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Blood Lead Levels Among Children in Hawaii " Gertraud Maskarinee MD, MPH* NOTICE: THIS MATERIAL MAY BE PRPTECt ec ^by Wjggffuw. The objectives ofthis study were to estimate blood lead lev els of children under 6 years ofage in the State of Hawaii, to identify high-risk populations, and to decide what land ofblood lead screening program is needed in Hawaii. Children from Oahu and Maui were recruited in medical carefacilities and 6 preschools. Informed consentfor a blood lead test was obtained from the parents. A questionnaire was administered whenever possible; participation/response rates were quite low, varying between 15% and 50%. The mean blood lead levelfor the 389 study participants was 4.5\tg/dL Twelve children (3% of children tested) hod a level above 9\ig/dL. No child was found to have a level above 14\tg/dL Blood lead levels varied by age, geographic area, occupq&onal factors, laboratory that performed the analysis, and type ofphlebotomy (capillary versus venous) but not by sex, ethnicity or age of home. Follow-up investigations in the 12 homes, ofthe children with levels above 9/lg/dL were performed andin 3 homes a possible source oflead exposure wasfound Introduction Despite the low participation rate, the study appears to be fairly representative of Hawaii's children since it included children from different geographic areas and housing types, with varying socioeconomic and educational backgrounds. There is no reason to think that die true distribution of blood lead levels among children in Hawaii differs drastically from the results in this study. Education of the public and alerting the physicians are needed to reach families whose children are at risk for lead exposure. Children exposed to any one risk factor (living in an old home with peeling paint, parents' occupational expo sure to lead, water catchment system) should receive a blood lead test. Mandatory lead testing of all children in Hawaii would not be cost-effective and is not recommended. Until recently, blood lead levels that did not cause symp toms of lead poisoning, namely anemia, abdominal pain, paralysis and encephalopathy, were considered safe. However, growing evidence indicates that low levels of blood lead have subtle adverse effects in children3-6, Neurobehavioral effects are of special concern during the fetal period and the early years of life because the neurologic system develops rapidly during that time. Lead's neurotoxic effects at relatively low exposure levels include impaired mental Or motor develop ment, decreased intelligence, learning disabilities, impairment of visual-motor functioning, poor perceptual integration and poor memory, hyperactive behavior and alteration of hearing thresholds. The damage to the neurologic system caused by lead is considered irreversible. Lead has no essential function in the human body. Studies among remote populations provide evidence that there is no "normal" blood lead level in the sense of a natural back ground level1-1; human blood lead levels are caused entirely by the products of industry and the resulting dissemination of * Hawaii State Department of Health Office of Health Status Monitoring A SERVICE OF THE 242 LEWIS B. FUNN LIBRARY DELAWARE ACADEMY OF MEDICINE lead into the environment. In 1970, a level of 60/g/dL was defined as "undue lead absorption." One year later this was lowered to 40/g/dL. In 1975, the Centers for Disease Control (CDC) changed the limit to 301g/dL and in 1985 to 25/Jg/dL10. In October 1991, the CDC published a recom mendation to lower the level of "undue lead absorption" to below 10/g/dL11, Levels in the border zone of 10 to 14/Jg/dL should be rescreened and should trigger a community public' health investigation. The steady lowering of the accepted threshold for lead's toxic effects can be interpreted as evi dence that there is no intrinsic threshold for lead and thus presents a "continuum of toxicity." Average blood lead levels in the United States decreased from 14.6 to 9.2 /Jg/dL from 1976 to 1980, and has possibly decreased since then11. This change has been attributed to the reduction of organic lead additives in gasoline during the same time period. However,, other possible sources for lead exposure remain: Lead-based'paint, lead in soil, foods, drink ing water, air, as well as occupational exposure. The main source of exposure