Blog: Elizabeth O’Brien, The LEAD Group Incorporated, 24th July 2014
If you have read our media release regarding the NHMRC draft information paper on lead you might have noticed that we sent in a list of questions to be answered by the committee, please find below response from a NHMRC spokesperson (highlighted in blue):
- How can the current air lead standard be regarded as sufficiently protective if more than half the young children in lead mining and smelting towns in Australia exceed PbB (blood lead) 5 ug/dL?
- Why hasn’t the Committee recommended that other standards be reviewed? eg the dust lead and soil lead standards in AS4361 Lead Paint Management Standards, the food lead standards, drinking water lead guideline (and thus rainwater system and plumbing component lead concentrations).
The draft Information Paper provides a plain language summary of the assessment of the evidence completed by the Cochrane Public Health Group relating to the health effects of low level exposure to lead and the effectiveness of interventions to reduce blood lead levels. Once the Information Paper has been finalised post public consultation, the NHMRC will revise its Public Statement on Lead Exposure in Australia. It is at this stage that jurisdictions and other government agencies may wish to review their relevant policies relating to environmental exposure to lead so that they reflect the best available evidence.
- We have evidence that PbBs of children under 5 yrs in these towns are plateauing or rising, but what published evidence is there that PbBs in the general population of all ages are falling in Australia?
Page 4 of the draft Information Paper identifies: “The average blood lead level among Australians today is not known, because few studies have measured levels in people who do not work in or live near lead mines, smelters, or workplaces that use lead (Laidlaw MA, Taylor MP. Potential for childhood lead poisoning in the inner cities of Australia due to exposure to lead in soil dust. Environmental pollution Barking, Essex : 1987 2011; 159: 1-9). It is probably less than 5 micrograms per decilitre (0.24 micromoles per litre), based on limited evidence from Australian studies in small groups of children (Gulson B, Mizon K, Taylor A, et al. Longitudinal monitoring of selected elements in blood of healthy young children. Journal of trace elements in medicine and biology : organ of the Society for Minerals and Trace Elements (GMS) 2008; 22: 206-214. Guttinger R, Pascoe E, Rossi E, et al. The Fremantle lead study part 2. J Paediatr Child Health 2008; 44: 722-726) and on studies in other developed countries (Armstrong R, Anderson L, Synnot A, et al. Evaluation of evidence related to exposure to lead. Canberra: National Health and Medical Research Council; 2014). This level is much lower than the level of exposure for previous generations (Donovan JW. Lead in Australian children: report on the National survey of lead in children. Cat. no. AIHW 151. Canberra: Australian Institute of Health and Welfare; 1996).
- Why hasn’t the Committee recommended that all PbB results (no matter what the level of lead) be notified in the future, and that past and future results be collated and analysed to determine trends in blood lead by age/sex/postcode/likely sources, as well as trends in the number of people being referred by their doctor for blood lead testing?
- Why hasn’t the Committee recommended that trends in PbB results and recommendations for more specific blood lead test referrals based on the risk factors identified in the PbB results reports, be regularly distributed to public health professionals and doctors?
The recommendations described are beyond the scope of the draft Information Paper which is a summary of the evidence relating to the health effects of exposure to lead and the effectiveness of interventions to reduce lead blood levels. The document does not intend to provide clinical or policy advice.
- When the Committee relies on evidence of falling PbBs in the general populations in developed countries overseas, have they also reviewed public health practices in those countries to determine how they have impacted on those falling PbBs and which practices therefore Australia should introduce in order to hope to see the same decreases? An example of population-wide interventions which have very likely brought down blood lead levels in the USA, would be to create, as was done in the USA, a licensing system for painting contractors and lead assessors, and require thru legislation that pre-1997 housing be sold or rented with lead-hazard warnings? Another example comes from Germany, whereby, the action level is 3.5 ug/dl for children under 14 yrs of age, and at PbBs above 3.5 ug/dL, doctors are required to take an exposure history and investigate likely sources, as well as give nutrition and hygiene advice.
As mentioned in question 3 the decrease in observed lead blood levels was determined by a number of small studies that occurred in Australia. The draft Information paper (Pages 4 and 10) and the Evaluation of the Evidence report (pages 15-18) outline public health practices/population wide interventions that have been implemented in Australia. The draft information paper also identifies that further research is required. The recommendation of population-wide interventions is beyond the scope of the draft Information Paper.
- Why has the Committee not recommended that all doctors use risk factor questionnaires to determine which of their patients, of any age, should be referred for blood lead testing?
It is beyond the scope of the draft Information Paper to provide specific clinical or policy advice.The draft Information Paper provides high level advice on who should be tested for lead exposure noting the recommendations of the World Health Organisation regarding testing for exposure to lead – pages 10 and 21 (World Health Organization. Childhood lead poisoning. Geneva: WHO; 2010. Available from: http://www.who.int/ceh/publications/childhoodpoisoning/en/
- Has the Committee considered, in how many more cases is the person showing symptoms never tested for lead?
This question is outside the scope of the review. The assessment of the evidence did not identify any data to indicate this issue and the extent it to which it is impacting on people’s health.
- Why has the Committee taken a backward step by at least two decades, by suggesting that only people in families / situations with known lead exposure problems, or those showing lead exposure symptoms should have blood lead tests? Clearly, the risk factor questionnaire produced by NHMRC for doctors in 1994 is a much better basis for ordering a blood lead test than those two criteria.
- Why hasn’t that 1994 child risk factor questionnaire been updated and another one written for adults and distributed to all doctors? Is the Committee aware, that the second July 2014 criteria, of showing symptoms before a blood lead test is carried out, has resulted in at least one severe case of lead poisoning being undiagnosed for 3 yrs while the patient went from doctor to doctor until he found a doctor who was capable of identifying his set of symptoms as possibly due to lead poisoning.
