Community Lead Exposure of Children In

Community Lead Exposure of Children in Developing and Emerging Economies: Problems, Policies, and Solutions Based on Case Studies in Eastern Europe, Caucasus, and Central Asia

Guidance Document

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Last Update 2020 Community Lead Exposure of Children in Developing and Guidance Document Emerging Economies: Problems, Policies, and Solutions Based on Case Studies in Eastern Europe, Caucasus, and Central Asia Developed by the AIHA Construction Committee and the AIHA International Affairs Committee

Table of Contents Acknowledgements Introduction...... 3 This document was prepared in collaboration with the International Task Force for Children’s Environ- Chapter 1. Childhood Lead Poisoning: mental Health (not affiliated with AIHA). What Do We Know?...... 4 • Lead in the Environment: Sources, Uses, Fate, Editors and Environmental Levels • Andrey Korchevskiy, PhD, Doctor of Biology, CIH • Lead Toxicology • James Rasmuson, PhD, CIH, DABT • Safety Criteria for Lead • Eric Rasmuson, MS, CIH • Prevention and Treatment of Childhood Lead Authors Poisoning • William S. Carter, Ph.D., CIH, Prof. Emeritus Chapter 2. Lead-Related Problems in the • Eduard Cetaruk, MD, FACMT Former U.S.S.R...... 16 • Curtis Chanda, BA, MA (Kazakhstan) • Lead in the Former Soviet Countries • David Goldsmith, MSPH, PhD • Case Study: Environmental and Public Health Problems of Lead in Kazakhstan • Eduard Granovsky, PhD (Israel) • Lead Poisoning Prevention: Typical Barriers to • Jeri Guthrie, BS Overcome • Alf Fischbein, MD, Prof. (Israel) Chapter 3. Working Together to Protect Children • Daniel Hall, BS, PE (Recommendations for the International • Dalmon Larson, PhD, DABT Community)...... 28 • Marianne Levitsky, MS, CIH (Canada) • Why Should International Community Care (Reasons for International Involvement) • Roger Olsen, PhD • What Can Be Done? • Boris Revich, PhD (Russian Federation) • Success Stories • Robert Strode, MS, CIH • The Future of Lead Poisoning Prevention • Jeffrey Temple, CCE (United Kingdom) Conclusions...... 33 References...... 35

The document was peer-reviewed by Andrew Burgie (Center for Occupational and Environmental Health, CUNY School of Public Health); Marco Pedone (Environmental Management Solutions of NY Inc.); Susan Viet (Westat Inc.); Kathy Lavaty (Total Safety); Alex Lehocky (Kennesaw State University), William Spain (Retired, Former State of Georgia Regulator), Mark Hartz (Alternate Construction & Environmental Solutions); Ed Rutkowski (AIHA); David Jacobs, PhD, CIH (National Center for Healthy Housing); Geoffrey Braybrooke (Army Public Health Center), and Michael Kosnett, MD, MPH, FACMT Member (University of Colorado, School of Medicine).

The authors express their special gratitude to Richard Hirsh, Margaret Wan and other officials and members of AIHA International Affairs Committee for their invaluable input and support in preparation of this document.

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Introduction The intent of the American Industrial Hygiene As- sociation (AIHA) in producing this reference doc- The purpose of this reference document is to pro- ument is to benefit local public health officials and vide recommendations on lead poisoning preven- environmental protection professionals, working in tion in developing and emerging economies, draw- developing countries, and AIHA members in building ing on the examples of conditions in the countries collaborations to resolve lead poisoning problems of Eastern Europe, Caucasus, and Central Asia (the throughout the world. former Soviet Union states). In some of these areas, the mean blood-lead levels (BLL) for children are ex- The document covers the environmental behav- tremely high.1,2 This document describes methods to ior of lead, lead toxicology and bioavailability, lead promote safe and healthy community environments contamination and poisoning in each region, pos- and to improve understanding among international sible solutions and barriers to overcome, program experts in environmental and public health prob- approaches, suggested environmental and biologi- lems involving lead (Pb), with a review of policies, cal criteria, medical intervention, economic damage standards, and proposed solutions. It describes up- evaluation, and success stories. The problem of com- to-date scientific approaches to lead poisoning pre- munity lead exposure is viewed from the standpoint vention with regard to unique conditions in Eastern of the definition of industrial hygiene as a science of Europe, Caucasus, and Central Asia as a starting anticipation, recognition, evaluation, and control,3 as point, and goes on to provide a wider perspective well as the Centers for Disease Control and Preven- by citing examples in other countries, such as Nepal. tion (CDC) National Institute for Occupational Safe- The data and conclusions in the paper are based on ty and Health (NIOSH) definition of the hierarchy the extensive experience of the group of authors in of controls.4 AIHA hopes to promote better under- dealing with lead poisoning issues in Kazakhstan, standing among governments, environmental and Russia, and other developing countries. This publica- public health professionals, physicians, and advo- tion significantly highlights a problem that seriously cates in the countries of Eastern Europe, Caucasus, influences the health of millions of children. and Central Asia as well as in other regions of the world, concerning the importance of intervention to protect children from lead poisoning.

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Chapter 1: Childhood Lead Poisoning: Agency for Toxic Substances and Disease Registry 11 What Do We Know? (ATSDR) toxicology profile for lead. The toxicity of lead has been most recently updated by the National Lead in the Environment: Sources, Uses, Fate, and Toxicology Program12 and in Jacobs (2012).13 Lead is Environmental Levels a multimedia pollutant that sometimes makes lead Elemental or metallic lead (Pb) has been used for exposures difficult to control.14 more than 6,000 years. The metal was employed in Lead content in the earth’s crust is around 0.0013%. numerous practical applications and goods because Lead in its elemental or metallic form is a bluish-white of its softness and malleability. While documented metal of bright luster, very soft, highly malleable and lead poisoning dates back to nearly 2,500 years, its ductile.15 Elemental or metallic lead is found in nature use and production remain widespread, sometimes (“native lead”), but its occurrence in nature is rare.16 with tragic results. For example, at least 400 children Lead is chiefly found in nature as PbS (lead sulfide, recently died from paraoccupational lead poisoning as the mineral galena) and less frequently as PbSO in Nigeria.5 Furthermore, in the World Health Organi- 4 (lead sulfate, as the mineral anglesite), and PbCO zation’s most recent ranking of environmental health 3 (lead carbonate, as the mineral cerrusite).17 Metallic threats, lead exposure is in the top five that together lead is typically obtained by roasting PbS-containing account for nearly 10% of deaths and disease bur- ores or by recycling lead batteries. Lead is used com- den globally and around one-fourth of deaths and mercially in a variety of forms and compounds. disease burden in children.6 WHO has highlighted the importance of responding to hot spots of lead expo- • The grid plates of storage batteries are composed sures, such as mines and smelters.7 Childhood lead of metallic lead but also typically contain antimony, poisoning from paint was first brought to the world’s some tin, and small amounts of arsenic and attention in Australia in the early 1900s, eventually copper.18 resulting in a lead paint prevention act in Australia in • Lead pigments were used in paint to speed drying, 1920 and an international ban of the use of lead in increase durability, and resist moisture. The most residential paint by the International Labor Organiza- common lead pigments are basic lead carbonate tion.8 The United States chose not to comply with the [white lead, 2PbCO3.Pb(OH)2], lead carbonate, and ILO ban and had no restrictions during this time and lead sulfate, which are all used in white paint19, childhood lead poisoning became epidemic, despite although lead is found not only in white paint. the fact that the problem was well understood.9,10 For example, lead chromate (PbCrO4) is a yellow pigment. Basic lead chromate (2PbO.CrO ) and red The 1976 European Union (EU) directive 76/769/EEC 3 lead (Pb O ) are red pigments.20 The manufacture banned the use of lead carbonate and lead sulfate in 3 4 paint except for historic buildings or art restoration. of paint containing high concentrations of lead The use of all lead-based paint in residential applica- (greater than 600 mg/kg) for interior and exterior tions was officially banned by the 1989 EU directive residential surfaces, toys, and furniture was 21 89/677/ECC. Some industrial applications of lead- banned in the United States in 1977 , but many based paint are still allowed in the United States and reports have shown that new lead-based paint EU (e.g., for road paint and marine applications). is being manufactured in many countries. The Consumer Product Safety Improvement Act of A detailed review of lead environmental sources, 2008 lowered the 600 mg/kg level to 90 mg/kg.22 fate, and levels in various media can be found in the The 1976 EU directive 76/769/EEC banned uses

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of lead carbonate and lead sulfate in paint except most common solder is composed of equal parts for historic building or art restoration. The use of of lead and tin (50/50 solder) with some trace all lead-based paint in residential applications metals.34 The 50/50 solder was used in plumbing was officially banned by the 1989 EU directive applications until the 1980s, when it was replaced 89/677/ECC. Some industrial applications of lead- by silver, antimony, and copper alloys, typically based paint are still allowed in the United States with tin. Note that 60/40 and 63/37 (percentage and EU (e.g., for road paint, marine applications). lead and tin) solders are currently used in electrical However, in several developing countries, lead in and electronic applications.35 architectural paint exceeds 600 ppm by a large • Metallic lead is used for pipes, radiation shields, margin. For example, a recent study of lead content weights (such as on fishing lines and for balancing in residential paint in Asian, African, and South tires), bullets and lead shot, and other products.36 American countries shows as high as 96% of the samples exhibiting paint levels above 600 ppm.23 • Lead may also be found in common household This finding of manufacture of new lead paint has items such as lead-glazed ceramic pottery and been confirmed in other recent studies.24,25 cooking utensils, tin cans (with soldered joints), jewelry and toys (in paints and enamels), imported • Litharge, a yellow lead monoxide [PbO], was used medicines and home remedies, cosmetics, and as a paint pigment in the manufacture of glass, some candies and food coloring.37,38 fluxing of earthenware, as filler in rubber, and in plumber’s cement.26 It is still used in plumber’s Elevated concentrations of lead can be found in en- paste, glass, and other applications.27 vironmental media such as soils, water, and air and are typically the result of industrial activities (pollu- • Tetraethyl lead [Pb(C2H5)4] is a liquid used as an tion). additive in gasoline to increase both the octane number and resistance to engine knock.28 Leaded • Some lead naturally exists in soils, typically referred gasoline was used in the United States from to as background concentrations. The arithmetic approximately 1923 until 1991.29 As a result of the mean concentration of lead in soils in the United Clean Air Act of 1970, leaded gasoline phaseout States is 19 mg/kg39 and typically ranges from less began in 1976 in the United States. As of Jan. 1, than 10 to 30 mg/kg.40 The levels of lead (dissolved) 1996, leaded gasoline was banned from use in in surface water and groundwater in the United all road vehicles in the United States. In the EU, States typically range between 5 and 30 µg/L leaded gasoline was banned as of Jan. 1, 2000. µg/L.41 The production of leaded gasoline in Russia was banned as of July 1, 2003.30 Emissions from primary lead and other metal smelters (processing of primary ore minerals such • Lead arsenate (PbHAsO4) was used as an as galena) or secondary lead smelters (recycling 31 insecticide. Its use declined in the late 1940s and of batteries) can result in elevated concentrations 32 early 1950s when DDT became available. Lead of lead in the air and soil around the smelters.42 arsenate use was banned in 1988 in the United Such primary and secondary smelters are common 33 States. around the world. During the smelting process, the • Plumber’s solder is a metal alloy used to join lead is in a molten state and results in the release copper pipes typically used for residential water of lead in vapor and particulate forms. If the lead distribution. Various compositions exist, but the in the gaseous emissions is not controlled (e.g., by