to lead among lead-poisoned children in urban areas is lead-based paint Children may ingest lead directly from paint chips, but an important route of exposure is the normal mouthing of hands or objects such as toys, result ing in the ingestion of small amounts of lead-paint-contaminated house dust and soil Children living in deteriorating housing built before 1950 are at high risk for excessive exposure to lead via this route. The lead content of paint used during that period var ied; with some, particularly in earlier years, containing as much as 50% lead by dry weight. The 1987 Housing Act established an allowable level of not more than 0.5% for paint used in public and Indian housing and on Indian reservations. The Federal Government has made lead abatement and the pre vention pf childhood lead poisoning a priority. The USDepartment of Health and Human Services (DHHS) published a Strategic Plan for the Elimination of Childhood Lead Poisoning in February 199111. Several environmental organizations, such as the Environmental Defense Fund2 and the Affiance to End Childhood Lead Poisoning, concentrate their efforts on this issue also. The most recent data on blood lead levels available for the State of Hawaii come from a study on the Big Island (unpub lished data) conducted jointly by the CDC and the Hawaii State Department of Health (DoH). In 1988, CDC-DoH investigated water catchment systems and offered testing for lead to families consuming drinking water from rainwater catchment. From the participating 93 children under age five, 12 (13%) had blood lead levels above lOpg/dL and 6 (6.5%) above 15|ig/dL. The mean blood lead level Was 6.4jxg/dL. in 1973 a small study compared bipod lead levels of children in Hawaii and New Jersey4. The mean blood lead level in Hawaii was 17pg/dL at the time. Other studies performed in the state used zinc protoporphyrin (ZPP) as a screening test which does not identify children with blood lead levels below 25pg/dL9. Nevertheless, the data provided evidence that very few children in Hawaii experienced severe lead toxicity. Our present study was initiated when a committee within the DoH realized data on blood lead levels were lacking at a (Continued on page 244) > Ha w a ii Me d ic a l Jo u r n a l --Vo l . 52, No. 9--Se p t e mb e r 1993 DUP040013879 vould be drastically different fix>m the test of the state. For nd of Hawaii, it is known that some water catchment sysintain lead. Data from the 1988 CDC-DoH study showed a )lood lead level in children under 6 years to be 6.4|/g/clL, was higher than that in the present study. Such a higher ould he a result of the lead in the drinking water from roof lent systems, where Vog-related acid rain tends to leach lead ails, solder, or paint and into drinking water, asurements of low levels of lead in blood are fraught with technical problems. Contamination pf test tubes and lab lent may increase the true lead concentration up to 150%3. uy samples also might be contaminated with lead from a Considering these factors, the actual blood lead levels in i could be even lower than this study indicates. The lab that inly venous samples and a particular type of vacutainer ed for heavy metal analysis had the lowest blood lead mean ;/dL). It is unfortunate that not all participating clinics ; to draw venous samples into blue-top vacutainers. sanation from the questionnaire provided very little explaabout the variation in lead levels among study participants. Considering the large number of factors analyzed, several vari ables are expected to be statistically significant just by chance. Even with respect to the few statistically significant variables, the actual difference between mean levels was less than Ijug/dL. The largest difference in lead levels seemed to be related to the labo ratory where the analysis was performed. Our study was unable to identify any new risk factors for high blood lead levels. Other possible explanations for the low blood lead levels found in this study are: Low soil and air levels due to steady circulation of fresh air, relatively small percentage of homes built before 1950, good maintenance of old houses (many of them are located in neighborhoods with high property prices), high percentage of time spent outdoors and tire comparatively good nutrition status of chil dren in Hawaii. The low levels in Maui may be a result of selection bias: All children