Lead Poisoning in Children Billiamin A. Alli, FRSH East Lansing, Michigan
In this study of the phenomenon of lead poisoning in children, the various approaches that several cities have employed to combat the problem are discussed. Several suggestions for dealing with the situation are proposed. These include educational programs, followup reports, legislation, and research. Knowledge of etiology, pathogenesis, pathophysiology, and epidemiology of lead poisoning in children could be translated into programs directed toward the control and prevention of this health hazard. The studies presented here are possible approaches that could be utilized in solving this serious problem. A number of cities in the US and in other countries have approached the problem in different ways with varying degrees of success. The Baltimore City Health Department, in 1935, started a free blood-lead laboratory service.' An increasing awareness by the pediatric services of large local hospitals provided relatively accurate morbidity data and called attention to the seriousness of the problem. A field follow-up program for each case and an educational program were started in coordination with other efforts. The Bureau of Industrial Hygiene was assigned the primary responsibility for lead paint poisoning investigation. The homes were visited and paint samples were taken to be tested for lead content. Where lead-bearing paint was found accessible to children, it was ordered removed under the Ordinance of Hygiene of Housing. This requires every dwelling to be maintained in good repair and to be fit for human habitation; where any condition is found to be dangerous or detrimental to life or health, the Commissioner of Health may order it removed. In 1951, by further legislative control, a regulation was adopted under the same ordinance prohibiting the use of paint
From the Department of Biology and Health Sciences, City University of New York. Requests for reprints should be addressed to Billiamin A. Alli, 2444A Wyoming Street, Dayton, OH 45410.
containing lead pigment for interior painting of dwellings. In 1958, a paint labeling ordinance was passed in Baltimore which required a warning label on paint containing more than one percent lead. In 1956, Dr. Huntington Williams, then Commissioner of Health of Baltimore, planned a vigorous campaign to eradicate lead poisoning in children. The Lead Poisoning Prevention Committee was organized, composed of staff members directly concerned with the problem. In 1957, in order to assess the prevalence of lead paint in Baltimore homes with a view to its possible removal as a preventive measure, the Committee conducted a survey of 100 randomly selected blocks of dwellings in the blighted areas of the inner city for lead paint sampling by a rapid screening test. Lead in excess of one percent in a paint was detected in 70 percent of 667 dwelling units and 47 percent of these units were occupied by children under three years of age.1 Owners were sent notices for removal of paint. In 1961, the possible extension of enforced lead paint removal to all dwelling units in those census tracts having the highest incidence of child plumbism was considered but was economically unfeasible. A more practical approach is reporting the locations of all flaking paint and broken plaster and notifying the owner that repair is essential. This follows the visit by public health nurses, sanitarians, and building inspection personnel. Where there is evidence of chewing on painted surfaces and actual cases of lead paint poisoning, investigation is made by the Bureau of Industrial hygiene. All peeling paint is ordered to be removed. Complete removal is ordered of all intact lead paint surfaces on window sills, door frames and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
windows below the four-foot level, on stair rails, stair treads, and four inches back on the hinge and latch edges of doors. Where lead-bearing paint is intact, its removal is not required on walls in good condition nor on any surface below the four-foot level not presenting a chewing surface. A mailing kit was devised by the Maryland Bureau of Laboratories to facilitate submission of paint-scraping samples. The tests for paint samples and blood lead examinations for the entire state have been done since 1964 by the Baltimore Branch of the Bureau of Laboratories, Maryland State Department of Health. The Lead Paint Poisoning Prevention Committee conducted a three-year, intensive, educational pilot program with a personto-person approach in selected census tracts where the incidence of childhood plumbism had been consistently high. Repeated house visits were made by a trained sanitarian, assigned exclusively to the project, and frequent reminder letters were sent to parents or guardians of the susceptible children. Simple leaflets based on the educational level in the study area were used. More than 1 ,500 families with children under four years of age were interviewed and six letters on the dangers of lead paint poisoning were sent to each family between visits. No significant statistical advantage could be shown for the program, probably because the population was highly mobile. Only one third of the families remained in residence for the entire study. The morbidity data in recent years suggests a degree of success in the control of childhood lead poisoning in Baltimore. In the three-year period, 1967-1969, there were 141 combined instances of clinically diagnosed lead poisoning and abnormal lead absorption as compared with 176 instances in the prior three years, 1964 through 1966, a drop of almost 50 percent.1 In New York City, since 1955, a screening program for early diagnosis and treatment has been carried out and, as a result, the number of children with lead poisoning reported annually 797
rose from an average of 29 during 1950-1954 to over 500 in 1964.2 Simultaneously, the fatality rate dropped from 27 percent (1950-1954) to 1.4 percent in 1964.2 The New York Scientists' Committee for Public Information announced, in 1968, that it would assist a community-action group in a case-finding study of lead poisoning in New York slums.3 A device that measures lead content in paint is currently used. The New York City Health Code states in reference to leaded paints: When the department finds that there is a paint containing more than one percent of metallic lead based on the non-volatile content of the paint on the interior walls, ceilings, door, baseboards, or window sills and frames of any dwellings, it may order the removal of the paint, under such safety conditions as it may specify, and the refinishing of such interior surfaces of the apartment, ....4 In 1966, the Chicago Board of Health launched a major case-finding program. Over 60,000 children were tested for urine coproporphyrin or blood lead.5 There was a marked rise in cases reported and a sharp decrease in fatality rate. In the summer of 1965, as a result of several cases of lead poisoning, the Citizens' Committee to End Lead Poisoning was organized in the East Garfield Park district of Chicago. With the assistance of Project House, of the American Friends Service Committee, they organized an educational and casefinding campaign. The Board of Health and later the Medical Committee for Human Rights assisted with urinary coproporphyrin and lead testing. A dedicated group of teenagers spent their summer and weekends in canvassing and other work for the project. Recommendations A planned approach for control and prevention should consist of several coordinated actions: (1) educational campaigns for health professionals and the public; (2) case-finding and fol-
low-up; (3) legislation; (4) research; and (5) improved housing.
