Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees

Key Points
  • Lead exposures among newly arrived refugees may include environmental and occupational exposures, as well as household and personal items.
  • Table 1 describes the lead screening recommendations for newly arrived refugee infants, children, adolescents, and pregnant and lactating women and girls

    Table 1. Screening recommendations for all newly arrived refugee infants, children, adolescents, and pregnant and lactating women and girls

    Table 1. Screening recommendations for all newly arrived refugee infants, children, adolescents, and pregnant and lactating women and girls
    Recommended Screening Measures Population
    Initial lead exposure screening with blood test
    • All refugee infants and children ≤ 16 years of age
    • Refugee adolescents > 16 years of age if there is a high index of suspicion, or clinical signs/symptoms of lead exposure
    • All pregnant and lactating women and girls*
    Follow-up testing with blood test, 3-6 months after initial testing
    • All refugee infants and children ≤ 6 years, regardless of initial screening result
    • Children and adolescents 7-16 years with EBLL at initial screening
    • Consider repeat testing in adolescents > 16 years of age with risk factors
    *All newly arrived pregnant or breastfeeding women should be prescribed a prenatal or multivitamin with adequate iron and calcium. Referral to a healthcare provider with expertise in high-risk lead exposure treatment and management may be indicated for EBLLs.
  • Elevated blood lead level (EBLL) is defined as a single blood lead test (capillary or venous) with a result of ≥5 µg/dL. Elevated capillary screening results should be confirmed with blood drawn by venipuncture 1 – 3
  • See the CDC Childhood Lead Poisoning Prevention Program’s Recommended Actions Based on Blood Lead Level for information on confirmatory testing, clinical follow-up, and case management of children with EBLL.

Background

Lead is a known neurotoxicant, and exposure can result in EBLL 4. Around the world, including many countries where refugees originate or seek asylum, environmental lead hazards are common and may include leaded gasoline, industrial emissions, lead-based paint, and burning of waste containing lead. Other environmental and occupational exposures include living near or working in mines, ammunition manufacturing, smelters, or battery recycling facilities. Furthermore, household and personal use items have been associated with increased lead levels, both before and after US arrival, such as car batteries used for household electricity, lead-glazed pottery, pewter or brass utensils or cooking pots, pressure cookers, leaded crystal, and chipped or cracked dishes 5 – 8. Additionally, refugees may use or consume products contaminated with lead such as traditional remedies, herbal supplements, spices, candies, cosmetics, and jewelries or amulets. Table 2 lists examples of traditional remedies, cosmetics, and foods that have been associated with EBLL in children.

Table 2. Examples of regional or culture-specific exposures associated with elevated blood lead levels in children

Table 2. Examples of regional or culture-specific exposures associated with elevated blood lead levels in children
Exposure Region or Culture of Origin Reported Uses and Treatment Description
Azarcon or greta (alarcon, azoque, coral, liga, maria luisa, or rueda) or albayalde 9 – 11 Central America and Mexico Treatment believed to alleviate digestive problems such as upset stomach, infantile colic, constipation, diarrhea, or vomiting. Also used to soothe teething babies. Yellow or orange powder added to oil, milk, sugar, tea, or tortilla dough. It may also be present in lead-glazed ceramic ware or baby bottles.
Ba-baw-san, Bo Ying 12 China Believed to treat colic or respiratory symptoms Herbal medicine or gray powder
Bint Al Zahab (Daughter of Gold) 13 Iran Believed to treat colic and trigger early passage of meconium after birth Rock ground into a powder and mixed with honey and butter
Daw tway (Daw Tway Go Mo Dah),  gaw mo dah 14 Burma General infant remedy believed to treat digestive symptoms Brown pellets taken orally or topically
Kajal, kohl, and surma 15 – 16 Afghanistan, India, Pakistan Believed to improve eyesight, protect the eyes, and/or prevent the evil eye. Black powder mixed into a liquid and applied at eyebrow or periorbitally
Litargirio 17 Dominican Republic Used as a deodorant or antiperspirant, or as a burn or fungal (usually foot) treatment Yellow or peach-colored powder applied to the skin
Lozeena 18 Iraq Flavoring Bright orange spice added to foods for flavor, particularly rice and meat dishes
Pay-loo-ah 19 Southeast Asia Treatment believed to treat fever and rash Orange-red powder administered by itself or mixed in tea
Select Ayurvedic preparations 20 – 21 India Treatment for wide range of ailments Preparations vary in appearance and how they are administered.
Tamarind candies (and packaging) 22 – 23 Mexico Candies often consumed by young children Candy often brought by visiting family members, sold by ethnic markets (embargoed in California), and available through itinerant vendors. “Bolirindo” lollipops by DulmexTM are soft and dark brown. Candied jams are typically packaged in ceramic jars.
Tiro (tozali and kwalli) 24 Nigeria Eye cosmetic used to improve vision or ward off the evil eye Fine powder often applied to the eyelid