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the use of filters), the lead is dispersed in the air • Deposition of lead from car exhaust occurs when and deposited on the ground. The lead is usually cars burn gasoline containing tetraethyl lead, which in the form of small amorphous (noncrystalline) can result in air and soil contamination near major lead oxide particles, which are relatively soluble highways and in the neighborhoods. The lead and react with water and soil to form other typically reacts with water and soil to form lead compounds such as lead sulfates, carbonates, and oxides, sulfates, carbonates, and phosphates. The phosphates, depending on the soil composition. In U.S. Geological Survey (USGS) measured lead in soil high organic-content soils, lead associated with samples near seven highways in Massachusetts the organic matter has also been observed as a where the concentrations ranged from 10 to 770 result of the dissolution of soluble lead oxides and mg/kg.47 In one of its studies, the Washington subsequent incorporation into the organic matrix. State Department of Transportation measured lead Concentrations of lead in soil greater than 60,000 concentrations in soil samples ranging from 176 to mg/kg (6%) have been measured near smelters.43 4,460 mg/kg, which were collected approximately • Waste products from the smelters typically result 80 feet from the road pavement.48 from the production of elemental lead. The largest Lead from waste battery storage, recycling, and waste stream is the molten slag that is cooled in cracking facilities may be deposited in the soil. air or with a water stream, resulting in a glassy During the process of cracking open the plastic solid product. Small inclusions of lead exist in casing on waste batteries to recover the lead, the glass matrix (usually present as lead oxides). sulfuric acid solutions containing dissolved lead in Concentrations of lead in slag and lake sediments the batteries may be spilled or discharged where it contaminated with slag from a smelter in Trail, reacts with the surrounding soil. The soil typically British Columbia (Canada), have been measured up neutralizes the acid resulting in lead sulfate and 44 to 920 mg/kg. Maximum concentrations of lead in carbonate. Metallic pieces of the lead plates that slag measured at the Midvale Tailings Superfund may also be present in the soil typically weather site in Utah (United States) ranged from 11,800 to to lead carbonate or lead oxides, or even lead 24,800 mg/kg depending on the type of slag (e.g., chloride (depending upon the environment). These water-cooled and air-cooled).45 secondary forms usually exist only as rims around • Wastes from mining of high-grade ore result in waste the primary lead metal particles, because lead is rock or low-grade ore being disposed at the mining not very mobile in soil. Concentrations of lead in sites. Waste from the milling and mineral processing soils at a battery recycling facility in Puerto Rico facilities (processes to concentrate the lead minerals) have been observed up to 29,000 mg/kg.49 is typically disposed of near the facilities. This may be • Concentrations in drinking water can be elevated in the form of fine-grained tailings and small particles where lead service lines are used, or where water of lead sulfide or lead sulfate (lead sulfide oxidized chemistry and sources are not properly considered. in the environment and may be as weathering rims on the lead sulfide), which are susceptible to wind Concentrations of lead in industrial wastewater transport. Lead concentrations in tailings typically discharges (before treatment) have been reported range from several thousand mg/kg to percentage as high as 900 mg/L (paint formulation), 880 mg/L levels. Lead concentrations in the tailings at the (porcelain enameling), and 560 mg/L (ore mining Sharon Steel Superfund site in Utah (USA) averaged and processing).50 The 1991 U.S. Environmental 5,500 mg/kg.46 Protection Agency (U.S. EPA) action level for lead

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in drinking water is 0.015 mg/L.51 The EU standard lead-based paint and other sources. Lead arsenate of lead in drinking water is 0.010 ug/L (effective compounds were typically used in orchards as a Dec. 25, 2013).52 Lead in water can result from pesticide, resulting in elevated concentrations of discharges of industrial wastewater; dissolution of lead (and arsenic) in the soils. Lead arsenate, used lead solder used in water pipes; use of lead drinking in the United States as a pesticide in orchards water service lines and fixtures; the discharge from the 1890s to the early 1950s,60 was applied of acid mine drainage from abandoned mines; frequently and at a high application rate. Annual reactions of rain with waste tailings or waste rock application rates as high as 215 kg Pb/hectare were at mining facilities; the dissolution of lead from recommended for apple orchards.61 Concentrations batteries as a result of contact with sulfuric acid; of lead found in orchard soils have ranged from 6.4 and so on. Lead can exist in the dissolved aqueous to 1,500 mg/kg.62 state in water typically as the lead cation (Pb2+), or it can be complexed (e.g., Pb- chloride complexes). Lead Toxicology • Older homes are likely to have lead paint on the interior and exterior surfaces, which may be The toxicology of lead is a discipline with a long his- peeling or otherwise deteriorated, or which may tory that has continued to develop actively during have been scraped to create a smooth surface recent decades. for new paint. More than 24 million homes in the Bioavailability and Toxicokinetics United States have lead-based paint hazards in the form of deteriorated lead-based paint, The deposition of airborne lead in the respiratory contaminated house dust and contaminated bare tract of adults varies from 30 to 85%, and in children soil, and about one-fourth of the U.S. housing it is even higher.63 stock has lead-based paint (38 million housing units).53,54 The paint chips from weathered exterior Children absorb as much as 50% of ingested lead 64,65 surfaces accumulate in the soil around the house with about 32% retention, in comparison with foundation. Lead in paint is typically in the form adults who absorb 5 to 15% of total ingested lead of lead carbonate, but it may also be present as and usually retain less than 5% of what is absorbed, lead oxide, lead chromate, and other lead salts. although there is wide variability. Paint from houses in London (UK) constructed Because of lead’s long half-life in bone, and its del- before 1910 had average lead concentrations eterious effect on the central nervous system and 55 ranging from 78,400 to 141,200 mg/kg. The other organs, lead exposure prevention is critical; 56 single highest value was 430,000 mg/kg (43%). lead exposure should be controlled for all ages. Lead Paint from houses constructed from the 1910s to has a potential half-life in bone of 27 years, so ex- the 1990s had lead concentrations ranging from posure at any age can result in residual exposures 57 10 to 177,000 mg/kg. Interior paint samples as bone stores are mobilized. During pregnancy, mo- from “high-risk” houses in California ranged from bilization results in fetal exposure (Reiss and Halm, 58 20 to 309,713 mg/kg. Lead concentrations in 2007; Gulson et al, 1997).66,67 Children with poorer new paints for residential use in the United States nutrition (e.g. iron deficiency) may absorb more lead 59 currently are limited to a maximum of 90 mg/kg. and are at greater risk from exposures (Cunningham, Lead is also found in soil as a result of its use in 2012).68 Inadequate nutrition (e.g. calcium deficien- pesticides and its previous use in gasoline, exterior cy) can also exacerbate the release of lead to the

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69 fetus during pregnancy (Gulson et al., 2004). The • Medium bioaccessibility (20 to 60%): PbSO4,

Centers for Disease Control and Prevention (CDC) Pb3(PO4)2, Pb-MnOOH has released guidelines for management of lead ex- • High bioaccessibility (60 to 100%): PbCO , PbO, posure in pregnancy and lactation.70 3 PbCl2 Despite these differences, all forms of lead Lead compounds vary in their ability to produce toxic are toxic. effects, although all have been shown to have toxic The low bioaccessibility of lead in slags is the result effects. The amount of lead that actually enters the of the lead being enclosed in a silicate (glass) matrix, body as a result of lead solubilization in the gastro- and therefore lead is not available for complete dis- intestinal fluid from an ingested medium and from solution in the gastrointestinal fluid. Lead carbonate inhalation depends to some extent on the physi- in paints and amorphous lead oxides from smelter cal-chemical properties of the lead and of the media. emissions are very soluble in the acidic gastrointes- The physical-chemical properties are affected by the tinal fluids and therefore have a high bioaccessibili- form, compound, or chemical species of the lead; the ty. Lead dissolved in the aqueous phase is typically size distribution of the lead-containing particles; and 100% bioaccessible. Importantly, it is not necessary the matrix associated with the lead particles71 (al- to determine bioaccessibility before taking action to though those characteristics are not usually consid- control exposures, because no form of lead has been ered in regulations anywhere in the world because found to be safe. However, differences in the bioac- total lead is more relevant). cessibility of lead are an important characteristic for modeling of toxicity and may be useful in establish- The bioavailability of different toxic compounds has ing lead remediation criteria, although total lead can been defined differently in various sources.72 Some of and has also been used. the recent publications use the term “bioaccessibility” as an experimentally determined estimate of what The amount of dissolution of lead in the gastrointestinal fluids and uptake in the human gut also de- is potentially bioavailable. In other words, the bioac- pends on the size of the lead-containing particles.76 cessibility is the percentage of lead compound that is The smaller particles are more easily and rapidly rendered soluble in the stomach acidic aqueous me- dissolved. The ease and rate of dissolution also de- dia.73 Bioavailability, then, is the overall percentage pends on the matrix of the lead-containing particle. of ingested lead, in the case of the oral pathway, for As discussed above, the lead in slag is less bioavail- example, that enters the bloodstream. For purposes able, although exposures should still be controlled. of this document, the bioavailability of ingested lead compounds is defined as the product of the experi- Standard in vitro tests (laboratory tests) for assess- mentally measured bioaccessibility multiplied by the ing bioaccessibility in soils77 simulate dissolution in fraction of bioaccessible lead taken up by the organ- the human gut and have an excellent correlation with ism. A similar concept can be applied to the inhalation in vivo swine studies (r2 = 0.83, p = 0.0001).78,79 route of exposure. Our definition of bioavailability is consistent with the U.S. EPA concept and is used in To describe the behavior of lead in different compart- BLL modeling.74 A summary of the overall bioaccessi- ments of the body, the Integrated Exposure Uptake bility of the various forms of lead follows:75 Biokinetic (IEUBK) Model for Lead in Children, developed by U.S. EPA, can be used. This model (and the • Low bioaccessibility (1 to 20%): PbS, lead in slag, corresponding software) can be used to predict the Pb metal, Pb-FeOOH risk (e.g., probability) that a typical child, exposed to

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specified media concentrations of lead, will have a Health Effects of Lead BLL greater or equal to the level associated with adverse health effects.80 Other models are also avail- Lead can cause various toxicological effects on the able.81 It should be repeated that prevention of ex- human body, including neurological, neurobehavior- posure to all forms of lead is the best response to al, developmental, hematologic, renal, cardiovascu- 91,92 preventing lead poisoning. lar, immunological, and skeletal. In addition, lead compounds have been classified as carcinogenic. Mechanisms of Toxicity The neurological system is especially susceptible The major mechanisms of lead toxicity are adverse to lead toxicity. Lead can affect the brain and pe- effects on the peripheral and central nervous sys- ripheral nervous system in multiple ways. In partic- tem,82 enzyme inhibition,83 protein binding,84 mim- ular, lead may act as a surrogate for calcium and/or icry (when lead substitutes iron and calcium in cel- disrupt calcium homeostasis. Lead affects virtually lular transportation and reactions),85 production of every neurotransmitter system in the brain, includ- 86 reactive oxygen species, and aberrant DNA mani- ing glutamatergic, dopaminergic, and cholinergic 87 festation. systems. All these systems are critically important for synaptic plasticity and cellular mechanisms for Multiple biochemical effects of lead are reported. 93 Lead binds to proteins, modifies their tertiary struc- cognitive function, learning, and memory. High ture, and inactivates their enzymatic properties. Mi- exposure to lead (probably at BLL greater than 80 tochondria are particularly sensitive to lead. Despite μg/dL) may cause clinically overt lead encephalopa- 94 the presence of a normal or increased intracellular thy. Various studies report a 1- to 4-point IQ defi- content of iron, the lead-affected mitochondria are cit for each μg/dL increase in BLL within the range starved for iron. Lead interferes at several points in of 5 to 35 μg/dL, and the data show that the rate the heme synthetic pathway in all cells, and that in- of IQ deficit is higher at the lower blood-lead lev- terference of lead ultimately can be responsible for els, showing that even so-called low-level exposure 95,96 the general toxic effects of lead, possibly even in must be controlled. the nervous system).88 It should be emphasized that Hematological effects of lead range from increased heme is of vital importance for hemoglobin and myo- urinary porphyrins, coproporphyrins, δ-aminolevulin- globin (responsible for oxygen transport); various ic acid (ALA), and zinc-protoporphyrin to anemia. cytochromes involved in electron transport; energy The most sensitive effects of lead are the inhibition generation and chemical metabolism; peroxidase of δ-aminolevulinic acid dehydratase (ALAD) and and catalase for H O activation; and for many other 2 2 ferrochelatase. A progressive, exponential increase enzyme systems.89 in erythrocyte protoporphyrin concentration is ob- In the toxicity of lead, molecular and ionic mimicry served at blood-lead levels of 5 to 90 μg/dL.97 The plays an important role.90 One example is the substi- World Health Organization (WHO) indicated that tution of lead for iron (Fe) in the synthesis of essen- anemia is the classic clinical manifestation of hema- tial proteins. Iron-containing proteins (brain compo- tological lead toxicity. The severity and prevalence nents) can be nonfunctional when lead substitutes of lead-induced anemia correlate directly with the for iron. Obviously, this is especially important when blood-lead concentration. Younger and iron-defi- the essential nutrient iron is in low concentrations cient children are at higher risk of lead-induced clin- and lead is in high concentrations. ical anemia.98

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Reproductive effects of lead toxicity are widely Lead has a long half-life in bone, accounting for over known as well. Effects reported in men include re- 90% of the body lead in adults.109 duced libido, spermatogenesis reduction, chromo- somal damage, infertility, abnormal prostatic func- Lead intoxication directly and indirectly alters many tion, and changes in serum testosterone. In women, aspects of bone-cell function. First, lead may indi- effects include infertility, miscarriage, premature rectly alter bone-cell function through changes in the membrane rupture, pre-eclampsia, pregnancy hy- circulating levels of hormones, particularly 1,25-di- pertension, and premature delivery.99 Lead can pass hydroxyvitamin D3, which modulate bone-cell func- through the placenta, exposing the fetus to maternal tion. Second, lead may directly alter bone-cell func- blood lead from both the mother’s current as well as tion by perturbing the ability of bone cells to respond her past exposures. Lead can be stored in the moth- to hormonal regulation. Third, lead may impair the er’s bones and can then be mobilized as her need for ability of cells to synthesize or secrete other compo- calcium increases to meet fetal bone development. nents of the bone matrix, such as collagen or bone Likewise, mother’s milk that is rich in calcium can be sialoproteins (osteopontin). Finally, lead may directly adversely impacted by the lead stored in bone from affect or substitute for calcium in the active sites of previous exposures.100 the calcium messenger system, resulting in loss of physiological regulation.110 The major renal effect of acute lead poisoning is dis- ruption of the proximal tubular architecture, with lab- Gastrointestinal disturbances are frequent com- oratory evidence of disturbances in proximal tubu- plaints in persons with increased lead absorption. lar function.101 Chronic lead nephrotoxicity consists These disturbances occur in both adults and children. of interstitial fibrosis and progressive nephron loss, As with symptoms related to the nervous system, the azotaemia and renal failure.102 Lead nephropathy is severity of gastrointestinal symptoms also spans a the main manifestation of renal lead toxicity. wide range. At elevated blood-lead concentrations in the range of 40 to 60 μg/dL, many of the symp- Lead affects the cardiovascular system, with the toms are nonspecific and may consist of epigastric pathogenesis including: (1) inactivation of endoge- discomfort, nausea, anorexia, weight loss, and dys- nous nitric oxide and cyclic guanosine monophos- pepsia. At very high blood-lead concentrations, usu- phate (cGMP), possibly through lead-induced reactive ally exceeding 80 μg/dL in adults but below that level oxygen species; (2) changes in the rennin- angioten- in children, these nonspecific symptoms can become sin-aldosterone system, and increases in sympathetic accompanied by severe, intermittent abdominal activity; (3) alteration in calcium-activated functions cramps known as lead colic.111,112 of vascular smooth muscle cells; and (4) a possible 103,104,105 rise in endothelin and thromboxane. The pri- Inorganic lead compounds were reclassified as prob- mary outcome of lead effects on the cardiovascular ably carcinogenic to humans by International Agen- system is hypertension, with blood pressure correlat- cy for Research on Cancer (IARC).113 Potential end 106 ing to BLL in observed cohorts and populations. points are stomach, brain, and breast cancer.

