Lead

Refugee Health Domestic Guidance

Key points

  • Refugees may be exposed to environmental and occupational sources of lead both before and after arriving in the U.S.
  • Blood lead levels at or above the blood lead reference value (BLRV) of 3.5 micrograms per deciliter (µg/dL) are used to identify children with higher levels of lead in their blood compared to most U.S. children.
  • Capillary screening results at or above 3.5 μg/dL should be confirmed with blood drawn by venipuncture.

Overview

Environmental lead hazards are common around the world, including in many countries where refugees originate or seek asylum. Therefore, at the first domestic health visit, certain refugees should receive lead screening.

Table 1: Initial screening and follow up testing recommendations for all newly arrived refugee infants, children, adolescents, and pregnant or lactating women and girls

Table 1: Initial screening and follow up testing recommendations for all newly arrived refugee infants, children, adolescents, and pregnant or lactating women and girls
Population Recommended Measures
Initial screening
  • All refugee infants and children < 16 years old
  • Refugees 16 to < 18 years old if there is a high index of suspicion, history, or clinical signs/symptoms of lead exposure
  • All pregnant or lactating women and girls

 
  • Conduct initial lead exposure screening with a blood test
Follow-up testing
  • Refugee infants and children < 6 years old
  • Repeat the blood lead test regardless of initial screening blood lead level (BLL) result.
  • For BLLs below 3.5 μg/dL, repeat the blood lead test within 3-6 months after initial screening.
  • For BLLs at or above 3.5 μg/dL, see Table 2 in CDC’s Recommended Actions Based on Blood Lead Level for information on confirmatory testing, clinical follow-up, and case management, including recommended testing intervals.

 
  • Refugees 6 to < 18 years old who had BLLs at or above 3.5 μg/dL at initial screening

 

 
  • Refugees 6 to < 18 years old with risk factors (for example, sibling with BLL at or above 3.5 μg/dL, environmental exposure risk factors), who had BLLs of less than 3.5 μg/dL at initial screening

 
  • Consider follow-up testing within 3-6 months after initial screening, based on individual assessment.
  • Pregnant or lactating girls (<18 years old) who had BLLs at or above 3.5 μg/dL at initial screening

 
  • Pregnant women (≥18 years old) who had BLLs at or above 5 μg/dL at initial screening
  • Lactating women (≥18 years old) who had BLLs at or above 40 μg/dL

Background

Lead is a known neurotoxicant, and exposure can result in blood lead levels at or above CDC's BLRV of 3.5 μg/dL 1. Mobile infants and young children are particularly at risk for lead exposure given their tendency to mouth objects, and young children can have increased contact with dust, dirt, and surfaces potentially contaminated with lead 1. This tendency for mouthing, as well as ingesting non-nutritive substances (pica) contaminated with lead, is exacerbated by the sweet taste of lead acetate in those substances. Infants and young children are predisposed to increased BLL at lower exposure levels because of their greater ratio of body surface area to mass than adults 12. Malnourished children may also be at an increased risk for harm from lead exposure, likely through increased intestinal lead absorption mediated by micronutrient deficiencies such as iron, calcium, or zinc 345.

Lead Exposure Before and After Arrival in the United States

Environmental and occupational sources of lead exposures include leaded gasoline, industrial emissions, lead-based paint, and burning of waste containing lead. Other risk factors overseas include living near or working in mines, ammunition manufacturing, smelters, or battery recycling facilities. Refugees may also be exposed to lead through household or personal use items such as car batteries used for household electricity, lead-glazed pottery, pewter or brass utensils or cooking pots, pressure cookers, leaded crystal, chipped or cracked dishes, cosmetics, spices, traditional remedies, and jewelry or amulets 678910111213.