Mobile infants and young children are particularly at risk for lead exposure given their tendency to mouth objects, and often have increased contact with dust, dirt, and surfaces potentially contaminated with lead 4. This tendency for mouthing, as well as ingesting non-nutritive substances (pica) contaminated with lead, is exacerbated by the lead’s sweet taste. Infants and young children are predisposed to increased BLL at lower exposure levels because they have a greater ratio of body surface area to mass than adults 4, 25. Malnourished children may also be at an increased risk for EBLL, likely through increased intestinal lead absorption mediated by micronutrient deficiencies such as iron, calcium, or zinc 26 – 27. In one analysis of lead exposures in children <2 years of age (n=642) in a Thai refugee camp, moderate-to-severe anemia (hemoglobin <10 g/dL) was associated with EBLL, and lead acid car batteries and traditional remedies were the most important sources of exposure 6. Mouthing of cosmetic products was also a suspected contributor 6. Certain subpopulations of women are also at increased risk for lead exposure; these include refugees and other recent immigrants. In one study, foreign-born pregnant women in the United States were 8.2 times more likely than non-foreign-born women to have EBLLs 28. Among the groups studied, women from Bangladesh, Mexico, and Pakistan had the highest BLLs 28.

Refugee children arriving in the United States have higher average rates of EBLL (≥5 µg/dL) than US-born children. However, EBLL rates vary among refugee populations. Analyses of domestic data have revealed that the prevalence of EBLL among newly arrived refugee children may be in excess of 40% in certain groups 5, 14, 29 – 33. These reports suggest that country of origin, country of last residence, and age are strong predictors of EBLL among newly arrived refugee children 33 – 34. In a recent assessment of refugee children 6 months to 16 years of age (n=27,284) resettled in 11 states (CO, ID, IL, KY, MA, MN, NC, NY [excluding New York City], TX, UT, and WA) and one county (Marion County, IN), the prevalence of EBLL at the initial domestic screening was 19.3% (n=5,275) 25. EBLL was associated with younger age (22.8% of children <7 years of age had EBLL, while 16.5% of children ≥7 years of age had EBLL), male sex, and country of overseas examination (EBLL prevalence was higher in children examined in India, Afghanistan, Burma, and Nepal) 25. For comparison, data indicate that 2.6% of children 1–5 years of age in the United States had EBLL ≥5 µg/dL (2007–2010) 35.

Refugee children are at continued risk for EBLL from ongoing exposures after arrival in the United States. One analysis of lead exposure among refugee children (n=705) 0–16 years of age in Syracuse, NY, found that 17% of refugee children had EBLL (≥5 µg/dL) upon initial screening 36. Of those who had EBLL at initial screening, 10% had persistent EBLL at follow-up (3–6 months after arrival), and 30% were found to have increased BLL at follow-up 36. Among 1,121 refugee children (6 months–16 years of age) resettled in five jurisdictions (CO, IL, IN [Marion County], MN, and NY) who had both initial and follow-up lead screening results (3–6 months after initial screening), 183 (16.3%) had EBLL at the initial and follow-up screening 25. Additionally, 71 (6.3%) children had EBLL at follow-up but had normal BLL at the initial screening 25. Overall, 117 (10.4%) children experienced a ≥2 µg/dL increase in BLL upon follow-up testing. Although increases in BLL were more common in younger children, data suggest that older children (including adolescents) are also at risk for increases in BLL after resettlement to the United States 25. Most often, lead exposures among children with new or increasing BLL after arrival include lead-based paints in older housing and lead-contaminated soil where children reportedly play 37. Furthermore, certain behaviors, such as pica (e.g., eating soil or paint chips); picking or handling of loose contaminated paint chips, plaster, or putty; or chewing on contaminated painted surfaces can be sources of lead exposure 37. Children, as well as adults, may also be at risk for EBLL after arrival due to continued use of spices, candies, traditional cosmetic products, and cookware brought from overseas 38 – 39. Some of these products may also be purchased in the United States.

Clinical Presentation

Children

BLLs ≥10 µg/dL are known to impair intelligence and neurodevelopment 40. A recent study suggests that the magnitude of decrease in intelligent quotient (IQ) for each incremental increase in BLL is greatest among children with BLLs below 10 µg/dL 41. At higher BLLs, acute symptoms of toxicity may appear. Above 60 µg/dL, children may experience headaches, abdominal pain, anorexia, constipation, clumsiness, agitation, and lethargy 41. At 70 µg/dL, children may develop severe neurological complications, including seizures, ataxia, mental status changes, coma, and death 27. Although severe poisoning is rare in the United States, the death of a newly arrived 2-year-old Sudanese refugee with a BLL of 391 µg/dL in 2000—which was the first lead-poisoning-related death in the United States in a 10-year period—underscores the importance of early identification and management of EBLL in resettled refugee children 42.