Lead is also known to cause immunotoxicologic ef- Susceptibility of Children fects, resulting in elevated immunoglobulin E (IgE) levels in children107 and potentially increased risks of Children are especially sensitive to lead poisoning childhood asthma in some groups.108 because114

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• a greater proportion of ingested lead is absorbed lead level has been established below which adverse from the gastrointestinal tract of children than of health effects are not detected. However, based on in- adults; ternational experience, some criteria can be proposed • a greater proportion of systemically circulating lead that indicate exposures that must be controlled, ac- gains access to the brain of children, especially those cording to best practices and regulations. five years of age or younger, than of adults; and Levels that should trigger exposure reduction are • the developing nervous system is far more listed in Table 1 on the next page. vulnerable to lead’s toxic effects than in mature individuals. Prevention and Treatment of Childhood Lead Poisoning123 An age threshold has not been determined that would singularly divide the “dangerous childhood” This section is intended to give guidance to the read- from “safer adult period.” For example, the blood- er regarding current recommendations for prevention brain barrier has been reported to be underdevel- of childhood lead poisoning as well as the treatment oped until the age of 6 months in humans.115 Some of childhood lead poisoning. The content of this sec- publications emphasize the ability of lead to impair tion is largely based upon research and public health blood-brain barrier functions.116 On the contrary, recommendations developed in the United States new evidence shows that many adult mechanisms, and Europe. including functionally effective tight junctions, are al- However, this document as a whole is intended to ready present in the embryonic brain.117 address the problem of childhood lead exposure in In spite of the controversy in determining the age of geographic regions where resources may be limited maturity, when a body becomes less vulnerable to to implement public health surveillance of lead expo- lead exposure, the overwhelming scientific consen- sure (i.e., monitoring of BLL in pediatric populations), sus is that children under 7 years are at much great- to perform environmental monitoring for sources of er risk and require special attention. exposure and to provide treatment.

No safe blood-lead level for young children has been Cessation of exposure is essential to any plan for the identified by the CDC.118,119 In 2012, the CDC estab- treatment of lead poisoning. Removal of the source lished “reference value” of 5 µg/dL and recommend- may range from decontamination of a small area ed that related exposures be controlled.120 Similarly, (e.g., building) or remediation of large geographic ar- WHO has concluded, “recent research indicates that eas. Cessation of exposure also includes cessation lead is associated with neurobehavioral damage at of production of new lead-based paint.124 Unfortu- blood levels of 5 µg/dL and even lower.”121 WHO also nately, large remediation projects (e.g., decontami- emphasized that lead can cross freely from the ma- nation of large land areas such as those surround- ternal to the fetal circulation throughout pregnancy, ing lead smelters) are extremely complex and costly: causing serious prenatal brain damage, that requires they are rarely feasible without government funding even stricter regulations and monitoring. and resources. However, noting the idea of elimi- nating exposure, this section will review the most Safety Criteria for Lead widely promulgated treatment recommendations for There is no unified standard for determining safe lev- lead poisoning in children as well as suggestions for els of lead in environmental media, because no blood- treatment under conditions of limited resources.

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Table 1. Recommended Trigger Levels of Lead in Environ- * The criteria of 5 µg/dL should be established based on the mental and Biological Media recent scientific developments and recommendations from CDC. Media Criteria ** The level of lead in residential soil corresponding to the Lead in blood reference value ≥5 μg/dL proposed acceptable median blood-lead level in children (children under 7 years)* was calculated using the U.S. EPA IEUBK model. With the Lead in residential soil (including Short term: ≥200 mg/kg Long level of lead in residential soil at 200 mg/kg, in air at 0.15 μg/ schools, playgrounds)** term: ≥100 mg/kg m3, and in drinking water at 0.015 mg/L, with a conserva- Lead in ambient air*** ≥ 0.15 μg/m3 tive assumption of 50% bioavailability of the lead in soil and Lead in drinking water**** ≥ 0.010 ppm dust, and with a soil/indoor dust weighting factor of 70%, the model predicts a geometric mean for lead in children’s 2 Lead in residential interior and By XRF method: 1.0 mg/cm blood at 4.9 µg/dL, with the fraction of children having lead in exterior building paint***** By dry weight: 90 mg/kg blood above 10 µg/dL expected to be 6.8%. With the same Lead in settled house dust by HUD 40 μg/ft2 (430 μg/m2) floors assumptions, but with the lead in soil at 100 mg/kg, the wipe sampling method***** geometric mean of lead in children’s blood would be 3.4 µg/ 250 μg/ft2 (2600 μg/m2) interior dL, with an expectation of 21% of children with lead in blood window sills above 5µg/dL. 400 μg/ft2 (4300 μg/m2) exterior *** Corresponds to U.S. EPA National Ambient Air Quality window troughs Standard. Lead in toys****** 90 ppm (total lead) **** 0.015 ppm is an U.S. EPA action level; the EU standard Lead in tableware****** 0.5 µg/ml (by leachate for drinking water is 0.010 ppm; the WHO (2008) guideline 122 method) is 0.010 ppm. Lead in candies****** 0.1 ppm *****EPA CFR Part 745. It should be noted that use of XRFs in lead-in-paint surveys is currently discouraged by some agencies, for example, by the U.S. Army. The focus, to the contrary, is made on the deteriorated or disturbed paint, and on dust and soil lead hazards. However, XRFs can be useful in screening studies, especially when no good information is available about lead in paint issues in different countries. ****** Corresponds to the levels allowable in the United States.

A complete review of all the pathophysiological their normal physiological roles (e.g., interruption of mechanisms of lead poisoning is beyond the scope neuronal transmission and cellular metabolism), and of this paper. Toxic effects of lead in the human body through lead’s affinity for sulfhydryl groups, espe- involve multiple complex mechanisms. Induction of cially those of metalloproteases like those found in oxidative stress and alteration in gene expression the heme synthetic pathway. Because of its molec- are emerging as important toxic modes of action, es- ular mechanism of toxicity and the ubiquity of tar- pecially at lower level exposure. Like many other tox- get molecules, lead poisoning manifests in multiple ic metals, lead exerts its toxicological effects at the organ systems (e.g., hematopoietic system and cen- molecular level. It does so by mimicking the divalent tral nervous system) and correlates with blood-lead cations zinc (Zn++) and calcium (Ca++), interfering with levels and chronicity of exposure. Mild symptoms of

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lead toxicity in children include irritability, hyperac- Therefore, the CDC now recommends elimination of tivity, decreased appetite, abdominal pain, and con- the use of the term “blood-lead level of concern” and stipation. However, lead toxicity at low dose results that public health actions be initiated at BLL ≥ 5 µg/ in subclinical (i.e., asymptomatic) adverse effects dl.125 However, these new recommendations do not on neurocognitive function and development. This change the current recommendation that chelation impact is nonetheless of considerable public health therapy be considered when a child is found with a concern. As levels increase, clinical manifestations of BLL greater than or equal to 45 µg/dl. lead poisoning increase in number and severity and include neurological findings such as peripheral neu- Iron and calcium deficiency both increase the ab- ropathy, altered mental status, ataxia, seizures, and sorption of ingested lead. Therefore, dietary sup- even cerebral edema, coma, and death. Lead poi- plementation with both of these nutrients is recom- soning in childhood can lead to significant and per- mended. Because the risk vs. the benefit of dietary manent developmental (including cognitive) deficits iron and calcium supplementation is quite favorable that may initially be subtle but worsen as lead levels and supplementation can be via diet (i.e., increased rise and length of exposure increases. Hematologic inclusion of iron and calcium-rich foods) and/or the toxicity includes impaired heme synthesis, hemoly- use of dietary supplements, routine testing of cal- sis, and shortened red blood cell life span leading to cium and iron levels prior to treatment is not rec- anemia. ommended. However, because exposure reduction and dietary supplementation may not be sufficient, Management priorities should include exposure mit- chelation treatment may be indicated in some chil- igation, assessment of the severity of poisoning, and dren.126.127 determining the need for treatment and/or other interventions. The initial clinical assessment should Although it must be emphasized that removal of be directed to the organ systems mentioned above the source of lead exposure is integral to any lead (i.e., neurological and hematological). In children, the poisoning treatment plan, additional treatment (i.e., neurological assessment should focus particularly chelation) may also be indicated in certain children. on neurocognitive and developmental milestones. There are several chelating agents available for the Laboratory assessment includes a whole blood- treatment of lead poisoning. Dimercaprol (British an- lead level, zinc protoporphyrin level, complete blood ti-Lewisite, or BAL) chelates a number of heavy met- count, and evaluation of renal function (e.g., blood als, including mercury and arsenic as well as lead, urea nitrogen [BUN], creatinine, and urinalysis). and it has been in use for decades. However, BAL Once an exposure and clinical assessment has been has significant adverse effects that range from rash, accomplished, the question of treatment, and what nausea, vomiting, and hypertension to hemolysis in kind of treatment, needs to be addressed. patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Because BAL is prepared in a Interventions and treatment are largely based on peanut oil excipient, it can be administered only in- whole blood-lead levels and clinical presentation. tramuscularly and is contraindicated in patients with No level of lead exposure without deleterious effects known peanut allergy. has been established. Recent research suggests that BLLs below the previously employed “level of con- Calcium disodium ethylenediaminetetraacetic acid cern” of 10 µg/L are associated with measurable (CaNa2EDTA) is another available parenteral che- toxicity, especially cognitive impairment in children. lating agent. It also forms a stable bond with lead

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and is eliminated in the urine. CaNa2EDTA is admin- diagnostic significance urine lead excretion post istered at a dose of 35 to 50 mg/m2 per day, either by chelation is not well established. Although the continuous intravenous infusion (preferred route) or blood-lead concentration is a poor indication of body intramuscular injection 2 to 3 times per day. Contin- burden, it is the test for which treatment is based. uous intravenous infusion is recommended because Practitioners should not treat with chelation therapy intramuscular injection of CaNa2EDTA is painful and based on the lead mobilization test, as there are no the infusion route helps maintain adequate hydra- standards for therapy including when to start, doses 128 tion. Because CaNa2EDTA can cause zinc deficiency, to be used, or duration of therapy. and to minimize the risk of nephrotoxicity, courses of treatment should be limited to five days. Also, a very Chelation therapy should never be used to treat elevated BLLs in the setting of ongoing exposure. similar chelating agent, Na2EDTA (disodium ethylenediaminetetraacetic acid or edetate disodium) Patient management should always include envi- should not be used to chelate children because it can ronmental intervention (e.g., remediation) to limit or cause fatal hypocalcemia. preferably eliminate the exposure.

