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ADULT PENNSYLVANIANS WORKING WITH LEADED MATERIALS
may be occupationally exposed to lead
BY REMY BABICH, PHD
PENNOSHS PROGRAM MANAGER AND CONTRACT EPIDEMIOLOGIST, DIVISION OF ENVIRONMENTAL HEALTH EPIDEMIOLOGY, BUREAU OF EPIDEMIOLOGY, PENNSYLVANIA DEPARTMENT OF HEALTH
Lead is a naturally occurring, toxic metal found in the Earth’s crust, and exposure is associated with many negative health outcomes. It has been traditionally used in pipes, paint, and gasoline due to its resistance to corrosion, malleability, and other properties. Although the use of lead has been banned in many materials, it is still used as an additive in battery manufacturing, bridge paint, and metal alloys. This creates the need for occupations in which the disposal, maintenance, production, and recycling of lead materials occurs. The risk of lead exposure and associated adverse health effects is high among workers within these occupations. It is an issue that needs to be prioritized and addressed, through collaborations of multiple agencies, to protect the wellbeing of the Pennsylvania (PA) workforce.
Individuals working in furniture restoration, construction and automobile repair, metal smelters and foundries, bridge sanding and painting, and battery manufacturers are among those at greatest risk. These industries employ upwards of half a million people in PA, making workplace lead exposure surveillance a primary concern. Monitoring workplace lead exposure can be accomplished by taking a venous blood sample to measure blood lead levels (BLLs). According to the National Institute for Occupational Safety and Health (NIOSH), a BLL ≥ 5 µg/dL is considered elevated in adults. PA has been, and continues to be, among the top states with adult BLLs that well exceed the elevated NIOSH case classification of 5 µg/dL. The annual prevalence rate of BLLs ≥ 25 µg/dL among adult employed Pennsylvanians in 2019 was 11.9 per 100,000. In the last five years, up to 1,300 Pennsylvanians annually have tested high (greater than 25 µg/dl BLL) and between 300 and 600 of those annually tested are newly reported cases.
Although incidence (new cases) and prevalence (existing cases) rates have declined over time, the number of individuals impacted is still great and is likely underestimated. For example, self-employed persons working in home renovation may not know that they should be monitoring their BLLs. In addition, physicians may not be aware of the many symptoms associated with lead poisoning and therefore may not recommend a blood lead test during diagnosis.
Lead cannot break down and serves no biological function in the body. Therefore, no amount of lead in blood is safe. Over time, lead can accumulate in bones, circulate in the blood, and cause damage to major organs and organ systems. Specifically, lead can harm the brain and result in symptoms such as loss of concentration, headache, irritability, difficulty remembering, and dizziness. In extreme cases, brain swelling may occur. Low level lead exposure in adults has recently been linked to an increased risk of cardiovascular disease. Lead induces reproductive toxicity in both males and females and may cause infertility. Other symptoms of lead exposure include fatigue, anemia, nausea and vomiting, anorexia, and joint and muscle pain. Lead has also been associated with hearing loss and kidney disease. Smoking increases oxidative stress which may worsen the symptoms associated with lead exposure. Due to lead contaminated tobacco, individuals who smoke, and their families, are at greater risk for lead exposure.
Adult Pennsylvanians working with leaded materials may be occupationally exposed to lead. The primary route of exposure at work is through inhaling lead fumes or dust. Additionally, individuals may unknowingly ingest lead-contaminated food or water. Not washing hands after handling leaded products will increase the likelihood of ingestion. The Occupational Safety and Health Administration (OSHA) has regulations to help protect workers from occupational lead exposure. If lead exposure is a known risk at the workplace, the employer is required to provide a safe working environment, which includes but is not limited to providing safety training, installing ventilation systems, and supplying personal protective equipment.
Occupational exposure increases the risk of take-home lead. Take-home lead exposure occurs when people exposed to lead at work or in other activities unintentionally bring lead into their homes. This is often in the form of lead dust that can be carried home on clothes, shoes, skin, or hair, exposing other family members including children. Children, as well as women who are pregnant or are planning to become pregnant, are at greater risk for the adverse effects from lead exposure. Washing hands, changing out of work clothes and shoes before entering the home, and routinely cleaning the car that is used for work travel can help protect families from take-home lead exposure.