Educational Campaign Educational programs for the medical profession including nurses and other health workers can be in the form of talks and exhibits. Literature can be distributed at medical and 798
nursing school hospital conferences, professional meetings, and conventions. Physicians should make routine inquires about pica in children, one to six years old, methods of screening and diagnosis, and available facilities and services for detecting childhood lead poisoning. Parents with young children should be informed of the hazards, sources, and methods by which lead poisoning occurs and the danger of pica. A well-informed public can take an active role in programs to reduce and eliminate lead poisoning. The effectiveness of such action by private citizens was illustrated by the citizens' organization in Chicago.
Case-Finding and Follow-Up Program Screening in clinics, hospitals, and health projects should be done by: 1. Routine inquiry about pica in children six years old or younger. 2. Blood lead level determinations in all children with a history of pica, and in siblings of children with either positive lead poisoning or pica. 3. Screening of children from highrisk areas by other inexpensive methods (urinary delta amino levulenic acid determinations) should be considered. 4. Re-evaluation, at regular intervals, of children from high-risk areas.
Home Surveys Home visits are especially useful to evaluate the home situation for evidence of flaking paint and as a personto-person approach with parents. Provision of prompt service in blood lead determinations by local health departments can reduce the risk of encephalopathy and irreversible damage in the patient. Follow-up programs to prevent reexposure are essential. Blood lead determinations at regular intervals, after discharge from hospital, are necessary. The efforts of health workers and social workers are extremely important. Removal of lead from the environment should be done before the child returns from the hospital. When it is not feasible to remove the lead from a home, the child should be placed in a convalescent or foster home until his home has been made safe.
Legislation 1. Reporting, by physicians, of lead poisoning cases to local health
departments is not necessary in many cities. If it is made mandatory, the health departments will be aware of the problem and could take necessary steps toward prevention. 2. Ordinances should require that dwelling places be maintained in good repair and be fit for human habitation. Conditions found dangerous and detrimental to life and health must be removed. Enforcement of laws is most important, however, this has been lacking in many instances. 3. The use of paints containing lead for indoor purposes, and on taps and furniture should be prohibited.
Research Research in behavioral patterns is necessary, particularly in the area of pica. The approach to the problem of pica should be studied in detail. In the past, children with lead poisoning were returned after treatment to the same environment with a strong admonition to parents not to allow the child to eat paint, dirt, paper, etc. It has been observed that large numbers of children admitted with accidental poisoning have pica. Hence, more research in the problem of pica would help not only the lead poisoning problem, but other accidental poisoning problems.