on Maui were recruited through private physi cians and only venous blood samples were taken. Another explana tion could be the higher proportion of newer housing on Maui; 32% of all housing on Maui was built since 1980, as opposed to 21% overall in the state. Only 19% of housing on Maui was built before 1950 as compared to 27% in the state (Census Data 1990). LE 4: Blood lead Means (ug/dL) for Selected Risk Factors MORAL iRS Chew on toys Eat dirt Rick paint Eat paint Fingers in mouth Chew an furnitures Use potteiy, cans or ceramics for food NO Number Mean 192 271 231 309 80 .281 4.3 4.4 4.4 4.5 4.1 4.4 ; 175 4.5 YES Number Mean 144 4.7 64 4.7 97 4.7 18 4,9 259 4.5 57 4.8 : . 161 4.5.:. . ENTIAL IRS Urban neighborhood Separate house Home older than30yrs. Reeling paint in home Repent paint removal 181 4.4 122 4.7 225 4.3 194 4.4 230 4.5 139 4.7 150 4.2 105 5.0 131 4.7 76 6.4 : PATI0MAI Battery wort Metal wort )RS Demolition Radiator repair Plumbing Sandblasting Auto body work Painting , Welding ' Otherlead handling 301 302 315 303 , 310 317 294 273 295 308 : : 4.4 4.4 45 44 46 4.4 4.4 4.4 46 47 29 28 13 26 18 12 35 56 , 34 17 5.1 5.1 3.8 5.4 4.1 6.4 5.1 47 5.7 5.0 IES INVOLVING LEAD 225 4.4 2 45 1- OMtC IRS Mother is homemaker Mother's education more than high school Father's education more than high school Income less than $15,000 169 4.2 162 4.5 168 4.5 156 4.6 154 4.5 98 4.6 218 4.4 96 48 iersin bafd/ltaltcs indicate that the mean among the exposed is staUstfcallyttgnificantly greater he mean among the enexposed (p<0.05). rAn Me d ic a l Jo u r n al --Vo l . 52, No. 9--Sept ember 1993 Conclusions 1. The mean blood lead level of 389 children was found to be 4.5pg/dL and none had levels above 14pg/dL. If more children had been tested, a few children with levels above 14p.g/dL might have been identified. ' 2. The level of parental knowledge and concern about lead and by health professionals varies widely. Overall it appears to be rather low. In combination with a widespread reluctance to subject a child to a phlebotomy, itresulted in a low participation rate in blood lead testing. 3. Children living in different geographic areas and housing types, with varying socioeconomic and educational backgrounds, were included in our study. Thus, despite the high refusal rate, there is no reason to think that the true distribution of blood lead levels among children in Hawaii differs drastically from our results. 4. Based on our study, mandatory lead testing of all children in Hawaii is not recommended. However, health care providers should routinely inquire about risk factors, such as flaking paint in old houses, parents' occupational exposure to lead, rainwater catchment systems, toys and hobbies that might be contaminated by lead. Children exposed to any one risk factor should be tested. However, living in a house older than 30 years cannot be regard ed asa risk factor unless flaking or chipping paint is present 5. Public education dealing with sources and risks of lead is essential in preventing exposure to lead in the future and in achieving an appropriate level of diagnostic suspicion. ACKNOWLEDGMENTS Federal funding was provided by the State Legalization Impact Assistance Grants, Family Support Administration, Department of Health and Human Services. All of the expenditures for research assistants, laboratory costs and printing for a total of $17,000 were covered by these funds. Thanks are due to the staff of Kapiolani Medical Center, Kaiser Pertnanente, Waianae Coast Comprehensive Health Center, Kokua Kalihi Valley CUnic, Waimanalo Children's project, PACT in Kalihi, Hawaii Children's Centers, and Olivet Baptist Preschool Appreciation also is expressed to the members of the "adhocracy" group, who planned much ofthis work. REFERENCES 1. Elwood PC, Blaney R, Robb RC, Essex-Cater AJ, Davies BE, Toothill C. Lead levels on trajfBc-less islands./Epidemiol Community Health. 1985; 39:256-8. 2. Environmental Defense Fund. Legacy oflead: America's continuing epidemic of childhoodleadpoisoning. Washington, DC. 1990. 3. Fleal RA, Smith DR. Current needs for increased accuracy and precision in measurements of low levels of lead in blood. Environmental Research. 