One of the most significant challenges in the man- Ideally, the patient should not be returned to the agement of childhood lead poisoning is determining same environmental exposure without a correction who is in need of chelation. Because of increased having taken place. susceptibility to the neurological and cognitive tox- In summary, the preferred treatment of lead poison- icity of lead and the potential for permanent impair- ing is removal of the exposure and monitoring of ment, children are more sensitive to the toxic effects BLLs. Chelation therapy is indicated in children with of lead compared to adults. Therefore, many of the clinically significant neurological toxicity and/or BLLs recommendations for the treatment of lead exposure exceeding 45 µg/dL. Although parenteral chelation in adults, including lead exposure in the occupation- agents such as BAL may be used in more severe al setting, are not suitable for the management of cases of poisoning, succimer is the preferred oral children. The current CDC recommendations state chelating agent. that chelation therapy can be effective at reducing high BLLs, but it is generally not indicated for indi- However, recommendations for treatment for 5 < viduals with BLLs <45 µg/dl. Chelation has not been BLL < 45 mcg/dl are less clear. As mentioned above, clearly demonstrated to reverse the adverse effects removal from the exposure is a central part of any of lead toxicity. However, it is still recommended for lead poisoning management plan. Other interven- high BLLs, because reduction of BLL with chelation tions may be helpful to reduce the impact of lead may prevent further translocation of lead into the exposure. Children with elevated blood-lead levels brain and prevent or mitigate the progression of lead may be at increased risk for learning disabilities and encephalopathy. Although it was recommended in some research has suggested that they even be at the past as a tool to determine which patients re- increased risk for problems in adulthood (e.g., vio- quire chelation treatment, in the average person the lence).129 Therefore, case management programs lead mobilization test (also known as a chelation for these children should include early identification challenge test or provoked urine test) is not effec- and intervention strategies (e.g., individual educa- tive in predicting the body burden of lead. In addition, tion plans) to help mitigate any cognitive deficits the whereas normal reference intervals for nonchallenge children may have developed due to their lead expo- urine metal testing are available, the prognostic or sure.130 Although these interventions do not directly

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address the problem of the exposure or poisoning, lation. As mentioned above, nutritional interventions they may minimize the impact lead exposure may to help mitigate lead’s toxicity (such as a diet with have on a child’s education and development, espe- adequate vitamin, calcium, and iron intake) are also cially in settings where definitive remediation of the reasonable additions to the management of child- exposure is not practical or tenable for any number hood lead poisoning.131,132 It is important to note that of reasons (e.g., lack of local government resources). additional research is needed to develop further ap- Ongoing monitoring of BLLs is also important to as- proaches to case management as well as education- sess whether levels fall in response to environmental al and developmental support for children affected interventions or increase, possibly precipitating the by lead poisoning in developing countries. need for more aggressive interventions and/or che-

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Chapter 2: Lead-Related Problems in Figure 1 is a map showing the main deposits of lead the Former U.S.S.R. in the countries of the former Soviet Union. The locations of the main smelting facilities are shown in Lead in the Former Soviet Countries Figure 2. Lead contamination of the environment and related childhood lead poisoning is a significant problem for The main lead-smelting enterprises were located in the countries of the former Soviet Union. The Soviet the North Caucasus (Ordzhonikidze); in the Far East

Union exemplified a society where the government (Dalnegorsk); in East Kazakhstan (lead-zinc plant was theoretically the owner of all industrial enter- in Ust-Kamenogorsk, polymetallic plant in Lenino- gorsk); in South Kazakhstan (Shymkent, based on prises. No private industry was allowed to exist. The development of industries was conducted based strictly on centralized planning. The huge territories of the country were underdeveloped prior to the 20th century, and an overwhelming industrialization program was introduced and realized in the 1920s and 1930s, with thousands of enterprises built in Rus- sian Siberia, Kazakhstan, Caucasus, and other areas. Mining and metallurgy was a central part of the Soviet industrial revolution.

In Russia, the utilization of lead started in ancientFigure 1. Primary Deposits of Lead in the Countries of the Former Soviet Union times, as evidenced by old mines and waste dumps (locations designated by blue boxes). found in the Altai, the Urals, and the Far East. The first Russian industrial lead smelter was built in Nerchinsk The main lead-smelting enterprises were located in the North Caucasus in the first quarter of the 18th century, and from the Figure 1. Primary Deposits of Lead in the Figure(Ordzhonikidze); 1. PrimaryCountries in Depositsthe ofFar the East of Former (Dalnegorsk);Lead in the Soviet Countries in East Union Kazakhst of the(locationsan Former (lead-zinc Soviet plant Union in middle of that century, the exploitation began of Ust-Kamenogorsk,lead polymetallic(locations plant designated in Leninogorsk); by blue in boxes) South K. azakhstan (Shymkent, deposits of the Altai and the North Caucasus.133 based on Karataudesignated lead deposit); by blue in Uzbekistan boxes). (Almalyk Mining and Metallurgical Combine); and in Ukraine (Konstantinovka). In Central Asia, lead has also been known and used for centuries. In Kazakhstan, in the valley of TheAchi main- lead-smelting enterprises were located in the North Caucasus (Ordzhonikidze); in the Far East (Dalnegorsk); in East Kazakhstan (lead-zinc plant in say, evidence was discovered of historic miningUst-Kamenogorsk, and polymetallic plant in Leninogorsk); in South Kazakhstan (Shymkent, smelting of lead ores. In the historic city of Turkestanbased on Karatau lead deposit); in Uzbekistan (Almalyk Mining and Metallurgical in Kazakhstan, lead was used to create tiled mosaicsCombine); and in Ukraine (Konstantinovka). in the famed mosque of Azretsultan. There is written evidence of lead smelting in Kazakhstan from the 17th century.134

In the former Soviet Union, the major lead-zinc deposits were in Kazakhstan, Uzbekistan, Tajikistan, and Azerbaijan. The main deposits of lead in Russia Figure 2. Primary Lead Smelters in the Countries are concentrated in Altai, Baikal, Primorye, Yakutia,Figure 2. Primary Lead Smelters in the Countries of the Former Soviet Union of the Former(locations Soviet designated Union (locations by blue boxes) designated. on the Yenisei River, and the North Caucasus. by blue boxes).

Figure 2. Primary Lead Smelters in the Countries of the Former Soviet Union (locations designated by blue boxes). AIHA | 3141 Fairview Park Dr., Suite 777 | Falls Church, VA 22042 | aiha.org

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Karatau lead deposit); in Uzbekistan (Almalyk Min- In the U.S.S.R., paint containing lead was banned for ing and Metallurgical Combine); and in Ukraine (Kon- indoor use in 1929138; however, its use continued for stantinovka). bridges, ships, etc. It is difficult to verify that the ban was actually enforced in the country. Vast amounts In 1990, the Soviet Union produced 0.45 million tons of official and counterfeit imports of paint from Chi- 135 of refined lead, or 13% of the world’s production. na, after the market reforms in 1991, has reintro- As is typical throughout the world, lead was exten- duced the lead paint problem into the post-Soviet sively used in the U.S.S.R. In addition to its use in am- countries because of the numerous incidents of high munition for firearms, lead was widely utilized in the lead content in Chinese paints (and paints produced 139 manufacture of lead acid batteries and for factory in other countries). equipment that required protection from corrosive Other applications of lead in the countries of the for- gases and liquids. Large amounts of lead were in- mer Soviet Union included the widespread use of volved in the manufacturing of the shells or covers lead water pipes; lead foil used for many customer for electrical cables, to protect them from corrosion products (as for tea packaging); medicinal purposes, and mechanical damage. Lead has been used as a such as the “lead water” prescribed for inflammato- protective shield material against ionizing radiation. ry diseases of the skin and mucous membranes; and Lead oxide (PbO) was introduced into crystal and simple or complex lead plasters for chronic inflam- optical glass production to achieve a high refractive matory skin diseases and boils. index. Red lead, lead chromate (yellow crowns), and basic lead carbonate (white lead) were used as pig- Regarding lead in industrial emissions, lead smelting ments. Tetraethyl lead has been used as an additive and other metallurgical processes have caused envi- to motor fuel, and in the Soviet Union, a special red ronmental contamination as well. For example, copper pigment was added to leaded gasoline. smelters, generating significant lead emissions, in the former Soviet Union were situated mostly in Kazakh- In some countries of the former U.S.S.R., the use of stan and the Ural region of Russia. Battery plants are leaded gasoline is currently prohibited. For example, another significant source of lead emissions. In Rus- in Russia, the Federal Law includes a ban on pro- sia, plants of this type are situated in Podolsk, Kursk, duction and turnover of leaded gasoline in the Rus- Tyumen, and Komsomolsk-on-Amur. In Kazakhstan, a sian Federation since July 1, 2003. However, a cer- battery plant is located in Taldikorgan. tain amount of leaded gasoline is probably produced in a so-called noncentralized way. According to the In spite of the widespread industrial use of lead in Russian Federation’s Customs Service, imports of the U.S.S.R. and for numerous practical applications, tetraethyl lead were about 3,245 tons in 2003 and information about lead in the environment in this re- about 4,735 tons in 2004.136 Tetraethyl lead is still gion is actually very scarce. Although environmental used in Russia as a component of jet fuel. Leaded monitoring was not a priority for government offi- gasoline has been prohibited by law in the territory cials, the toxic properties of lead were well known of the Ukraine since Jan. 1, 2003. In the founding [as to Soviet health experts, and restrictive regulations opposed to the addition of Armenia] countries of the were issued, especially for occupational purposes. Eurasian Customs Union (Russia, Belarus, and Ka- However, the potential lead exposure of children zakhstan), the use of metal additives (iron, manga- was not recognized as an important problem. For nese, and lead) in motor vehicle fuel is prohibited.137 example, in a review of lead toxicity issued by the

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Russian Ministry of Health Care issued in Table 2. Population Sizes, Lead Emission Sources, and the Number 1997,140 the influence of lead on the health and Ages of Children Tested for Lead in Blood in 1996–2000 of children is mentioned only briefly. The Number of document, however, quotes some West- children Age ern authors, referring to the effects of lead City in studied range on children’s hearing abilities, IQ, the ages (population) Industrial sources of lead emission samples (years) when infants start walking and speaking, Krasnouralsk A big copper smelter inside the city 357 3–7 and stability of posture. (33,600) Pervouralsk A big copper smelter located at 9 km 339 3–7 A Russian government report on environ- (164,000) windward of the city 141 mental lead problems (1997) concluded Upper Pyshma A big copper refinery (smelting and – – that 10 million urban citizens in Russia are (51,000) electrolysis) inside the city affected by lead contamination of soils. For Kirovgrad A medium-size copper smelter inside 135 4–7 example, in Moscow, the concentration of (35,000) the town lead in soil ranges from 8 to 2,000 mg/kg. Kushva The Krasnouralsk and Kirovgrad 54 3–7 Various effects of lead on public health were (56,800) copper smelters at 50 km in different directions from this city described. For example, in Belovo, Kem- erovskaya oblast, Russia, where the aver- Table 3. Blood-Lead Levels in Five Russian Ural Locations age BLL was determined to be 9.9 (±0.5)µg/ % of chil- Arithmetic dL, the level of anxiety in children was high- dren with mean BLL er than in other regions, and diseases of the Method, year, BLL ±S.E., µg/ Range, nervous system in infants included enceph- Town (number of children) >10 µg/dL dL µg/dl alopathy and convulsion syndrome. In older Krasnouralsk Modeling 61.1 10.7 – children, nervous system diseases included Bio-monitoring, 1996 64.5 11.8 ±0.5 5.0–46.3 neuroses, enuresis, and epilepsy. In Kras- (107 children) nouralsk, where the average BLL in children Bio-monitoring, 1997 59.5 11.2 ±0.2 3.2–29.4 was 13.1 (±0.5) µg/dL, retarded develop- (250 children) ment was observed in 76% of the children. Pervouralsk Modelling 22.5 7.2 It was suggested that 44% of the children in the urban population of Russia suffer from Bio-monitoring, 1999 25.9 7.4±0.2 2.4–29.04 (339 children) behavioral and learning issues that could be caused by lead poisoning. Upper Pyshma Modeling 29.3 8.1 Kirovgrad Modeling 47.5 10.1 A comprehensive study of lead-related Bio-monitoring, 2000 60.7 10.8 ±0.4 3.7–28.8 problems was performed in several cities (135 children) 142 in the Russian Ural region. The U.S. EPA Kushva Bio-monitoring, 2000 22.2 7.5±1.08 2.8–22.9 IEUBK model was used along with the ac- (54 children) tual blood-lead measurements, to evaluate the effect of lead exposure in five locations. The results of the study are summarized in tables 2 and 3. The fraction of children with BLL above 10 µg/dL varied from 22 to 62%.