Improved Housing Slum clearance is not the least important way to solve the problem of lead poisoning. Clearing of old, dilapidated houses and providing modern low-cost housing should be the ultimate aim of the prevention program. Every large city should have a prevention program since the ultimate cost of lead poisoning is borne by the community in terms of wasted human resources, institutionalization of victims, and the resulting burdens on municipal health facilities and finances. Literature Cited 1. Kaplan E: Environmental aspects of childhood lead poisoning. Presented to the 97th Annual Meeting of the American Pub-
lic Health Association, November 1969 2. Jacobziner H: Lead poisoning in childhood: Epidemiology, manifestations and prevention. Clin Pediatr 5:277-286, 1966 3. Scientist and citizen: A call for help. Statement of the Scientists' Institute for Public Information. April 1968, 49-89 4. The New York City Health Code. Section 173.13, sub-section (d) 5. Blanksma LA, Sachs HK, Murray EF, et al: Incidence of high blood lead levels in Chicago children. Pediatrics, 44(5) :661-667, 1969
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
In this study of the phenomenon of lead poisoning in children, the various approaches that several cities have employed to combat the problem are discussed. Several suggestions for dealing with the situation are proposed. These include educational programs, followup reports, legislation, and research. Knowledge of etiology, pathogenesis, pathophysiology, and epidemiology of lead poisoning in children could be translated into programs directed toward the control and prevention of this health hazard. The studies presented here are possible approaches that could be utilized in solving this serious problem. A number of cities in the US and in other countries have approached the problem in different ways with varying degrees of success. The Baltimore City Health Department, in 1935, started a free blood-lead laboratory service.' An increasing awareness by the pediatric services of large local hospitals provided relatively accurate morbidity data and called attention to the seriousness of the problem. A field follow-up program for each case and an educational program were started in coordination with other efforts. The Bureau of Industrial Hygiene was assigned the primary responsibility for lead paint poisoning investigation. The homes were visited and paint samples were taken to be tested for lead content. Where lead-bearing paint was found accessible to children, it was ordered removed under the Ordinance of Hygiene of Housing. This requires every dwelling to be maintained in good repair and to be fit for human habitation; where any condition is found to be dangerous or detrimental to life or health, the Commissioner of Health may order it removed. In 1951, by further legislative control, a regulation was adopted under the same ordinance prohibiting the use of paint
From the Department of Biology and Health Sciences, City University of New York. Requests for reprints should be addressed to Billiamin A. Alli, 2444A Wyoming Street, Dayton, OH 45410.
containing lead pigment for interior painting of dwellings. In 1958, a paint labeling ordinance was passed in Baltimore which required a warning label on paint containing more than one percent lead. In 1956, Dr. Huntington Williams, then Commissioner of Health of Baltimore, planned a vigorous campaign to eradicate lead poisoning in children. The Lead Poisoning Prevention Committee was organized, composed of staff members directly concerned with the problem. In 1957, in order to assess the prevalence of lead paint in Baltimore homes with a view to its possible removal as a preventive measure, the Committee conducted a survey of 100 randomly selected blocks of dwellings in the blighted areas of the inner city for lead paint sampling by a rapid screening test. Lead in excess of one percent in a paint was detected in 70 percent of 667 dwelling units and 47 percent of these units were occupied by children under three years of age.1 Owners were sent notices for removal of paint. In 1961, the possible extension of enforced lead paint removal to all dwelling units in those census tracts having the highest incidence of child plumbism was considered but was economically unfeasible. A more practical approach is reporting the locations of all flaking paint and broken plaster and notifying the owner that repair is essential. This follows the visit by public health nurses, sanitarians, and building inspection personnel. Where there is evidence of chewing on painted surfaces and actual cases of lead paint poisoning, investigation is made by the Bureau of Industrial hygiene. All peeling paint is ordered to be removed. Complete removal is ordered of all intact lead paint surfaces on window sills, door frames and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
windows below the four-foot level, on stair rails, stair treads, and four inches back on the hinge and latch edges of doors. Where lead-bearing paint is intact, its removal is not required on walls in good condition nor on any surface below the four-foot level not presenting a chewing surface. A mailing kit was devised by the Maryland Bureau of Laboratories to facilitate submission of paint-scraping samples. The tests for paint samples and blood lead examinations for the entire state have been done since 1964 by the Baltimore Branch of the Bureau of Laboratories, Maryland State Department of Health. The Lead Paint Poisoning Prevention Committee conducted a three-year, intensive, educational pilot program with a personto-person approach in selected census tracts where the incidence of childhood plumbism had been consistently high. Repeated house visits were made by a trained sanitarian, assigned exclusively to the project, and frequent reminder letters were sent to parents or guardians of the susceptible children. Simple leaflets based on the educational level in the study area were used. More than 1 ,500 families with children under four years of age were interviewed and six letters on the dangers of lead paint poisoning were sent to each family between visits. No significant statistical advantage could be shown for the program, probably because the population was highly mobile. Only one third of the families remained in residence for the entire study. The morbidity data in recent years suggests a degree of success in the control of childhood lead poisoning in Baltimore. In the three-year period, 1967-1969, there were 141 combined instances of clinically diagnosed lead poisoning and abnormal lead absorption as compared with 176 instances in the prior three years, 1964 through 1966, a drop of almost 50 percent.1 In New York City, since 1955, a screening program for early diagnosis and treatment has been carried out and, as a result, the number of children with lead poisoning reported annually 797
rose from an average of 29 during 1950-1954 to over 500 in 1964.2 Simultaneously, the fatality rate dropped from 27 percent (1950-1954) to 1.4 percent in 1964.2 The New York Scientists' Committee for Public Information announced, in 1968, that it would assist a community-action group in a case-finding study of lead poisoning in New York slums.3 A device that measures lead content in paint is currently used. The New York City Health Code states in reference to leaded paints: When the department finds that there is a paint containing more than one percent of metallic lead based on the non-volatile content of the paint on the interior walls, ceilings, door, baseboards, or window sills and frames of any dwellings, it may order the removal of the paint, under such safety conditions as it may specify, and the refinishing of such interior surfaces of the apartment, ....4 In 1966, the Chicago Board of Health launched a major case-finding program. Over 60,000 children were tested for urine coproporphyrin or blood lead.5 There was a marked rise in cases reported and a sharp decrease in fatality rate. In the summer of 1965, as a result of several cases of lead poisoning, the Citizens' Committee to End Lead Poisoning was organized in the East Garfield Park district of Chicago. With the assistance of Project House, of the American Friends Service Committee, they organized an educational and casefinding campaign. The Board of Health and later the Medical Committee for Human Rights assisted with urinary coproporphyrin and lead testing. A dedicated group of teenagers spent their summer and weekends in canvassing and other work for the project. Recommendations A planned approach for control and prevention should consist of several coordinated actions: (1) educational campaigns for health professionals and the public; (2) case-finding and fol-
low-up; (3) legislation; (4) research; and (5) improved housing.