1992:58:125-133. (Continued on page 250) > 247 BLOOD LEAD LEVELS AMONG CHILDREN IN HAWAII (Continuedfrom page 245) difference between thee labs persists after controlling for age and type of phlebotomy (venous versus capillary). Figure 4 illustrates the complex relationship between age of child, type of phleboto my, and laboratory. Of the 389 in the study, 284 (73%) included a parental inter view. The mean blood level of those interviewed was significantly higher than in those not interviewed (4 7pg/dL versus 4.0pg/dL, p<0.004). Of all children whose parents were interviewed, only 3 (2.1%) had ever received a lead test before. Of 187 (67%) chil dren, their health was described as excellent or very good. The blood lead levels did not differ significantly based on health status nor by number of symptoms experienced during the previous 3 months. Table 4 lists mean blood lead levels by risk factor. The differences between the means are minute for the most part and only 3 are statistically significant: Putting fingers into mouth, welding as father's occupation, and mother's occupational status as homemaker. Of the 178 children living in homes less than 30 years old, the mean blood lead was 4.6pg/dL, whereas in the 95 children in homes older than 30 years, the level was 4.99. That dif ference is not statistically significant The parents of the 12 children (all in (Efferent families) with levels above 9(ig/dL were offered follow-up investigations. Five families agreed to an investigation, 5 families could not be contact ed, 1 family refused a visit and 1 home had already been checked for lead by the Housing Authority and no lead had been found. In 2 of the 5 homes visited, no leaded paint or other potential source for lead could be identified in or around the home. The babysitter's house could have been a source of lead for 1 of those 2 children. In one home, older layers of paint in the kitchen and outside the house contained lead Most of it was in a satisfactory state and the parents were advised to take care of the few flaking spots. In another home the paint was new; however, the father, who was occupationally exposed to lead brought home metal pieces con taining lead and the children had actually played with them. The child with the highest level (14pg/dL) lived in a modem apartment building with latex-based paint However, several old buildings had been tom down in the neighborhood and dust could have blown into the area where the child played outside. Since some tests had been done on capillary samples, a repeat test was recommended to these 12 families. So far, no family has taken the children to the lab for retesting. Discussion The mean blood lead level of 4J5pg/dL and the 3% proportion of levels above lOpg/dL in toe 389 children tested is very low in comparison to toe Big Island roof catchment study in 1988 and as toe national studies. The trend of decreasing levels has been observed across toe nation and is attributed to toe introduction of unleaded gasoline11. We would like to know how many children in Hawaii might have levels above 14pg/dL despite the fact that no child with _ such a level was found in the study. Assuming that the 389 study par ticipants are representative of all children in Hawaii, toe upper limit for a 95% confidence interval for toe proportion ofchildren with lev els above 14jig/dL can statistically be calculated as 0.0077. That means a 95% probability that not more than 0.77% of all children have blood lead levels above 14|j.g/dL. In approximately 100,000 children < 6-years old, as many as 770 children in Hawaii could have levels above 14pg/dL. Such a number is considerably lower than that estimated by the Agency ofToxic Substances and Disease Registry13, In 1988, they estimated that 31% of all children in Honolulu might have levels above 9|ig/dL and that 9% had levels above 14(j.g/ciL. The major shortcoming in our study was the enormous rale of refusal to undergo a blood lead test Many parents had never heard about lead. Many ofthose who had heard about it believed that they did not have a problem. However, the strongest factor in deciding whether or not to participate seemed to be the reluctance of the par ent (even among health and public health workers) to have a child undergo a phlebotomy. On the other hand, toe children themselves were mostly cooperative and showed few signs of fear when they underwent phlebotomy at the preschools. If the 389 samples are representative of children in Hawaii, this study shows that lead is not a major health problem for children in the state. There are some indications that