Common sources of lead exposures after arrival in the United States include lead-based paints in older housing, lead-contaminated soil, pica behaviors, picking or handling of loose contaminated paint chips, plaster, or putty, or chewing on contaminated painted surfaces (see CDC's Lead Exposure). Children, as well as adults, may also be at risk for BLLs at or above the BLRV after arrival due to continued use of spices, candy, traditional cosmetic products, and cookware brought from overseas or purchased in the United States 114151617. Additionally, certain consumer products sold in the United States have been recalled due to lead contamination (see CDC's Recalls of Children's Products, Foods, Cosmetics, and Medicines Due to Lead Hazards), and some antique and vintage items sold online or in U.S. stores, including painted toys or collectibles, jewelry, ceramics and furniture, may also contain lead (see CDC's About Lead in Consumer Products). Table 2 lists examples of traditional remedies, cosmetics, household items, and foods that have been associated with blood lead poisoning (see CDC's About Lead in Foods, Cosmetics, and Medicines for additional information).

Table 2: Examples of regional or culture-specific exposures associated with blood lead levels at or above CDC's BLRV in children

Table 2: Regional or culture-specific exposures associated with blood lead poisoning
Item Region, Country of Origin, or Cultures Reported Uses Description
Spices (such as turmeric, chili, masala, curry, paprika)16 Vietnam, India, Syria, Georgia, Bangladesh, Pakistan, Nepal, Morocco Cooking and food seasoning Spices from these countries have tested positive for lead contamination.
Medical powders/tablets East Indian, Indian, Middle Eastern, West Asian, Hispanic cultures Treatments for arthritis, infertility, colic, stomach issues, menstrual cramps and other illnesses. Traditional remedies may contain lead due to ingredient contamination during grinding, coloring, or from packaging materials.
Traditional metalware (kansa, pital)8 South Asia; India, Nepal, Afghanistan Used for cooking and storage Bronze or brass metalware
Sindoor17 India (Hindu and Sikh traditions) Cosmetic use and sometimes used as a food additive. Red powder traditionally worn in hair parting; has been found with high lead levels (up to 83%).
Ba-baw-san, Huang Dan Fen, Hu Wang Fen, jineijin18, 19 China Herbal remedy for colic and calming young children. Also to treat diaper rash, infantile eczema, heat rash and other skin disorders. Used in traditional Chinese medicine.
Daw Tway 20 (Daw Tway Go Mo Dah),  gaw mo dah  Thailand, Myanmar (Burma) General infant remedy believed to treat digestive symptoms. Brown pellets taken orally or topically. Samples have been shown to contain as much as 970 parts per million (ppm) of lead.
Greta and Azarcon21 (also known as alarcon, coral, luiga, maria luisa, or rueda) Hispanic cultures Treatment for an upset stomach (empacho), constipation, diarrhea, and vomiting. Also used for teething babies. Fine orange powders; may contain up to 90% lead.
Ghasard India Used as a tonic Brown powder used in folk medicine; has been found to contain lead.
Kohl, kajal, al-Kahal, surma, tiro, tozali, and kwalli2223 Parts of Africa, South Asia, and the Middle East Eye cosmetic Traditional eye care product; often contains high lead levels.
Bint Al Zahab (Daughter of Gold)24 Iran Believed to treat colic and trigger early passage of meconium after birth. Rock ground into a powder and mixed with honey and butter
Litargirio25 Dominican Republic Used as a deodorant or antiperspirant, or as a burn or fungal (usually foot) treatment. Yellow or peach-colored powder applied to the skin
Candy (commonly imported; flavored with chili powder or tamarind)26 Mexico Candy for consumption (for example, tamarind lollipops) Candy may be contaminated with lead through improper drying, storing, and grinding of ingredients, or from lead-containing ink in wrappers.
Lozeena26 Iraq Flavoring Bright orange spice added to foods for flavor, particularly rice and meat dishes.
Pay-loo-ah27 Southeast Asia Treatment believed to treat fever and rash. Orange-red powder administered by itself or mixed in tea
Select Ayurvedic preparations728 India Treatment for wide range of ailments. Preparations vary in appearance and how they are administered.