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Other examples of lead-related environmental prob- using lead-based compounds are responsible lems in the former Soviet Union include: for annual emissions of lead and its inorganic compounds at the level of up to 150 tons per year. • In the city of Dalnegorsk and the town of Rudnaya Lead releases are also associated with production Pristan in the Russian Far East, where a lead mine of lead-containing ammunition, application of lead and smelter were situated, the average level of coatings, and other special works.149 lead in soil was found to be 1,000 mg/kg, with a maximum up to 200,000 mg/kg. The average level The countries of the former Soviet Union have gen- of lead in the soil of ogorods (gardens where the erally inherited the environmental and workplace locals grow vegetables) was 2,000 mg/kg, and at standards of the former Soviet Union. In Russia, the the children’s playgrounds and close to the school, allowable 24-hour average levels of lead and its in- 3 550 mg/kg. The concentrations of lead in potatoes organic compounds are 0.1 mg/L in water, 5 µg/m 3 150 were 1 to 3 mg/kg. Out of 376 children tested, in in working zone air (excursion level 10 µg/m ), and 3 3 151 31% the level of BLL was higher than 10 µg/dL 0.3 µg/m in ambient air (excursion level 1 µg/m ). and 6% were higher than 20 µg/dL. In Rudnaya In Kazakhstan, the allowable level of lead in soil is 152 Pristan, where the smelter is located, 64% of the 32 mg/kg. 143 children had BLL above 10 µg/dL. Case Study: Environmental and Public Health • The annual average of lead in air close to the Problems of Lead in Kazakhstan battery plant in Kursk in the 1990s reached 1.6 µg/ Introduction m3 and soil concentration was 500 mg/kg.144 • In the Ural city of Karabash, where one of the oldest The situation with the impact of lead on children in copper smelters in the country is located, the levels the Republic of Kazakhstan was explored in depth of lead, zinc, and arsenic in the soil were found in by a group of Kazakhstani and U.S. scientists from 153–161 the ranges of 1,500 to 2,000, 700 to 1,000 and 150 1997 to 2009. The situation in the following cit- to 300 mg/kg, respectively. The annual average ies was assessed: 3 145 concentration of lead in the air was 24.3 µg/m . • Pavlodar — a prominent industrial city with • In the city of Chapaevsk, where no sources of emission sources from alumina production, an oil emissions from lead industries were known, the refinery, a chemical plant, and located close to a median level of BLL was 3 µg/dL, and in 3% of large regional coal power and ferroalloys facilities 146 children, BLL was higher than 10 µg/dL. • Shymkent — an industrial hub in the south of • Concentrations of lead well above background the country, with the largest lead smelter in the levels were found in soils near Ukrainian airports.147 region, which was built in the 1930s and continued • Producers of military hardware are also sources of to operate until 2012, as well as other industrial substantial releases of lead and its compounds. For pollution sources including an oil refinery, and an example, soldering operations in Russia contribute asbestos cement plant emissions of lead and its inorganic compounds to • Tekeli — a small city with a lead mine, currently the lower layers of atmosphere at the rate of 1 ton discontinued 148 per year. • Taldykorgan — a city with a battery recycling • Painting, impregnation, and enameling works facility

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• Ust-Kamenogorsk — a large industrial center with toxication or iron-deficient anemia. The instrument a lead-zinc smelter, a titanium-magnesium facility, calibration was checked twice per day using three beryllium production, and other plants standards (26, 78, and 145 µg/100ml whole blood).

• Kysylorda — a rural city in a desert region, close to Lead in paint using X-ray fluorescence (XRF). Paint the epicenter of the Aral environmental catastrophe on the walls, floors, toys, eating utensils (plates, • Almaty — the former capital of the country, with bowls, etc), and play equipment at the kindergar- exceptionally high levels of air pollution from tens and orphanages was examined using a porta- automobiles but without significant industrial ble XRF spectrum analyzer (KeyMaster Technologies emission sources. Inc. model MAP 4). Lead K-shell and L-shell fluorescence was measured and read as mg/cm2. The K-line Analytical Methods reflects lead concentrations to a depth of several mm, and the L- line is more indicative of lead on the A wide variety of methods were used to characterize very surface, although K-shell data are more reliable. the lead and other heavy metals that were contrib- Calibration was checked before and after each se- uting to and impacting the environmental and public ries of analyses. health situation. Metals in soil using X-ray fluorescence (XRF). Di- Lead in blood by anodic stripping voltammetry rect on-site reading of soil contamination levels was (ASV) portable device. Blood samples were collect- utilized for screening purposes using a portable XRF ed and analyzed on site in selected kindergartens spectrum analyzer (NITON XL-700 in 2002-2003 (educational and day-care centers) and other similar and InnovXsystem Alpha-4000 in 2008). Simultane- facilities using the ESA Lead Care Blood Lead Testing ous K-shell and L-shell analyses were performed by System (model 3010B analyzer). In particular, 50 ul of blood were quantitatively transferred and mixed X-ray detection measured in ppm (mg/kg)for the fol- with a treatment reagent that removes the lead from lowing metals: Pb, As, Mo, Zr, Sr, Rb, Hg, Zn, Cu, Ni, the red blood cells. The sample was transferred to Co, Fe, Mn, and Cr. Co-located composite samples the ASV instrument, where the lead was detected were also collected (usually 4 to 5 composites at each and results displayed as µg/dL of lead in the blood location), dried, and analyzed by a XRF spectrum an- sample. Analysis took approximately 10 minutes per alyzer. The accuracy of the analyses was checked by sample. The instrument calibration was checked us- reanalyzing selected samples in the United States ing two blood-lead standards (8.2 and 31.6 µg/dL) with a laboratory XRF (Spectrace 7000 according to twice per day. EPA approved method162). Calibration of the portable XRF instrument was checked before and after Zinc protoporphyrin (ZPP) in blood by hematoflu- each series of analyses. Confirmation of the analyti- orometer portable device. Blood samples were col- cal results was performed using split sample analy- lected and analyzed on site using a Kaulson Labo- ses in the U.S.A. and Kazakhstani laboratories (U.S. ratories Inc. hematofluorometer model 2001. In the EPA Method for ICP/MS163). presence of iron deficiency, zinc is incorporated into protoporphyrin 1X in place of iron. ZPP associated Bioaccessibility determination. The bioaccessibility with red cells gives rise to red-cell florescence and of lead in soil and dust was measured for four repre- can be measured by the hematofluorometer. ZPP sentative samples from Shymkent, Kazakhstan, us- in blood is an effective indicator of chronic lead in- ing U.S. EPA Method 9200.164,165

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Air samples by X-ray fluorescence (XRF). In Shym- The ranges of the content of lead and arsenic in soil kent, air samples were collected on filters using per- are shown in Table 5. sonal hygiene sampling pumps. The pumps recorded the volume of air that passed through the filters. The The levels of lead in different types of paint (com- pumps and filters were typically mounted on school bined, for all types of measured surfaces) are dis- rooftops to avoid tampering and theft, except for played in Table 6. one pump and filter that was mounted on the prop- In various toys in Kazakhstan, the concentrations of erty of a fenced-in home, close to the lead smelter, lead determined by a lead leachate method167 were at approximately the height of a person’s breathing found in the range from 16 to 32,048 ppm, with the zone. The pumps ran continuously and the filters 168 were changed every 24 hours. The air concentration maximum acceptable level of 90 ppm. In the ex- was determined by dividing the mass (determined amples of tableware (cups), the concentrations of by the XRF technique), by the total volume of air that lead varied from nondetectable to 0.86 µg/ml (allow- 169 passed through the filter during the sampling peri- able level in the US 0.5 µg/ml). od. Air sampling and XRF analysis was conducted in Specific results of the measurements performed in general accordance with the NIOSH 7702 method.166 different locations (kindergartens and orphanages) Results in the city of Shymkent are presented in Table 7.

The results of the measurements of lead in blood in dif- The isoclines of the levels of soil contamination of ferent cities in Kazakhstan are summarized in Table 4. lead and arsenic in Shymkent are shown in Figure 3.

Table 4. Lead in Blood in Kazakhstani Children

Standard Geometri c Geometric Main source Number of deviation mean (µg/ standard Maximum >10 City of lead tests Mean (µg/dL) (µg/dL) dL) deviation (µg/dL) µg/dL (%) Almaty Lead in paint 70 6.1 4.1 5.00 1.9 23.6 16 Kyzylorda Lead in paint 303 6.0 3.2 5.42 1.5 25 7 Pavlodar Lead in paint, 160 5.4 3.9 4.29 2.0 30.3 9 industrial emissions Shymkent Major primary 157 20.7 16.0 15.62 2.2 103 66 (95% lead smelter close to the emissions smelter) Taldykorgan Battery plant 70 8.9 5.9 7.73 1.6 32 20 emissions Tekeli Lead mine 75 8.7 6.2 7.49 1.6 38.4 16 Ust- Kameno- Lead in paint, 237 6.6 4.2 5.56 1.8 29.4 15 gorsk industrial emissions

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Table 5. Lead and Arsenic Content in the Soil of Table 6. Levels of Lead in Painted Surfaces in Kazakhstani Cities Kazakhstani Cities (mg/cm2)

City Pb (mg/kg) As (mg/kg) Number Geometric Almaty 7–97 ND–22 of Standard Geometric Standard City samples Mean deviation mean deviation Kyzylorda 29–5,628 9–756 All measure- 1,539 1.11 1.73 0.59 3.0 Pavlodar 53–5,568 153–874 ments Shymkent 49–24,896 ND–2,539 Kyzylorda 359 0.86 1.77 0.37 3.6 (77,000 close to emission source) Pavlodar 269 1.33 1.55 0.87 2.5 Taldykorgan 33–5,958 ND–160 Shymkent 135 1.64 3.06 0.77 3.4 Tekeli 43–3,612 9–88 Taldykorgan 188 0.99 1.71 0.49 3.2 Ust- Kamenogorsk 53–1,410 1–95 Tekeli 48 0.78 0.94 0.49 2.5 Ust-Kameno- 540 1.11 1.30 0.72 2.5 gorsk

Table 7. Results of the Tests for Various Locations in Shymkent

Avg. lead Avg. soil lead Average indoor dust Lead in blood: GM, ZnPP in blood: GM, concentration in air concentration lead concentration Location GSD, range (µg/dL) GSD, range (µg/dL) (µg/m3) (mg/kg) (mg/kg) House of Invalids 12.8, 1.6, 47.4, 1.6, 7.9 1,313 4,625 (close to the lead 4.7–22.8 28–96 smelter) Orphanage 3 (close to 18.4, 1.4, 50.2, 1.5, 5 794 433 the lead smelter) 9.7–29.9 23–91 “Pink Flower” kinder- 7.72, 1.6, 46.9, 1.4, 1 104 1,400 garten (far from the 3.0–20.5 13–124 lead smelter) “Sholpan” (kindergar- 27.7, 1.8, 57.8, 1.7, 5 1,530 795 ten) (close to the lead 2.1–103 23–325 smelter) GM – geometric mean GSD – geometric standard deviation

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The isoclines of the levels of soil contamination of lead and arsenic in Shymkent are shown in Figure 3. The situation in Shymkent is the worst in the country and probably one of the worst in the post-Soviet region. It is aggravated by the fact that lead in Shymkent soil is highly bioavailable. Based on the analytical results (XRF and ICP/MS), four representative soil samples ranging from 3,030 to 18,924 mg/kg of lead (<250 µm fraction) were evaluat - ed using the in vitro procedure described above. The bioaccessibili - ty values ranged from 93 to 113%, which means that the lead has the maximum possible availability for a child’s body.

Economic Evaluation 0 1 2 3 4 5 The impact of childhood lead poison- Kilomet ing in polluted areas has serious eco- Coordinates nomic consequences. This section demonstrates a way to estimate the Figure 3. Lead andFigure Arsenic 3. Lead andin Shymkent Arsenic in Shymkent Soil (mg/kg) Soil (mg/kg) blue (blue isocline, lead; red isocline, arsenic). effect in U.S. dollars related to the isocline, lead; red isocline, arsenic). human impact of the Shymkent lead contamination. The consequences of childhood lead poisoning on the economicThe develop situation- in ShymkentFor our purposes,is the worst inno the economic country and impact probably is one assumed of the worst in ment and social stability of different regionsthe has post-Soviet been region.below It the is aggravated current target by the fact level that of lead 10 inµg/dL Shymkent BLL, soilwhich is highly 170–172 bioavailable. Based onin vitrothe analy tical results (XRF and ICP/MS), four representative soil demonstrated in numerous studies. Onesamples aspect ranging implies from 3,030 a tomedian 18,924 mg/kglevel of lead4.6 (<250 µg/dL. µm Therefore, fraction) were the involves the likelihood of criminal acts. Adjustedevaluated total using economicthe procedure benefits described presented above. T hehere bioaccessibility are likely values to be arrest rates were shown to be significantlyranged greater from 93 toconservative, 113%, which mea underestimatingns that the lead has the the maxim trueum benefits. possible for each 5 µg/dL increase in blood-lead concentraavailability for- a Thechild’s current body. median BLL in Shymkent’s children was tion, especially for prenatal and young children’s measured to be 20 µg/dL, with a 90% approximate blood-lead levels.173 prediction interval of 8 to 50 µg/dL, although the BLL

data ranged up to 103 µg/dL. The number of affect- We used an estimation of economic benefits of BLL ed children of preschool age in the city was taken as reduction derived from Nevin, 2008174 at the level 106,000 per 10 years. of $8,741 per child per 1 µg/dL BLL in the U.S.A. In 30 58 proportion to the difference in GDP per capita be- With these assumptions,Page of the Monte Carlo-modeled tween the U.S.A. and the Republic of Kazakhstan, results of the economic benefits of the proposed this estimation was adjusted to $2,370 per child per lead remediation program in Shymkent are shown in 1 µg/dl BLL. Figure 4.