Educational Campaign Educational programs for the medical profession including nurses and other health workers can be in the form of talks and exhibits. Literature can be distributed at medical and 798
nursing school hospital conferences, professional meetings, and conventions. Physicians should make routine inquires about pica in children, one to six years old, methods of screening and diagnosis, and available facilities and services for detecting childhood lead poisoning. Parents with young children should be informed of the hazards, sources, and methods by which lead poisoning occurs and the danger of pica. A well-informed public can take an active role in programs to reduce and eliminate lead poisoning. The effectiveness of such action by private citizens was illustrated by the citizens' organization in Chicago.
Case-Finding and Follow-Up Program Screening in clinics, hospitals, and health projects should be done by: 1. Routine inquiry about pica in children six years old or younger. 2. Blood lead level determinations in all children with a history of pica, and in siblings of children with either positive lead poisoning or pica. 3. Screening of children from highrisk areas by other inexpensive methods (urinary delta amino levulenic acid determinations) should be considered. 4. Re-evaluation, at regular intervals, of children from high-risk areas.
Home Surveys Home visits are especially useful to evaluate the home situation for evidence of flaking paint and as a personto-person approach with parents. Provision of prompt service in blood lead determinations by local health departments can reduce the risk of encephalopathy and irreversible damage in the patient. Follow-up programs to prevent reexposure are essential. Blood lead determinations at regular intervals, after discharge from hospital, are necessary. The efforts of health workers and social workers are extremely important. Removal of lead from the environment should be done before the child returns from the hospital. When it is not feasible to remove the lead from a home, the child should be placed in a convalescent or foster home until his home has been made safe.
Legislation 1. Reporting, by physicians, of lead poisoning cases to local health
departments is not necessary in many cities. If it is made mandatory, the health departments will be aware of the problem and could take necessary steps toward prevention. 2. Ordinances should require that dwelling places be maintained in good repair and be fit for human habitation. Conditions found dangerous and detrimental to life and health must be removed. Enforcement of laws is most important, however, this has been lacking in many instances. 3. The use of paints containing lead for indoor purposes, and on taps and furniture should be prohibited.
Research Research in behavioral patterns is necessary, particularly in the area of pica. The approach to the problem of pica should be studied in detail. In the past, children with lead poisoning were returned after treatment to the same environment with a strong admonition to parents not to allow the child to eat paint, dirt, paper, etc. It has been observed that large numbers of children admitted with accidental poisoning have pica. Hence, more research in the problem of pica would help not only the lead poisoning problem, but other accidental poisoning problems.
Improved Housing Slum clearance is not the least important way to solve the problem of lead poisoning. Clearing of old, dilapidated houses and providing modern low-cost housing should be the ultimate aim of the prevention program. Every large city should have a prevention program since the ultimate cost of lead poisoning is borne by the community in terms of wasted human resources, institutionalization of victims, and the resulting burdens on municipal health facilities and finances. Literature Cited 1. Kaplan E: Environmental aspects of childhood lead poisoning. Presented to the 97th Annual Meeting of the American Pub-
lic Health Association, November 1969 2. Jacobziner H: Lead poisoning in childhood: Epidemiology, manifestations and prevention. Clin Pediatr 5:277-286, 1966 3. Scientist and citizen: A call for help. Statement of the Scientists' Institute for Public Information. April 1968, 49-89 4. The New York City Health Code. Section 173.13, sub-section (d) 5. Blanksma LA, Sachs HK, Murray EF, et al: Incidence of high blood lead levels in Chicago children. Pediatrics, 44(5) :661-667, 1969
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