most pop ulation groups were represented in Our study. The proportion of Hawaiians/Part Hawaiians in the study is approximately equal to their proportion among recent births. Recent immi grants were included through the Headstart and Zero-to-Three program in Kalihi. By comparing the income structure of the study families to that in the 1990 census (Table 1), it can be ^ interpreted that a greater proportion of low-income families were included in our study. Educational attainment was slight ly higher among study participants than in the general popula tion. The age of the home, as far as it was known, was approx imately representative of homes in general. It may still be pos sible that those children whose parents did not accept a lead test had radically different lead levels than our participants. Certain geographic areas are under-represented in our study. For toe island of Kauai, there is no known reason to indicate that lead TABLE 3: Mean Blood Lead Levels b y Geographic Area Island Number Mean Blood Standard Area Tested Lead (pg/dL) Error Sampling Index* OAHU j. ... - Alea Ala Moana/Waikiki Downtown East Honolulu Ewa Beach Kalihi Manoa Moiliili/McCully Nutianu Pearl City Salt Lake Wahlawa/Mililant/ North Shore Walanae Waimanalo Waipahu Windward KAUAI East Kauai West Kauai North Kauai MAUI All areas UNKNOWN/ 0THEB TOTAL 11 13 13 23 23 76 22 19 25 10 18 18 17 22 . 19 19 84 68 14 49 6 569 5.6 ; 5.3 : 4.8 4.1 3.9 4.9 : 4.6 4.6 5.0 .4.1 3.6 1.02 0.71. 0.38 0.22 0.33 0.23 . 0.36 0.63 0.35 0.53 0.44 0.6 1.0 1.7 0.9 0.7 2.6 1.8 1.6 . 1-2 . 0.6 9-4 4.8 0.54 0.3 5.5 0.59.: 0.6 4.4 : 0.41 3.4 4.8 0.69-;. 0.6 4.5 0.56. 0.4 3.2 0.19 5.9 3.4 0.23 7.8 3,8 0.55 2.8 2.9 0.29 1.2 4.2 0.83 n.a. 4.1 0.09 1.0 * Index >1 indicates a higher than average number of children were tested. 246 Ha w aii Me d ic a l Jo u r n a l --Vo l . 52, No. 9--Sept ember 1993 c i I; e .( | t h if ci 1 DUP040013881 BLOOD LEAD LEVELS AMONG CHILDREN IN HAWAII (Continuedfrom page 242) time when new CDC recommendations to lower intervention levels for lead were imminent The objectives of our study were to estimate blood lead levels of children under 6 years of age in Hawaii, to identify high-risk populations, and to decide what kind of blood lead screening program is needed in Hawaii, Methods Children from Oahu and Maui were included in the study and were recruited either in a medical facility or in a day-care center (Table 1). Budget constraints and logistical problems made it impossible to include the Big Island and Kauai. Blood samples Were collected between March and August 1992. In the participat ing clinics, research assistants talked to parents of children <6years old, preferably to those who were scheduled to have blood taken for other reasons. Some older children were included on par ents' requests. After explaining the purpose of the study, the research assistant obtained written informed consent for the blood lead test and administered a short questionnaire. Blood was taken in the lab after the child had been given a health check by the doc tor. Table 1 shows estimated acceptance rates. A high percentage of parents refused to have their child tested and another smaller percentage failed to take the child to the lab even though they had signed the consent form. Physicians at the Waianae Coast Comprehensive Health Center, at Maui Medical Group, and in pri vate practice recruited their own patients for the study and no infor mation on participation rate is available from these sources. The preschools were selected to cover different areas on Oahu. Not all preschools that we approached were willing to participate; one organization refused because of legal concerns. In the cooper ating schools, we sent a letter to the parents of the preschool chil dren asking them to sign the consent form and to send it back to school. Depending on the school, between 15% and 30% of the parents consented. The highest acceptance rate was achieved in Kalihi's Headstart and Zero-to-Three Program where we had the opportunity to meet with some of the mothers and to explain the significance of high blood lead levels to them. The blood from the pre-schoolers was drawn at the school on a designated day. The blood lead analysis were performed by 3 different laborato ries. The choice of a particular lab for a sample was dictated by practical considerations. One of the labs (Kaulson) is located on the