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Economic Evaluation

The impact of childhood lead poisoning in polluted areas has serious economic consequences. This section demonstrates a way to estimate the effect in U.S. dollars related to the human impact of the Shymkent lead contamination. The consequences of childhood lead poisoning on the economic development170 171and 172 social stability of different regions has been demonstrated in numerous studies. One aspect involves the likelihood of criminal acts. Adjusted total arrest rates were shown to be significantly greater for each 5 µg/dL increase in blood-lead concentration, especially for prenatal 173 and young children’s blood-lead levels.  We used174 an estimation of economic benefits of BLL reduction derived from Nevin, 2008 at the level of $8,741 per child per 1 g/dL BLL in the U.S.A. In proportion to the difference in GDP per capita between the U.S.A. and the Republic of Kazakhstan, this estimation was adjusted to $2,370 per child per 1 g/dl BLL.

Community Lead Exposure of Children in Developing and  Guidance Document EmergingFor Economies: our purposes, Problems, no economic Policies, impactand Solutions is assumed Based below the current target level of 10 on Case Studiesg/dL BLL, in Eastern which Europe,implies Caucasus,a median level and Centralof 4.6 Asiag/dL. Therefore, the economic benefits presented here are likely to be conservative, underestimating the true benefits. The current median BLL in Shymkent’s children was measured to be 20 g/dL, with a 90% approximate prediction interval of 8 to 50 g/dL, although the BLL data ranged up to 103 g/dL. The number of affected children of preschool age in the city was taken as 106,000 per 10 years.

Figure 4. Estimation of Benefits from BLL Reduction in Shymkent, Kazakhstan.

With these assumptions, the Monte Carlo-modeled results of the economic benefits of Thus, thethe mean proposed estimated lead remediation economic benefit program from in Shymkent incidence are of shownchildhood in Figure lead poisoning. 4. For example, lead in blood reduction in Shymkent is roughly 4.6 recent studies were conducted by the Blacksmith In- billion in Thus,U.S. dollars the mean over estimated 10 years. economic benefit fromstitution lead in(USA) blood in re Balkhashduction inCity, Shymkent Karaganda region in Kazakhstan, where the largest copper smelter, General isAssessment roughly 4.6 of billion the Lead in U. ProblemS. dollars in over 10 years. owned by a British company, operates. The studies Kazakhstan demonstrated that the average level of lead in res- The comparative distributions of lead in blood in all idential areas was 1,626 mg/kg (SD 1,098 mg/kg). studied cities of Kazakhstan and in Shymkent are This can mean that 87% of the children living in such demonstrated in Figure 5. conditions probably have blood-lead levels higher than 10 µg/dL (according to the U.S. EPA IEUBK There is an extremely high level of lead impact on model). Lead content in soil strongly correlates with children in Shymkent, where annually, based on the copper concentrations (r=0.98, P<0.05). estimations above, around 40,000 children of preschool age (0 to 6 years) are suffering from lead The impact of the new CDC reference blood-lead poisoning. This is an example of a long-term critical level of 5 µg/dL compared to 10 µg/dL175 has a dra- situation that has never been addressed properly. matic effect on the interpretation of the Kazakhstani Barriers that prevent situations like this from being testing results. In Table 8, this effect is assessed. resolved will be discussed later. The case study in Kazakhstan proves that lead However, it is clear that Shymkent is not the only city should be considered one of the most significant in the territory of Central Asia that has such a high environmental health issues in the countries of the

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The comparative distributions of lead in blood in all studied cities of Kazakhstan and in Shymkent are demonstrated in Figure 5.

KazakhstanKazakhstan City Cityof Shymkent of Shymkent

Figure 5. HistogramsFigure 5. Histogramsof Blood Lead of Blood in Children Lead in forChildren All of for Kazakhstan All of Kazakhstan Compared Compared with Shymkent.with Shymkent. former Soviet Union. The potential health risks there Table 8. Comparative Estimation of Children Affected by are very high and require urgent health protection Lead Poisoning in Kazakhstan, Based on the Old and New CDC Standards and remediationThere measures.is an extremely high level of lead impact on children in Shymkent, where annually, based on the estimations above, around 40,000 children of preschool age (0 Kazakhstan For the situation in Shymkent and other locations to 6 years) are suffering from lead poisoning. This is an example of a long-term critical with with intensive industrial lead contamination, reme- situation that has never been addressed properly. Barriers that prevent situationsShymkent, like Shymkent diation of the soil, combined with an effective ongo- Kazakhstan Kazakhstan data excluded this from being resolved will be discussed later. ing community educational program, will dramat- % of children 19 66 12 ically improve the neurobehavioral status of young However, it is clear that Shymkent is not the onlywith citylead in the territory of Central Asia children. Additional measures should also be imple- blood above that has such a high incidence of childhood lead poisoning. For example, recent studies mented, such as environmental and biological moni- 10 µg/dL were conducted by the Blacksmith Institution (USA) in Balkhash City, Karaganda % of children 63 89 59 toring and creationregion in of Kazakhstan, “clean playgrounds” where the thatlargest could copper smelter, owned by a British company, with lead in allow childrenoperates. to spend The studiestime in demonstrated safe environmental that the average level of lead in residential areas conditions. Kazakhstan also needs state-of-the-art blood above was 1,626 mg/kg (SD 1,098 mg/kg). This can mean5 µg/dL that 87% of the children living in proceduressuch for theconditions treatment probably of children have bl diagnosedood-lead levels higher than 10 µg/dL (according to with lead poisoning. the U.S. EPA IEUBK model). Lead content in soilthe strongly unavailability correlates or withdifficulty copper in attaining appropri- Lead Poisoningconcentrations Prevention: (r=0.98, Typical P<0.05). Barriers to ate technology. Overcome Historically, the large-scale industrialization that The impact175 of the new CDC reference blood-lead level of 5 µg/dL compared to 10 To resolve µg/dLthe problem has aof dramatic childhood effect lead on poisoning the interpretation was performed of the Kazakhstani in this region testing in a results. comparatively short in the formerIn Table Soviet 8, thisUnion, effect many is assessed. barriers must be period — aggravated by two major wars during the overcome. Many of those barriers are rooted in the century, general military orientation of the econo- common history and heritage of the new indepen- my, and priorities of space and atomic industries

dent states, in economic realities, in legislative and — caused excessive environmental pollution and in- social environment, in aging industrial facilities, and32 creased58 occupational and environmental risks.176 Page of

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The Soviet government was especially interested the plant to function under the current economic sysin the growth of production, ensuring its ability to tem. Many groups and individuals have a vision for supply the population with its minimal needs and what is meant by a clean environment, and general- to increase the country’s military capabilities. Min- ly, the concept is not opposed. However, on a prac- ing and metallurgy in this context became a sector tical level, “it is sometimes difficult to achieve in our of special interest. The quick growth of metallurgical circumstances today,” is a ready excuse. production of the Soviet Union was often achieved by ignoring environmental and occupational safety Currently, difficulties remain in resolving the problems requirements. For this reason, the level of environ- of environmental contamination left as an “historical mental contamination in the former Soviet Union is heritage” in the new independent states. On a na- extremely high and contributes to the low life expec- tional level, no one takes ownership for the historical tancy in the region.177 In the Russian Federation, the pollution, laying the blame on a country (the U.S.S.R.) average life expectancy in 2012 was 64.3 years in that no longer exists. The legal framework inherited men, 76.1 years in women.178 Life expectancy in oth- from the Soviet Union remains complex, with many er countries of the region is of the same order. recent laws simply superimposed on retained older laws and regulations, with resulting inconsistencies, With the breakup of the Soviet Union, the region overlaps, and gaps. For example, international ex- entered a transition period, with sharp econom- perts noticed that one of the countries in the region ic decline and worsening social and environmental conditions, combined with extremely high levels of … developed an extensive corpus of poverty. It was inevitable that issues concerning en- environmental laws and put in place a system vironmental protection would come in second behind of non-compliance response in order to make economic concerns during the transition period. environmental law work. This system foresees administrative, civil, and criminal liability Industry in the post-Soviet countries, as a rule, went and provides for administrative and judicial through a privatization process that sometimes did paths of enforcement. It includes a panoply of not change its close governmental ties (that in the sanctions (such as corrective orders, fines, permit transition period were the only way of survival for withdrawal, production closure, imprisonment), both government and industry). The equipment that comparable in scope with those used in OECD industry inherited from the Soviet period was more countries. However, pervasive disregard for law often than not in a state of disrepair and exhaustion, — a legacy from the country’s Soviet past — since due to difficult economic circumstances, there continues to raise concerns … as non-compliance has been little additional investment. prevents the country from achieving ambitious environmental objectives.179 Business owners are often more interested in survival, rather than having much concern for the envi- The present system depends on a rigid analysis of ronment, knowing full well that they will never have conformity to numerous laws, some of which are in- to pay significantly for any consequences (except appropriate today for the purpose of protecting the perhaps in the form of health effects). The mode of environment. When it comes to enforcement, the operation has moved from one of Socialism to sim- system is one of penalties. Rather than considering ple protectionism. It is this protection of the business investment in environmental protection measures, through exceptions to rules (and laws) that allows the system sets fines so low that they actually en-

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courage operators to pay them and to consider it a Another barrier that should be mentioned is the spe- normal business operating cost.180–182 cial and artificial requirements for the environmental laboratory tests established by some of the former Sometimes, the recently introduced environmental Soviet republics. In some of those countries, the ap- permit system in the region remains similar to the plication of traditional Western (or even internation- Soviet central planning system, and also, at times re- ally accepted ISO standards) laboratory methods mains highly nontransparent. In international prac- and techniques requires local recertification that can tice, proper environmental impact assessment is a sometimes take years. This factor is sometimes cit- process of systematic analysis and evaluation of envi- ed by the authorities, who are trying to prevent the ronmental impacts of planned activities, consultation environmental and health problems of the regions with affected parties, and utilization of the results of from being known internationally and to keep local the analyses and consultations in planning, autho- control of the situation. Although it is understand- rizing, and implementation of the activity. The pro- able that local health authorities are interested in es- cess is thus based on a number of principles, such as tablishing local procedures, the priority of children’s transparency, public involvement, and accountability. health should not be questioned. The achievements In the countries of the former Soviet Union, however, of Western countries in developing environmen- there is a significant lack of quality, scientific validity, tal and health laboratory equipment should not be and integrity when environmental impact assessment overlooked. is performed as a part of a permitting procedure. In many situations, if environmental impact assessment There are other obstacles worth mentioning that are were performed for industrial operations in a proper beyond the scope of this document, such as cultural and timely manner, and if environmental monitoring and linguistic differences that frame and shape per- were in place, many of the lead pollution issues in the ceptions of problems, unavailable medical and re- region could be prevented. mediation technologies, and the shifting priorities of international donors. In addition, a local perception, Besides these industries, the population very often is real or imagined, of Western scientist attitudes of su- not psychologically prepared to protect its environ- periority can set up roadblocks to progress. Patience mental and health interests. The environmental con- is needed to build relationships of trust that address cerns of individuals were historically nonexistent in these interconnected barriers that are hindering the the region, yielding to much more actual fear of pov- prevention of lead poisoning in children. erty and hunger. A self-perception of people in the region is often one of denial concerning the harmful effect of poisoning.

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Chapter 3: Working Together to Protect • Criteria and standards for lead should be determined Children (Recommendations for the based on the risk assessment approach (as it was recommended in the Chapter 1 of this document). International Community) • Sources of elevated lead exposure should be Why Should International Community Care? determined. (Reasons for International Involvement) • Environmental remediation programs should be The following are reasons that the international introduced. community needs to address the problems of child- • Medical intervention policy should be established, hood lead poisoning in the countries of the former with approved methodologies and training Soviet Union: for physicians, including chelation treatment • Lead is a significant environmental factor in many methodologies. of the post-Soviet countries. • Additional controls are needed to prevent illegal • As our studies show, in many regions, lead issues use of tetraethyl lead in motor vehicle fuel. are not addressed and children are poisoned. • Special permitting procedures for lead-emitting • The international community has the experience to industrial sources including life-cycle environmental resolve problems of lead contamination that can impact assessment should be beneficial. be effectively applied in the post-Soviet countries. • Environmental remediation technologies should • Leaving the problems unaddressed can gradually be included as a part of international help and increase the world division into “healthy” and technology transfer packages. “nonhealthy” territories. • The countries of the region should remove the • The results of the studies in developing countries limitations for applying more modern environmental can be beneficial in making further progress in lead devices, methods, and standards. toxicology. Success Stories What Can Be Done? In many countries of the world, the prevention of In the countries of the former Soviet Union, as well environmental impacts from lead on the health of in other countries where the problem of childhood/ children has had positive results, starting with mea- community lead poisoning is similar, science-based surement and evaluation of the problems, followed policy should be implemented to prevent the envi- by measures to reduce childhood blood-lead levels. ronmental impact of lead. The following steps should U.S. Experience be considered: As an example, the trend for lead in blood of chil- • Lead poisoning of children should become a priority dren in the United States is summarized in Table 9.183 in public health and environmental protection. Geometric mean of blood-lead level for U.S. children • National screening programs for lead in blood reduced by an order of magnitude in 20 years. and lead in environmental media should be implemented. The observed significant decrease of lead in blood in Western countries is a result of systematic government programs, including:

