Athipat Athipongarporn, Adisak Plitponkarnpim, Chatchai Im-arom, Ratchaneewan Sinitkul,

Sakda Arj-ong Vallipakorn

Department of Pediatrics Faculty of Medicine Ramathibodi Hospital

Mahidol University

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

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

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)

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

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

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

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)

1st: Rapport. February, 2013

2nd : Interview by pilot questionnaire. February, 2013

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

Demographic data Risk factors

School and Home duration Father’s and mother’s

occupation Home products Interior and exterior paint Playground Industry

Program STATA 13

Univariate analysis & Multivariate logistic regression analysis

p-value

Odds ratio (95 % Confidence Interval)

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

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

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

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

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

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

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

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

Different time of collection

Blood sampling

Environmental sampling

Insufficient information of manufacturing in the study area

Screening BLL among children in industrial area

Raise community awareness in lead poisoning by the research evidences for Thailand policy and future researches

All students and teachers in Ban Nong Hat Yai School

The psychologists Boonrananives Foundation Olympus Company, Lead Paint Handheld XRF

Analyzer

Factory

School

100m

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

Low IQ, Hearing, Growth

Encephalopathy Nephrotoxic

Encephalopathy Anemia

DEAD

www.aafp.com

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

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

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

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