East Coast. Two are located in Hawaii (SmithKline and Diagnostic Laboratory Services) but these also send their samples to the Mainland for analysis. At this time no laboratory in Hawaii performs blood lead analysis routinely. All 3 labs participate in regular quality assurance programs. The measurement error for the atomic absorption spectrometry method is approximately +2pg/dL. To avoid contamination, venous blood was drawn when ever possible; 237(61%) of all samples were venous samples. However, some of the clinics preferred to take capillary samples, and they were instructed on. how to clean the finger appropriately. Interviews were conducted over the phone in those families who had not been recruited by one of our research assistants. The questionnaire contained questions about the Child's behav ior and health, the child's home, risk factors for lead poisoning such as parents' occupation and hobbies. Ceramic dishes, edu cation and income level (Appendix). Test results were returned to the health care providers for children recruited in clinics and to the parents for children recruited in preschools. Parents of children with blood lead levels of 10/Jg/dL and above were contacted and offered a home visit to check for lead in paint and other potential sources. A commercial kit for instant envi ronmental lead testing was used (LeadcheckTM). The zip code information was aggregated into larger geo 244 graphic areas with the goal of calculating mean levels of bloo i lead from at least 1.0 samples per area. To get a rough idea t ; which areas sampling proportions were higher or lower than v jj the entire study, a sampling index was calculated. The number e I TABLE 1: Locations of Sample Collection and Participation Rate Location Number Percent Mean blood Tested Participation Lead (pg/dl CLINICS PRESCHOOLS All OOH-Kauai ' Kaiser Moanalua Kaiser Honolulu S Kapiolani Waianae Coast Maui Medical Other All PTA(Kalihi) Olivet Baptist HCC-Waipahu HCC-Kailua HCC-Salt Lake Kamehameha/Waimanalo 445 166 70 67 .61- 12 49 20 124 62 22 15 17 9 9 7 7 .50% 26% 20% ? ? 7 23% .30% 25% 20% 20% 15% 20% 4.1 3.4 4.7 5.2 4.8 5.3 2.9 5.6 4.0 4.7 3.5 32 3.5 2.0 5.6 TABLE 2; Characteristics of Study Population Number Percent Census9C SEX male female 289 51 280 49 __ -- AGE RESIDENCE <1 year 1 year 2 years 3 years 4 years >5 years Oahu Kauai Maui Big Island 35 6 119 21 90 16 117 21 137 24 15 3 353 62 166 29 35 6 1 <1 -- ------- 4- -- --. -- --f ETHNICITY (n=334) FAMILY INCOME (n=314) EDUCATION OF PARENT (n-326) AGE OF HOME (n=330) Hawaiian Mixed Samoan Filipino Caucasian Japanese Chinese Black Other C$15,000 $15-30,000 >$30,000 <12 years High School College Graduates <15 yearn 15-30 years >30yeats 105 31 83 25 35 10 24 7 35 10 21 6 72 62 . 18 5 96 31 92 29 126 40 24 7 115 35 149 46 38 12 100 30 125 38 105 32 ____ -- -- -- -- j-- -- -- 10 21 69 20 29 44 7- 21 52 27 DUP040013882 Ha w a ii Me d ic a l Jo u r n a l --Vo l . 52, No. 9--Se p t e mb er 199. tests performed per geographic area was divided by the number of births in 1991 for the same geographic area. The resulting fig ure for each area was divided by the overall ratio, ie 389 teste by 19,880 annual births. This index is greater than one if proportion ately more children were tested in a particular area than across the State and less than one if proportionately fewer children were tested than across the State, The study made an effort to include many children from areas that were considered high-risk because of old housing, such as Waimanalo, Kalihi and Waianae. All data were entered into a spreadsheet. The statistical anal ysis was performed with the help of SAS, using standard proce dures for calculating prevalence rates, chi-squares, and T-tests. Results Altogether, 389 children were tested for lead. Characteristics of the study population are listed in Table 2. The mean blood lead level in tins study was 4.5pg/dL with a standard error of 0.11. That means fee population mean for children in Hawaii can be expected to lie between 4.3pg/dL and 4.7pg/dL, assum ing feat fee study participants are representative of fee popula tion. The overall distribution of blood lead levels (Figure 1) shows feat over 50% of all lead levels were < 5fig/dL. Twelve children had a level above 9jig/dL (3% of all children tested). No child was found to have a level above 14pg/dL. Figure 2 illustrates fee distribution of blood lead levels