOL. 09-NUMBER 2--FEBRUARY,- 1972 105 A ` j X -V . *? ` . ? s: { ` V >4 ' - 4:; i- BibliograpHy 6. Oberle, Mark W.: Science, 165:991 (September 5, 1969) 1. U.5. Census of Housing I960, Newark, N.J., -TJ.S. 7. Griggs, Robert ., et at: JAMA, 187:703 (March Department of Commerce 7, 1961) ' 2. Bradley,. J. Edmund, et at: J of Ped, 49:1 (July .8. Rothschild, Edmund: NEJM, 283:704 (September 1956) . 24, 1970) 3. Lanzkowsky, Philip: Arch Dis of Child, 34:140 (1959;. 4s Barltrbp, D.: Arner J Dis Child, 112:116 (August 1966) 5. Newark, New Jersey, Population and Labor Force Spring 1967, Institute of Management and Labor Re lations, Rutgers-The State University 9. Chisolm, J. J. and Harrison, H. E.: Pediatrics, 18:943 (1956) ID. Schucker, George W., et al.: Public Health Repts, 80:969 (November 1965) II. Spector, Michael j. and Guinee, Vincent F,: "Epidemiology of lead poisoning in NYC-1970," APHA 98th Annual Meeting, Houston, Texas, October 26, 1970) 100 Bergen Street Radiation Safety Standards The Food and Drug Administration has pro posed that equipment manufactured for x-ray diagnosis in the healing arts incorporate new radiation control features to reduce exposure during x-ray examination. The new standard was developed fay the FDA Bureau of Radio logical Health, X-ray examinations, the FDA noted, constitute the largest source of man made radiation' reaching American people, "While the beneficial applications of' radia-' tion in the healing arts are well recognized, exposures from, diagnostic x-ray procedures have far more public health significance than exposures from all other man-made radiation sources," said Charles C. Edwards, M.D., Food and Drug Commissioner. "More than 90 per cent of all human exposure to man-made ra diation comes from the diagnostic use of xray, in contrast with afaput one per cent from radioactive discharges from nudear power plants about which there has been so much public concern." One new proposal would require stationary general purpose x-ray machines to be de signed to insure limitation of the beam to approximately the size of the body area to be examined. The other would require radiographic equipment to be able consistently to reproduce exposure and, therefore, image quality for given settings for voltage, current, and time. Failure to keep the x-ray beam within the area of the body undergoing diagnostic exam ination is one of the commonest causes ofunnecessary x-ray exposure. Reduction of as much as 50 per cent or more in the genetical ly significant dose from diagnostic x-ray can result from limiting the beam to approximate ly the size of the film or other x-ray receptor. The exposure reproducibility requirement of the standard would enable the tedmologist to know with confidence what results to expect at various equipment settings and thus to avoid picture retakes, a common cause of un necessary diagnostic x-ray exposure. X-ray equipment manufacturers would be giv en a year following the effective date of the ..standard to produce equipment complying with its provisions. The proposed standard would become effective upon repubiication in the Federal Register after 60 days for public comment. 103 THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY DUP04Q009Q49 'A*'