Pregnant and Lactating Women and Adolescent Girls

Lead exposure (and associated toxicity) remains a public health concern for certain groups of women of childbearing age (15–44 years), developing fetuses, and nursing infants 43. Lead toxicity in pregnant women has been associated with an increased risk of spontaneous abortion, gestational hypertension, abnormal fetal neurodevelopment, and low birthweight. Additionally, strong evidence shows that prenatal lead exposure impairs children’s neurodevelopment, placing them at increased risk for developmental delay, reduced IQ, and behavioral problems 43. Because more than 90% of lead is stored in bone, it is thought that long-term exposure in women may cause lead to accumulate in bone and be released during times of higher metabolism, such as pregnancy and lactation, potentially placing the fetus or nursing infant at risk of exposure 43.

Recommendations for Post-arrival Lead Screening

All refugee infants and children 0-16 years of age should be evaluated for lead exposure with a blood lead test. Older refugee adolescents should be tested if there is a high suspicion or clinical signs/symptoms of lead exposure, or if currently pregnant or lactating. A history of lead exposure includes questions about signs and symptoms (e.g., developmental history), behaviors (e.g., pica), and potential exposures such as use of cosmetics (purchased overseas), ceramics, spices, foods, tobaccos, or remedies 17 – 18, 24. An in-depth discussion of the clinical management of EBLL is beyond the scope of this document.

Reference Values for EBLL

An EBLL is defined as a single blood lead test (capillary or venous) result at or above the CDC blood lead reference value of 5 µg/dL established in 2012 44. This reference value was determined by using data from the National Health and Nutrition Examination Survey (NHANES). Elevated capillary screening results should be confirmed with blood drawn by venipuncture 1 – 3. For additional information on lead surveillance, see CDC’s Childhood Lead Poisoning Prevention Program.

Pediatric Recommendations

Given the neurodevelopmental and health complications associated with EBLL, all refugee infants and children ≤16 years of age should be evaluated for lead exposure at the domestic medical screening visit with a blood test. Adolescent refugees >16 years of age should be tested if there is a high index of suspicion (e.g., sibling with EBLL, environmental risk factors), if there are clinical signs or symptoms of EBLL, or if pregnant or lactating. Venous or capillary lead levels should be reported to state or local lead programs. Clinicians may refer to the CDC Summary of Recommendations for Follow-up and Case Management of Children Based on Confirmed Blood Lead Levels for additional information.

Within 3–6 months after initial testing, a blood lead test should be repeated for all refugee infants and children ≤6 years of age, regardless of initial screening BLL result. Repeat testing is also recommended for refugee children and adolescents 7-16 years of age who had EBLL at initial screening. Repeat testing is also warranted in adolescents >16 years of age with specific risk factors (e.g., sibling with EBLL, environmental risk factors). Additional information on case management and follow-up of EBLL is available in Managing Elevated Blood Lead Levels among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention pdf icon[PDF – 152 pages]. Clinicians should also familiarize themselves with local lead resources, as well as state or local recommendations for treatment and prevention.

Recommendations for Pregnant and Lactating Women and Adolescent Girls

CDC and the American College of Obstetricians and Gynecologists (ACOG) do not recommend routine universal screening for EBLL for all pregnant or lactating women and adolescent girls in the United States. However, a risk evaluation of every pregnant or lactating women is encouraged, with screening recommended when one or more risk factors is identified 45. Common risk factors for EBLL in pregnant women and girls include pica behaviors, occupational exposure, use of traditional remedies or supplements, cosmetics manufactured overseas, use of traditional lead-glazed pottery, and nutritional status (e.g., low body mass index [BMI]) 43. Importantly, recent emigration from or residency in areas where ambient lead contamination is high is considered an indication for screening 45. Because refugees generally have lived in areas where ambient lead exposure is high, it is recommended that all newly arriving pregnant or breastfeeding women be screened for lead exposure at the domestic medical screening with a blood test. A BLL of ≥5 μg/dL in pregnant women indicates prior or ongoing lead exposure 43. Follow-up blood lead testing is recommended for those whose BLL is ≥5 µg/dL upon initial screening. Frequency of follow-up and actions taken are dependent on the BLL (see Table 1 in the ACOG Committee Opinion on Lead Screening during Pregnancy and Lactationexternal icon). The provider should recommend a prenatal or multivitamin with adequate iron and calcium to pregnant or lactating women 45. Clinicians should consider a referral to a local provider with expertise in high-risk lead exposure or consult a high-risk OB provider for treatment and management. Those with a confirmed EBLL should be reported as determined by local policies. Children in the household should also be tested for BLL. For interpretation of lead levels in pregnant and lactating women, refer to the ACOG Committee Opinion on Lead Screening during Pregnancy and Lactationexternal icon. Additional information on case management and follow-up of elevated BLL in pregnant and lactating women is available from the CDC Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women pdf icon[PDF – 302 pages].

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