by age. As expected, fee younger children had a somewhat higher pro portion of levels above 5(ig/dL. The mean blood lead level dif fers significantly (p=0.04) among age groups. Infants under one year had fee lowest mean level wife 3.8pg/dL, whereas 1- and 2year-old children had slightly higher mean levels (4.9pg/dL and 5. lfeg/dL respectively). This difference is significant (p=0.04). The sex of fee child was not associated with fee blood lead level; fee mean was 4.6/Jg/dL and 4.4g/dL for boys and" girls respectively. Information on ethnicity was available in only 278 children. Among those, no statistically significant differ ence in lead levels was found (Figure 3). Filipino and Japanese children were underrepresented in fee study. Mean blood lead levels by geographic area (Table 3) range between 3.2pg/dL on Maui and 5.6pg/dL in Aiea. Considering fee measurement error of fee lab method, this range is quite narrow. The sampling index indicates areas wife a high pro portion of samples, especially Waimanalo, Kalihi, Manoa and Moiliili/McCully, whereas Pearl City, Salt Lake, Waianae Coast, Windward Oahu and fee north shore were Jess well rep resented. The smaller fee standard error of fee mean for each area, fee more stable fee mean blood lead level for this area. The mean blood lead levels differed significantly among fee 3 laboratories: Kaulson 5.0jig/dL, SmifeKline 4.5p.g/dL, and Diagnostic Lab Services 3.4|ig/dL. The mean blood lead level for capillary samples was 4.9|ig/dL which statistically is signifi cantly higher than fee mean of 4.2p.g/dL for venous samples. The (Continued) > 1441 Kapiolani Blvd. Suite 1409, (Ala Moans Bldg) RATES AT A 20 YEAR LOW - ACT NOW! George Qiao President Big Loan Specialist SPECIALIZING IN JUMBO AND NO INCOME VERIFICATION FOR THE PROFESSIONAL AND SELF-EMPLOYED A POINT LOANS VS AVAILABLE John M. Shubert Sr. Exec. Loan Officer Jumbo Specialist REFINANCING & NEW MORTGAGES We Close Loans in 45 Days 30 Year Fixed 1 Year ARM 6.875% 7.24% 3.875% 4.20% Simple Rate APR Simple Rate APR 941-7711 Ha w aii Me d ic al Jo u r n a l --Vo l , 52, No. 9--Sept ember 1993 Allen R. Miller Manager Ghu Lan Shubert Sr. Exec, Loan Officer Jumbo Specialist DUP040013883 :z4b EDITORIAL (Continuedfrom page 232) Ma`i Ulu In this issue of the Journal, we rec ognize our neighbors to the south-- Amerika Samoa. American Samoans have the rights of citizenship in the USA. Out community includes a great many Samoans and Samoan athletes have put Hawaii on the world map. The coming and going between here and Samoa fill the air planes. It seems quite appropriate, therefore, that we have a research article on a pub lic health issue in Amerika Samoa-- "Stroke mid Traumatic Brain Injury in that southern Pacific group of the islands--known to Samoans as Ma'i Ulu." The author, Gloriajean L Wallace PhD, researched extensively on the subject while she was based in Hawaii at the University during the last decade. She is a speech-language pathologist with imposing credentials and has had a particular interest in the health and well-being of the Samoan people. JI Frederick Reppun MD STROKE AND TBI (MAT ULU) IN AMERIKA SAMOA (Continuedfrom page 240) BLOOD LEAD LEVELS AMONG CHILDREN IN HAWAII (Continuedfrom page 247) 13. Maxwell RJ. Samoan Temperament. PhD Diss. Ithaca, NY. Cornell Univ. 1969. 14. Keene, DTP. Bouses without Walls: Samoan Social Control. PhD Diss, Univ. of Hawaii. Honolulu, Hawaii. 1978. 15. Gerber E R. The Cultural Patterning of Emotions in Samoa. PhD Diss. Pro-Ed. Univ of California. San Diego, Ca. 1975. 16. Shore B. Sala `ilua: A Samoan Mystery. Columbia Univ. Press. New York, NY. 1982. 17. Freeman, D. Margaret Meade and Samoa: The Making and Unmaking of an Anthropological Myth. Cambridge, Mass. Harvard U. Press. 1983. 18. Baker P, Hanna H. and Baker T. (Eds). The Changing Samoans, Behavior and Health in Transition. New York, NY. Oxford U. Press. 1986. 20. Amerika Samoa Government Public Law 2079. Passenger Safety Law, Signed by the Governor on October 9,1988. 21. Anderson D, Fitzgerald M, Yee H, and Wallace G. Planning Rehabilitation Services for Rural and Remote Communities. In Wallace G., Adult Aphasia, Andover Medical Publishers. Ontario. Canada. 1993 22. Wallace G. Traumatic Brain Injury (Ma'i Ulu) in Amerika Samoa: Rehabilitation Needs and Services. Published report of research supported by a Fellowship from the World Rehabilitation Fund. Durham, New Hampshire (under a grant from the N1DRR, U.S. Department of Education). 