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Table 9. Blood-Lead Levels of Children (ages 1 to 5) in the viet era, the Dalnegorsk District was developed as United States: National Health and Nutrition Examination an industrial mining area because it has one of the Survey for Selected Years richest mineral deposits in the Far East. The govern- % with Geometric mean ment built numerous mines, plants, and smelters in Year BLL ≥ 10 µg/dL BLL (µg/dL) the area. 1976–1980 88.2 15.0 Based on the referenced source, the Rudnaya Pristan 1991–1994 4.4 2.7 lead smelter, located at the mouth of the Rudnaya 1992–2002 1.6 1.9 River approximately 1.5 km from the bay, was established in 1930 by actor Yul Brynner’s family. It is 1. the ban of leaded gasoline; the only known remaining open-hearth furnace in Russia utilizing the British “Newman” process. The 2. the banning of lead-based paints in households; plant was nationalized by the Soviets in 1932, and 3. special measures undertaken to regulate paint few technological improvements have been made renovation in houses where lead-based paint since. may be present; Therefore, at present, the main technological pro- 4. remediation of industrial sites contaminated by cesses are much the same as they were in the 1930s. lead; and One of the few updates was the installation of a 5. monitoring of blood-lead levels in preschool chil- mechanized forklift in 1970, to replace hand labor to dren and individual case management for children stir the ore. The plant appears to be in abject disre- with elevated lead in blood. pair, operating with technology from the 1930s and It is obvious, however, that in the United States with few health or safety precautions. Starting in the much more remains to be done, because the latest 1930s, industrial development of Rudnaya Pristan estimate from CDC is that there are 535,000 children brought a variety of contaminants into the area. with elevated blood-lead levels.184 Sources of environmental pollution included construction, operation of the smelter, transportation, Lead Contamination in the Russian Far East: Case and related poor hazardous waste management. Study Air pollution remains one of the main environmental problems. In the developing world, examples of successful res- olutions for the problems with childhood lead poison- Particulates with high lead content come from the ing are still very rare. A unique example, however, is smelter stacks and are distributed throughout the a systematic program of lead remediation in the Dal- site with the wind. From this airborne transport and negorsk and Rudnaya Pristan projects in Russia.185 deposition, lead and other heavy metals accumulated ubiquitously and contaminated soils, houses, and Rudnaya Pristan is a small industrial town in the gardens. Russian Far East, approximately 400 km northeast of Vladivostok. The population averages 5,000 peo- An approximate 3 km strip around the smelter is ple, including nearby villages. This area is part of the denuded and heavily eroded. The shrubs and trees Dalnegorsk District, with the administrative center growing in this area are stressed, lack normal lichen in the city of Dalnegorsk (population 45,000), about cover, and exhibit poor, abnormal growth due to 30 kilometers from Rudnaya Pristan. During the So- sulfur dioxide emissions. Plant extracts have been

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reported to have 0.3 mg/L arsenic, 9 mg/L zinc, 20 most prevalent garden crops are tomatoes, cucum- mg/L lead, and 0.5 mg/L copper.186 bers, and a number of berries. Both tomatoes and cucumbers are popular summer foods used primarily According to Sharov, the environment of Rudnaya for making salads, and marinated or preserved for Pristan has been studied for a number of years and winter in large quantities. In preparing these vege- area soils have been found to be highly contaminat- tables, they are always washed, which reduces risk ed with heavy metals, such as lead, cadmium, zinc, of ingestion of accumulated lead-containing dust. and copper.187 A study conducted in 1997 to1999 Like potatoes, these vegetables also may accumu- revealed dangerous concentrations of lead in soil late lead in their tissues from the contaminated soil near the smelter and throughout the town. Sampling in which they are grown. Potatoes, tomatoes, and efforts focused on roadsides, gardens, yards, river- cucumbers are consumed year-round, which may banks, railroad beds, beaches, and playgrounds. Soil mean year-round exposure to lead for most of the samples taken from residential gardens averaged families. 2,200 mg/kg lead. School areas and playgrounds averaged 550 mg/kg, with a maximum of 1,350 mg/ The Blacksmith Institute reported that some vegeta- kg lead in soils. One paint sample was collected and bles and fruits from the area have been character- contained 0.75% lead, compared to the U.S. trigger ized and have yielded average dry weights of 16.5 level of 0.5%. The exteriors of houses were common- mg/kg lead, 5.6 mg/kg cadmium, and 32.0 mg/kg ly painted with lead-based marine paints salvaged zinc in strawberries, with lesser but significant levels from ship maintenance activities in the local port. indicated in potatoes, cucumbers, and tomatoes.188 Soil lead contamination levels up to 95,000 mg/kg Another study conducted in 2003 to 2005 revealed were found. The highest levels were from the sam- high concentrations of heavy metals in edible parts of ples near the railroad where lead concentrate was potatoes grown in Rudnaya Pristan and neighboring spilled. Even the lowest concentrations of lead at lo- villages. Concentrations of lead ranged from 0.08 to cations farthest from the smelter still show contam- 23.93 mg/kg (2.22 mg/kg average). Concentrations ination at160 to 896 mg/kg, far exceeding the back- of cadmium ranged from 0.2 to 1.27mg/kg (0.39 mg/ ground level. kg average); zinc ranged from 7.39 to 46.14 mg/kg (22.19 mg/kg average); and copper ranged from According to Petr Sharov, another important path- 0.78 to 7.23 mg/kg (3.10 mg/kg average). way of exposure to lead is the consumption of locally grown fruits and vegetables. It is common in the Rus- Health studies of the whole Dalnegorsk District con- sian countryside and is true in Rudnaya Pristan, that ducted during the Soviet era revealed the anoma- people try to grow as much food as possible in their lous structure and extent of local health problems. gardens in order to avoid buying food at the market Respiratory pathologies and infections held first and to ensure a year-round food supply. The primary place among the priorities of diseases and health crop is potatoes, which are grown in larger quanti- problems. In 1987 to 1989, on average, there were ties than any other crop. In Russian cuisine, potatoes 538 cases of respiratory problems per thousand are almost always peeled and washed, which ex- residents per year, the highest rate among all includes the risk of ingestion of contaminated soil with dustrial centers of Primorye. At the same time, there consumption of the potato. On the other hand, lead were 1,048 and 1,010 cases of respiratory problems contained in soils of the area may be accumulated per thousand children in Dalnegorsk and Rudnaya in tubers of the plant and thereby ingested. The next Pristan, respectively. Beginning in 1981, a steady

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increase was noted of heart pathologies in children 1. For the reduction of the exposure of young chil- from birth to age 14. dren to lead: In 2005, in the towns of Dalnegorsk, Serzhantovo, • establishment of a multidisciplinary lead working Monomakhovo, and Rudnaya Pristan, BLL testing of group, which included kindergarten teachers, children was conducted, which was financed by the doctors, and environmental health specialists; Blacksmith Institute and organized by the Far East- • procurement of equipment for lead-in-blood ern Health Fund and the Dalnegorsk Division of the tests (atomic absorption spectrophotometer) Center of State Sanitary and Epidemiologic Supervi- and enrollment of the local laboratory staff in sion for Primorye. In Rudnaya Pristan, 120 children the International Blood Lead Proficiency Testing were tested and over 50% of them had blood-lead Program; concentrations above 10 μg/dL. The blood-lead level ranged from 1.6 to 56.7 μg/dL (average 12.4 μg/ • training for the local specialists; dL). Spatially, the children at the highest risk of lead • development of a health education program for poisoning lived closer to the smelter in the central, kindergartens and for families to reduce lead eastern, and western parts of town. Most of children exposure of children; tested lived in the southern part of Rudnaya Pristan, where the lead health risk is lower. These data gen- • development of a community awareness erally support the results of the IEUBK analysis, thus program, utilizing newspaper, magazine, radio, indicating that the methods presented for health risk and television outlets; assessment for lead could be successfully used for • institution of a lead awareness counseling purposes of developing risk mitigation measures and program for families; and environmental remediation projects. • provision of a summer health education camp for As the Blacksmith Institution has reported, an envi- children and parents. ronmental remediation project was implementedAs in the Blacksmith2. For improvement Institution has reported, of air-quality an environmental monitoring remediation capac project- was this region. During 2008 to 2009, five playgroundsimplemented ity in and this region. data Dumanagement:ring 2008 to 2009, five playgrounds were cleaned up were cleaned up (by taking the soil out, safely dis(by- taking the soil2 out, safely disposing of it, and replacing it with clean soil) at the total posing of it, and replacing it with clean soil) at thearea of 6,240• establishment m . Additionally, an of educational an air working program was group; introduced for children and parents. The average blood-lead level for children in Dalnegorsk has been reduced, 2 total area of 6,240 m . Additionally, an educationalas shown in Figure 6.

program was introduced for children and parents. 14 The average blood-lead level for children in Dalne- level 11.8 12

gorsk has been reduced, as shown in Figure 6. lead 10 9.4 Lead in Zlatna, Romania

blood 8 (µg/dL)

6.4 6 In Zlatna, a community of approximately 10,000 people in the Transylvanian region of Romania, a Average 4 comprehensive project was organized by USAID and 2 other supporting organizations, to reduce lead expo- 0 sure risks for children caused by emissions from a Figure 6. Lead2007 in Blood of the2008 Children of 2009 Figure 6. Lead in Blood of the Children of Dalnegorsk (Russia) During copper smelter. The interventions performed includ- DalnegorskRemediation (Russia) ProgramDuring Implementation. Remediation ed the following: Program Implementation. Lead in Zlatna, Romania

In Zlatna, a community of approximately 10,000 people in the Transylvanian region of Romania, a comprehensive project was organized by USAID and other supporting organizations, to reduce lead exposure risks for children caused by emissions from a AIHA | 3141 Fairview Park Dr., Suitecopper 777 smelter. | Falls TheChurch, interventions VA 22042 performed | aiha.org included the following:

 establishment of a multidisciplinary lead working group, which included kindergarten teachers, doctors, and environmental health specialists; procurement of equipment for lead-in-blood tests (atomic absorption  spectrophotometer) and enrollment of the local laboratory staff in the  International Blood Lead Proficiency Testing Program; training for the local specialists;  development of a health education program for kindergartens and for families to reduce lead exposure of children;  development of a community awareness program, utilizing newspaper, magazine, radio, and television outlets; institution of a lead awareness counseling program for families; and Community Lead Exposure of Children in Developing and Guidance Document Emerging Economies: Problems, Policies, and Solutions Based on Case Studies in Eastern Europe, Caucasus, and Central Asia

• delivery of a four-day air-quality management for International Development Cooperation), and and air-monitoring training program; other NGOs.190–194

• procurement, delivery, and installation of two The Future of Lead Poisoning Prevention state-of-the-art monitoring stations; and Childhood lead poisoning is a serious problem that • operations and maintenance training and follow- in the last few decades has significantly changed its up. geographical focus. In developed countries, progress 3. For improvement of occupational health and safe- has been made, although far too many children still ty (OHS) at the smelter: remain at risk. In the developing world, the situation • establishment of an occupational health and has worsened, with an increase in the size of con- safety working group; taminated territories and the number of suffering children. Therefore, the future of lead poisoning pre- • implementation of a training program on worker’s vention lies in continuous international collaboration health and safety; and in a global search for better health and environ- • equipment procurement and delivery, including mental solutions. respirators and hazardous exposure assessment devices; Lead is a unique example of a dangerous poison for which public health effects can exist without be- • establishment of a medical surveillance program ing identified for decades, gradually degrading the coordinated with worker blood- lead sampling social well-being. Low-level lead poisoning, which results; and does not cause acute symptoms but produces irre- • provision of a training program for workers and versible consequences for the nervous system, does providing workers with the results of workplace not appear to have been treated as a top priority. air-monitoring and blood-lead testing data. However, the impact of lead poisoning is devastat- As an outcome, a 25% reduction of average children’s ing, including a decreased potential of a society to blood-lead level (age group 1 to 11 years) was report- develop, along with an increase in individual aggres- ed. The reduction was from 40 µg/dL to 28 µg/dL.189 sion and criminalization that negatively affects international stability. Example of other heavy metals The Western international community is very sensi- Additional cases of potential approaches to the tive to the violation of human rights, especially those community management of childhood exposures of children. However, millions of children worldwide are illustrated for other heavy metal community con- are being involuntarily poisoned by lead, thus vio- taminants. For example, lead and arsenic contami- lating their human rights. Democracies should ac- nation were addressed during several international knowledge the problem and take strong diplomatic environmental health projects. Detailed review of measures to protect the rights of children to a life un- the steps undertaken in Bangladesh, India, and Ne- fettered by the bonds of lead. International mecha- pal can be found in selected publications. These ap- nisms for childhood lead poisoning prevention should proaches to effectively prevent arsenic poisoning in be determined and established as soon as possible. communities involved the active participation of the group of William Carter and Linda Smith, with sup- As an example, International Task Force for Children’s port from UNICEF, FINNIDA (the Finnish Department Environmental Health (not affiliated with AIHA) pro-