- Is the committee not aware that there are people with blood lead levels above 5 ug/dL and even above a level that is fatal to other individuals, who show NO symptoms? Even if symptoms are present, they are consistently overlooked by doctors or assigned as having other causes. This is the quintessential nature of lead exposure being insidious, under-diagnosed and thus rightly earning the title of “the silent pandemic”.
The purpose of the draft Information Paper is to provide a summary of the evidence relating to the health effects of exposure to lead and the effectiveness of interventions to reduce lead blood levels. It is beyond the scope of the document to provide clinical advice on the management of lead exposure. Once the public consultation period has finished other issues, such as those you mention in questions 9-11 may be considered in the review of the NHMRC’s position statement.
- Why has the consumer representative on the Lead Committee had no previous association with lead? Was she chosen because of her lack of knowledge on the topic? Why to this day has she never web-published anything about lead?
The role of the consumer representative is to provide insight to the committee on matters that are of concern to consumers and the community. The representative was selected based on their experience as a health consumer advocate as well as possessing expertise in the areas of healthcare safety and quality, research, occupational health and safety, risk management, industry standards and policy development. Under NHMRC’s Deed of Confidentiality the committee members, including consumer representatives, are not permitted to discuss or publish issues discussed by the Lead Working Committee without the permission of NHMRC.
Elizabeth O’Brien, president of The LEAD Group has also sent an email to all LEAD Group members, urging them to submit feedback and comments on the NHMRC draft paper which is open for consultation until 5PM Sunday 17th of September 2014. Please find below the message:
“Whilst the best part of the draft paper is that the blood lead level which may eventually become an intervention level, has been halved, from 10 micrograms per decilitre (ug/dL), to 5 ug/dL for all ages (a global precedent), the health effects information seems to be presented in a way which minimalises concern and therefore action (such as blood lead testing), and casts doubt on the “certainty” of research findings. For instance, the “Evidence on the Effects” document states: “there is uncertainty regarding the clinical significance of the findings regarding an increase in blood pressure [for blood lead levels <10 ug/dL]. I know some researchers who will be irate about this doubt-casting, but unfortunately, they’re not in Australia so may not be part of the consultation process.
LEAD Group members and any other lead-knowledgeable citizens (please forward this email widely) are urged to read the documents and submit comments before the deadline.”
There has also been a decent amount of media reporting on this matter, any sort of effort to bring lead into the public eye is more than welcome. Please find links to interviews with, among others, experts from The LEAD Group’s Technical Advisory Board, appearing on the 16th and the 17 of July, 2014 in the media:
No safe lead level: NH and MRC (By: Matthew Doran, PM with Mark Colvin)
Lead level reporting change to reduce brain damage (By: Ian Townsend, RN Breakfast with James Carleton)
Report: no safe level of lead exposure (By: Elly Bradfield)
Additionally, these articles are either based on the interviews or related to lead and/or the NHMRC draft paper:
Health body recommends less lead exposure (By: Sara Phillips and Matthew Doran)
More children at risk from lead dust (By: Sarah Martin)
Our Media Release on the Tasmanian Times
Lead tailings discover on 10pc on Northampton properties (By: Gian De Poloni)
For medical professionals, Neil Bramwell published his article about this issue in this week’s Medical Observer.
Please take a look at all these media articles and listen to the interviews then let us know if you find any others on the topic! Also, don’t forget to send in your comments by the deadline!
PS: Please submit your entry to the Volcano Art Prize by the Monday 24th August 2014 deadline! Currently we have 38 more prizes than entries!! And the People’s Choice prize is $500 cash!
What do other professional bodies have to say about Australian blood lead action levels?
According to the Public Health Association of Australia (PHAA) POSITION STATEMENT: Environmental Lead Exposure, February 2014
The Public Health Association of Australia:
Recognises that for communities where lead exposure is widespread and long-term, preventive strategies at the community/ population level are the most effective way to reduce lead exposure.
Advocates to the Australian government for a National Plan for Lead Exposure Prevention and Management, to include strategies and funding to research, prevent and manage individual and population level exposures of lead as part of the National Environmental Health Strategy
Advocates for State government resources to deal with lead exposures for families in long-standing legacy areas.
Advocates for a review of the adequacy of the current BLL guidelines for Australians, especially for children and pregnant women, and that guidelines for occupationally exposed workers be consistent with national recommendations.
SafeWork Australia calls for comments on their new occupational blood lead action levels
On 17th July 2014, SafeWork Australia published a report called: REVIEW OF HAZARDS AND HEALTH EFFECTS OF INORGANIC LEAD – IMPLICATIONS FOR WHS REGULATORY POLICY, and summarised the proposals as follows:
This research report will form the evidence base for a consultation Regulation Impact Statement (RIS).
The report finds the current BLRLs [blood lead removal levels] contained within the model WHS Regulations are not sufficiently protective of the health of workers in lead risk work and adverse health effects may occur at those levels. It proposes changes to the BLRLs. The report also proposes changes to the WES for inorganic lead because blood lead levels are influenced by levels of lead in air and this is an important hazard control measure.
The report proposes the following:
- For women of non-reproductive capacity and men two options are suggested:
- BLRL of 20 µg/dL, or
- Target Blood lead of 20 µg/dL and BLRL of 30 µg/dL.
- For women of reproductive capacity a BLRL of 10 µg/dL is recommended.
- To help achieve these BLRLs it is suggested the WES be reduced from 0.15 mg/m3 to 0.05 mg/m3.
Please provide any comments to firstname.lastname@example.org or call 1300 551 832 to discuss.