1992. 4. Joselow MM. Banta JE, Fisher W. Environmental contrasts: blood lead levels of children in Honolulu and Newark. J Environ Health. 1974:37:10-2. 5, Needleman HI, Gunnoe C, Leviton A, Reed R, Peresie H. Maher C, Barret P. Deficits in psychologic and classroom performance of children with elevated dentine lead levels. NEnIJMed. 1979:300:689-95. 6- Needleman HI, Schell A, Belliner D, Leviton A, Allred EN. The long-term effects ofexposure to low doses of lead in childhood: an 11-year follow-up report NEngJMed. 1990322:83-8. 7. Piomeili S. Corash L, Corash MB, Seaman C, MushakP, Glover B, Padett R. Blood lead concen trations in a remote Himalayan population. Science. 1980:210:1135-7. 8. State of Hawaii: The Auditor. Study ofHealth ' Insurancefor lead Poisoning Screening. Special Report No. 92-10. April 1992. 9. Wiebe.RA, Anderson BS, LehmanCW.FuDJ. Lead poisorung in Hawaii:1990. Hawaii Medical JoumaL 199130:89-95. 10. U.S. Department of Health and Human Services. Centers for Disease Control- Preventing leadpoison ing in young children. Atlanta, Ga: CDC, Department ofHealth and HumanServices, 1985. 11. U.S. Department of Health and Human Services. Centers forDisease Control. Preventing leadpoison ing in young children. Atlanta, Ga: CDC, DepartmentofHealth and Human Services, 1991, 12. U.S. Department of Health and Human Services. Centers for Disease Control. Strategic Plan for the Elimination of Childhood Lead Poisoning. Department of Health and Human Services. Public Health Service. Atlanta, 1991. 13. U.S. Department of Health and Human Services. Agency for Toxic Substances and DiseaseRegistry. The nature and extent ofleadpoisoning in children in the United States: a report to Congress. Atlanta, Ga: ATSDR, 1988. J"- 1/4-30 HJ> , Classified Notices To plat* i Clauifitd Nodes: MEMBERS, pleat* tend typewritten ad to HMA office. NONMEMBERS, please call Lallaid at 521-0021. Four iin* minimum, approximately five words par lino. Rato* an $8.40 par line. EMPLOYMENT OPPORTUNITY POSITIONS AVAILABLE. Physician Placement Hawaii has openings for physicians $ other medical professionals all across the U S. Mainland as well as here in Hawaii. We also have candidates interested in a Hawaii position. Call Earl Pajari at 395-7099. REAL ESTATE LESS COMMISSION/MORE QUALITY I We offer reduced rates for our Buyers & Sailers! Many satisfied physician clients! Patricia Case, Esq. (R) Case Properties, Inc. Ph. 526-CASE 250 FOR SALE SERVICES 1987 ATL PORTABLE ultra-sound machine. Used less than 1 yr. In A/C storage since. Recently certifieo-functioning normally. Harold Lawson, MD 261 -0802. ITEMS FOR SALE: Ritter III electric, fully articulated procedure table. Procto, lithotomy, table & chair positions. Comes with headrest, chair arms, & adjustable armboard. Soft blue & like new. $3,300. UMF 5160 soft blue exam table, 2 drawers & electric olutlet (right side access) Like new. $400. Halogen "Coolspot* procedure lights mounted on mobile stand. Two available. Excellent condition. $400 each. Scale $80. Office chairs, charcoal grey tweed with armrests. Two available. $100 each. If interested, call 524-3276 & leave messsage. Items available for inspection M-F 8:30-4:30. RENTALS WAIMANALO, OAHU. Beachfront. Beautiful beach home on magnificent white sand beach. Sleeps 8, $1500/week, Barbara, 733 Bishop, Ste. 1800, HNL, HI 96813; 808-531-1411. LOCUM TENENS PROVIDED. Internal Medicine and Family Practice available. Please contact Acute Care Medical Services. 262-4181, LOCUM TENENS AVAILABLE. Family Practice, Pediatrics, Urgent Care. No agency fees. Deal sfirect Phone 923-2981. LOCUM TENENS: Coverage for family practice, pediatrics and internal medicine. I can cover your medical office practice during your vacation and CME leave. For further Information contact Ruby De Alday, M.D., Family Practice, 2452 Tusitala St. PH #3, Honolulu. HI 96815, Ph. (808) 926-4078 OFFICES KUAKINI MEDICAL PLAZA. Office space to sub-lease. Terms nego. May sub-tease full or part-time. Call 524-5225; 833-5722. OFFICE SPACE available for full time practice in Queen's POB. Call 523-1600 OFFICE SPACE available for immediate occupancy near Ala Moana area. Ideal for professional practice. Long term okay. Contact John at: 373-8880. Ha w a ii Me d ic a l Jo u r n a l --Vo l . 52, No. 9--Se p t e mb e r 1993 DUP040013884