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posed a “Zone of Hope” initiative as one part of a Conclusions solution. “Zone of Hope” is a status that an area can Lead poisoning of children in developed and develop- obtain to help alleviate environmental threats to chil- ing countries has by no means been eliminated, and dren. The goal of the initiative is to develop interna- mitigating the problem should have a high priority tional tools to protect children’s rights to a safe envi- among environmental health issues. Lead is especial- ronment by enhancing and coordinating information ly dangerous because of its ability to target a vulnera- transparency, independent expertise, and business ble age group, with its impact starting at low levels of involvement in a manner that is acceptable to local exposure, and its propensity to cause hidden, nonspe- governments and communities. cific, and irreversible effects. The recent recommendation of the CDC to implement a reference value of For inclusion in the “Zone of Hope” status, the criteria 5 µg/dL in blood reflects an opinion within the expert for acceptance should be supported by a group of community that significant health and behavioral dis- international experts. Data on local conditions and ruptions from lead in blood may result at even lower eligibility should be peer reviewed. Incentives will be levels than previously anticipated. provided to facilitate industrial and other economic growth as an alternative to processes that harm the In the countries of Eastern Europe, Caucasus, and environment. The “Zones of Hope” can be announced Central Asia (the former Soviet Union states), expo- on the web site of the initiative. Progress will be reg- sures to lead in the environment during childhood ularly monitored and reported. International busi- have been seriously underestimated. As a result, nesses working in the “Zone of Hope” will be invited hundreds of thousands of children who are residents to assist with local environmental issues in a positive of numerous communities in those regions continue manner and to assist with community education to to be affected every year. Not only the health and help minimize negative impacts. well-being of these children is compromised, but also the current and future economic impact from Regions where lead contamination of the environ- lead pollution on society in the region will total bil- ment causes significant health deterioration of chil- lions of dollars. dren can benefit from inclusion in “Zone of Hope” The endeavors of local scientists and experts to ad- listings, thus making international involvement nec- dress lead issues, and government efforts to deal essary and legitimate. with the problems caused by lead are acknowl- Resolving childhood lead poisoning problems re- edged. However, it is clear that the capabilities of quires significant financial input from local, regional these countries will need to be strengthened to re- and national governments and the private sector, the solve the lead problem at a faster pace, more effec- last being an area in which the international com- tively, and in a more comprehensive manner. munity should find ways to help. Large foundations Although delays are not acceptable, international and businesses should be made aware of the serious organizations and bodies do not seem to be taking threat of lead poisoning in developing countries, and action to offer assistance in these situations. Per- they should be invited to participate in funding solu- haps this is because lead risks have not attracted tions. The status quo of ignoring or postponing pre- enough attention and are outside the interests of vention of the loss of much of the future generation’s major donors who may prefer to work with problems creativity and well-being should be changed. that seem more generalized and projects that are

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less specific. An apparent lack of funding may also With this situation in mind, the goal of AIHA with this have created limitations in public awareness of the reference document is to publicize the problem, to situation in both developed and developing parts of help achieve a better understanding of international the world. Sometimes, there may be an unwarranted lead poisoning problems, and to develop sharehold- sense of “problem solved,” and the enormity of the ers for international collaboration. We encourage remaining problem has not made the news. The con- cooperation among various groups and countries sequences of lead exposure of a substantial percent- to finally control and eliminate the problem of lead age of children in the post-Soviet region can, how- exposure of children. This document also presents ever, affect the entire world, given that borders have comparisons of lead issues in various regions and become more permeable for all aspects of safety, provides valuable information for further addressing health, environment, and economics. lead issues in developed countries, where lead remains a significant hazard requiring constant updat- ing of research, knowledge, education, and policy.

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References 12. National Toxicology Program (NTP): Monograph on Health Effects of Low- level Lead, June 2012. Avail- 1. Rasmuson, E., A. Korchevskiy, and J. Rasmuson: able at http://ntp.niehs.nih.gov/pubhealth/hat/noms/ Lead-in-Blood Safety Criteria for Young Children: In- lead/index.html (accessed July 15, 2015). ternational Applications and Ramifications, Abstract 13. Jacobs, D.: Lead. In Patty’s Toxicology, 6th ed. E. #3843, P‒2‒18‒10, “Environment and Health.” Ba- Bingham & B. Cohrssen (eds.) New York: Wiley, 2012. sel, Switzerland, Aug. 19‒23, 2013. pp. 381‒426. 2. World Health Organization (WHO): Comparative 14. Levin R., M.J. Brown, M.E. Kashtock, et al.: Lead ex- Quantification of Health Risks: Global and Region- posure in U.S. children: Implications for prevention. al Burden of Disease Attributable to Selected Major Environ. Health Perspect. 116:1285‒1293 (2008). Risk Factors, Majid Ezzati (ed.). Geneva: WHO, 2004. 15. Hammond, C.R.: The Elements. Handbook of Chem- 3. Occupational Safety and Health Administration istry and Physics, 81st ed. D.R. Lide (ed.). Boca Ra- (OSHA): Informational Booklet on Industrial Hygiene, ton, FL: CRC Press, 2000. OSHA 3143. Washington, DC: 1998. 16. Ibid. 4. Centers for Disease Control and Prevention (CDC), 17. Ibid. National Institute for Occupational Safety and Health 18. Brady, George S., and H.R. Clauser: Materials Hand- (NIOSH): Hierarchy of Controls, April 2015. Available at book, 11th ed. New York: McGraw-Hill, 1977. pp. 424, http://www.cdc.gov/niosh/topics/hierarchy. 426, 427, 725. 5. CDC: Morbidity and Mortality Weekly Report 19. Ibid. (MMWR). Assessment of Blood Lead Levels Among 20. Ibid. Children Aged ≤5 Years — Zamfara State, Nigeria, 21. U.S. Consumer Product Safety Commission (CPSC): June–July 2012. Ban of Lead-Containing Paint and Certain Consum- 6. WHO: “Global Health Risks; Mortality and Burden of er Products Bearing Lead-Containing Paint. 16 CFR Disease Attributable to Selected Major Risks,” Gene- 1303 Fed Reg 42:44199 (1977). Also see CPSC, va, 2009. What you should know about lead-based paint in 7. WHO: Childhood Lead Poisoning. Geneva, 2010. your home. Publication 1990‒726‒058. Washing- Available at http:///www.who.int/ceh/publications/ ton, DC: U.S. Government Printing Office, 1990. childhoodpoisoning/en. 22. U.S. Public Law: PL 110‒314 Section 101‒2008 (ef- 8. International Labor Organization (ILO): White Lead, fective Aug. 14, 2009). [Online] Available at http:// Studies and Reports. Series F, Industrial Hygiene, no. www.okinternational.org/lead-paint/Background 11. Geneva, 1927. (accessed May 1, 2013). 9. Markowitz, G., and D. Rosner: Deceit and Denial: 23. Clark, C.S., et al.: Lead levels in new enamel house- The Deadly Politics of Industrial Pollution. California/ hold paints from Asia, Africa and South America. Milbank Books on Health and the Public, Los Ange- Environ. Res. 109(2009):930–936 doi:10.1016/j.en- les, 2003. vres.2009.07.002, 2009. 10. Jacobs, D.: Lead-Based Paint as a Major Source 24. Gottesfeld, P., G. Kuepouo, and S. Tetsopgang, et of Childhood Lead Poisoning: A Review of the Evi- al.: Lead Concentrations and Labeling of New Paint dence. In Lead in Paint, Soil and Dust: Health Risks, in Cameroon. J. Occup. Environ. Hyg. 10:5:243‒249 Exposure Studies, Control Measures and Quality As- (2013). surance, Michael E. Beard and S.D. Allen Iske (eds.). 25. ScottClark, C., et al.: Total lead concentration in new Philadelphia: American Society for Testing and Ma- decorative enamel paints in Lebanon, Paraguay and terials, 1995. pp. 175‒187. Russia. Environ. Res. 138(2015):432–438. 11. Agency for Toxic Substances & Disease Registry (ATS- 26. Brady, George S., and H.R. Clauser: Materials Hand- DR): Toxicological Profile for Lead. CAS #7439-92-1. book, 11th ed. New York: McGraw-Hill, 1977. pp. 24, [Online] Available at http://www.atsdr.cdc.gov/toxpro- 426, 427, 725. files/tp.asp?id=96&tid=22 (accessed May 1, 2013). 27. Ibid.

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28. Ibid. 46. U.S. EPA: EPA Superfund Record of Decision. Sharon 29. Lah, K.: History of Lead Use. [Online] Available at Steel Corp. (Midvale Tailings). EPA/ROD/R08‒94/082, http://toxipedia.org/display/tosipedia/History+of+ 1994. lead+use (accessed May 1, 2013). 47. U.S. Geological Survey: Quality of Stormwater 30. www.en.wikipedia.org/wiki/tetraehtyl_lead. Runoff Discharged from Massachusetts Highways, 31. Peryea, F. J.: “Historical Use of Lead Arsenate In- 2005‒2007. USGS Scientific Investigations Report secticides, Resulting Soil Contamination and Impli- 2009‒5269, 2009. cations for Soil Remediation.” In Proceedings of the 48. Wang, T.-S., D.E. Spyridakis, et al.: Transport Depo- 16th World Congress on Soil Science, Montpellier, sition and Control of Heavy Metals in Highway Run- off. (Report WA‒RD‒39.10). Washington State Dept. France, Aug. 20‒26, 1998. of Transportation, 1980. 32. Ibid. 49. U.S. EPA: Remedial Investigation. Scorpio Recycling 33. Ibid. Inc. Superfund Site. personal communication with 34. Brady, George S., and H.R. Clauser: Materials Hand- Roger Olsen) book, 11th ed. New York: McGraw-Hill, 1977. pp. 24, 50. U.S. EPA: Treatability Manual. Vol. I: Treatability Data. 426, 427, 725. (Publication EPA-600/2‒82‒001a). EPA, 1980. 35. www.en.wikipedia.org/wiki/solder. 51. U.S. EPA: 40 CFR, Subpart I—Control of Lead and 36. ATSDR: Toxicological Profile for Lead (CAS Copper, 56 FR 26548, June 7, 1991. Also see 2011 #7439‒92‒1). [Online] Available at http://www. Edition of the Drinking Water Standards and Health atsdr.cdc.gov/toxprofiles/tp.asp?id=96&tid=22 (ac- Advisories (Publication EPA 820‒R‒11‒002). 2011. cessed May 1, 2013). 52. European Commission: Opinion on Lead Standard in 37. Ibid. Drinking Water. Scientific Committee on Health and 38. Kinder, C.: Lead Contamination in our Environment. Environmental Risks, Jan. 11, 2011. New Haven, CT: Yale-New Haven Teachers Institute, 53. Jacobs, D., R. Clickner, J. Zhou, et al.: The prevalence 1997. of lead-based paint hazards in U.S. housing. Environ. 39. Shacklette, H.T., and J.G. Boerngen: Element Con- Health Perspect. 110:A599‒A606 (2002). centration in Soils and Other Surficial Materials of the 54. Dewalt, F.G., et al.: Prevalence of lead hazards and Conterminous United States. U.S. Geological Survey soil arsenic in U.S. housing (Quiz 52). J. Environ. Professional Paper no. 1270 (1984). Health 2015 Dec; 78(5):22‒29. 40. ATSDR: Toxicological Profile for Lead (CAS 55. Horner, J.M.: Lead in house paints – Still a health risk #7439‒92‒1). [Online] Available at http://www. that should not be overlooked. The Chartered Insti- atsdr.cdc.gov/toxprofiles/tp.asp?id=96&tid=22 (ac- tute of Environmental Health 3(1) (2004). 56. Ibid. cessed May 1, 2013). 57. Ibid. 41. Ibid. 58. Sutton, P.M., M. Athanasoulis, R. Flessel, et al.: Lead 42. United Nations Environment Programme: Draft Fi- levels in the household environment of children in nal Review of Scientific Information on Lead, Nairobi, three high-risk communities in California. Environ. Kenya, 2008. Res. 68:45‒57 (1995). 43. Ibid. 59. U.S. Public Law: PL 110‒314, Section 101‒2008 44. Cox, S.E., P.B. Bell, J.S. Lowther, et al.: Vertical Distri- (effective Aug. 14, 2009). [Online] Available at http:// bution of Trace-Element Concentrations and Occur- www.okinternational.org/lead-paint/Background rence of Metallurgical Slag Particles in Accumulated (accessed May 1, 2013). Bed Sediments of Lake Roosevelt. USGS Scientific In- 60. Peryea, F. J.: “Historical Use of Lead Arsenate In- vestigations (Report 2004‒ 5090), September 2002. secticides, Resulting Soil Contamination and Impli- 45. U.S. Environmental Protection Agency (U.S. EPA): cations for Soil Remediation.” In Proceedings of the EPA Superfund Record of Decision Midvale Slag 16th World Congress on Soil Science, Montpellier, OU2. EPA/ROD/R08‒03/002 (2002). France, Aug. 20‒26, 1998.

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