Other non-occupational sources of lead exposure can contribute to an individual’s lead burden or increase the likelihood of take-home lead. Some common activities that increase the risk of lead exposure include home restoration projects (especially sanding walls with leaded paint), fishing and hunting, metalwork, art restoration and stained-glass work, cooking with imported ceramicware or spices, wearing imported cosmetics or using imported medicines, and drinking home-distilled liquids such as moonshine. Due to the traditional use of lead in pipes, older homes built before 1986 may contain leaded pipes that increase the risk of ingestion of lead contaminated drinking water. Homes built before 1978 may contain lead paint which contributes to lead dust in the home once it begins to peel and crack. In rare cases, retaining a bullet or bullet fragments after a gunshot wound can result in continuous exposure to lead in adults.
Given the number of symptoms associated with lead exposure, along with the many potential sources, it is important for healthcare practitioners to ask questions about employers, workplace activities, and hobbies when collecting patient information and taking a patient history. If reasonable suspicion exists for lead exposure, a BLL test should be conducted. Test results of BLLs ≥5 µg/dL among individuals ≥16 years of age are reportable to the PA Department of Health (DOH) by law (28 Pa. Code § 27.34). The newly funded Pennsylvania Occupational Safety and Health Surveillance (PennOSHS) program within the PA DOH monitors workplace injury and illness in PA, including elevated BLL reports. It is critical to include employer and demographic information with test results, as this greatly enhances PA DOH lead surveillance. Many test results are submitted with “Unknown” employers which hinders the ability of PennOSHS to collaborate with industries and occupations that require updated lead exposure safety information. In efforts to increase surveillance, PennOSHS is currently conducting interviews of Pennsylvanians with elevated BLLs and no additional workplace information. One effective way to collect relevant patient information would be to revise patient intake forms to include questions on employers and hobbies.
It is important for healthcare practitioners to follow up with patients after a BLL test has been conducted and to determine the best course of action to reduce elevated BLLs. The most effective way to reduce lead toxicity is to eliminate the source of lead exposure. However, that may not be feasible especially if an individual is exposed at work and depends on that work for their livelihood. Discussing best practices to reduce lead exposure in both occupational and non-occupational settings with patients will help mitigate personal and take-home lead exposures. These may include:
• Wash hands often, especially before eating, drinking, smoking, or leaving the workplace. • Only eat or drink in a designated clean space when at work. • Use the appropriate personal protective equipment (PPE) when working with lead, such as gloves and respirators. Ensure that respirators, and other PPE, fit properly. • Clean the car that is used to travel to and from work, as lead dust may accumulate there. • Remove lead contaminated clothes and shoes at work and change into clean clothes before returning home.
In extreme cases, chelation therapy has been used to lower an individual’s BLL. Chelation therapy involves the administration of a medication, such as a chelating agent, that will bind to metals in the blood so that they may be excreted through urine. Although chelation therapy has been shown to help remove lead from the body, it does not reverse damage to organs that may have occurred. Due to the cellular toxicity of lead, treatment with antioxidants has also been shown to help in reducing harmful effects. It is also important to make sure patients are aware of take-home lead and how that may be impacting their families. If children are living in the home, and there is a chance of takehome lead exposure, then a blood lead test for the child should be recommended. BLLs should be monitored in both adults and children until the BLL has declined to less than 5 µg/dL or 3.5 µg/dL respectively. Follow-up testing is dependent upon severity of exposure and age. The higher the initial BLL and younger the individual, the more quickly follow-up and subsequent testing should be conducted to ensure that the source of lead exposure has been removed. Individuals exposed to lead should contact their primary care physician for blood lead testing and to seek medical treatment.
The PA DOH and PennOSHS program welcomes healthcare practitioners in its efforts to reduce adult lead exposure in Pennsylvania. Some resources that the PennOSHS program can offer include help in developing educational material or providing guidance on ways to collect and interpret patient information for lead exposure risk. If you are interested in learning more information, or building a partnership, please reach out to PennOSHS (email: dehe@pa.gov). PennOSHS will continue to take action to reduce lead exposure that impacts so many Pennsylvanians.
Note: Data were collected from the PA National Electronic Disease Surveillance System (PA-NEDSS) program and the Bureau of Labor Statistics (BLS) Geographic Profile of Employment and Unemployment. For more information on PennOSHS and adult blood lead surveillance please see the PennOSHS 20212022 Annual Report.