Studies on Lead Exposure in Refugees

Refugee children arriving in the United States can have higher average rates of BLLs exceeding the BLRV than U.S.-born children. Analyses of domestic data have revealed that the prevalence of a BLL at or above 5 μg/dL among newly arrived refugee children may be in excess of 40% in certain groups 29. Studies also suggest that country of origin, country of last residence, and age are strong predictors of BLLs at or above 5 μg/dL among newly arrived refugee children293031323334. In a study of 3,054 refugee children < 7 years old resettled in Massachusetts between 1998 through 2015, 1,279 (42%) had BLLs at or above 5 μg/dL, with the highest prevalence among children from Sub-Saharan Africa (47.9%), East Asia and Pacific (52.2%), and South and Central Asia (52.9%) 29. An assessment of 27,284 refugee children 6 months to 16 years old resettled in 11 states (CO, ID, IL, KY, MA, MN, NC, NY [excluding New York City], TX, UT, and WA) and one county (Marion County, IN) from 2010 to 2014, showed that 5,275 (19.3%) had BLLs at or above 5 μg/dL at the initial domestic screening 34. Of those screened, 22.8% of children <7 years had BLLs at or above 5 μg/dL, while 16.5% of children 7 years and older had BLLs at or above 5 μg/dL 34.

Refugee children may be at continued risk for ongoing lead exposures after arrival in the United States. Several studies showed that refugee children had increased BLLs at follow-up testing 3031343536. An analysis of lead exposure among refugee children (n=705) 0 to 16 years old in Syracuse, NY, between 2012 and 2017 found that 17% of refugee children had BLLs at or above 5 μg/dL upon initial screening, and 10% had increased BLLs at follow up 3-6 months after resettlement 36.

Studies show that foreign-born women are more likely to have higher BLLs than U.S.-born women, including those who are pregnant or lactating 373839. In a study of 312 refugee females 13 to 45 years old undergoing initial domestic medical examinations at a Denver clinic from 2014 to 2019, 16 (5.1%) had BLLs at or above 5 μg/dL, including 14 nonpregnant and 2 pregnant women 40. Among the groups studied, BLLs at or above 5 μg/dL were more prevalent in women from Afghanistan after adjusting for age 40.

Clinical Presentation

Children

There is no safe level or threshold for BLL 41. Scientific evidence has shown that BLLs ≤10 µg/dL are associated with adverse cognitive and behavioral development 1. At higher BLLs, acute symptoms of toxicity may appear. Above 40 µg/dL, children may experience headaches, abdominal pain, anorexia, constipation, clumsiness, agitation, and lethargy 142. At 70 µg/dL, children may develop severe neurological complications, including seizures, ataxia, mental status changes, coma, and death 142. Although severe blood lead poisoning is rare in the United States, the death of a newly arrived 2-year-old Sudanese refugee with a BLL of 391 µg/dL in 2000—which was the first lead-poisoning-related death in the United States in a 10-year period—underscores the importance of early identification and management of cases in children with BLL at or above the BLRV in resettled refugee children 43.

Pregnant and Lactating Women and Adolescent Girls

Lead exposure (and associated toxicity) remains a public health concern for women and girls of childbearing age (15–44 years), developing fetuses, and nursing infants 44. More than 90% of lead is stored in bone, and lead accumulated in bone can be released during times of higher metabolism, such as pregnancy or lactation, potentially placing the fetus or nursing infant at risk of exposure 45. Lead toxicity in pregnant women has been associated with an increased risk of spontaneous abortion, gestational hypertension, abnormal fetal neurodevelopment, and low birthweight 44. Additionally, strong evidence shows that prenatal lead exposure impairs fetal neurodevelopment and increases risk for developmental delay, reduced IQ, and behavioral problems in childhood 45.

Recommendations for Post-arrival Lead Screening

Clinicians should complete a review of past medical history for all refugees. Evaluation of past medical history should include questions on developmental history, behaviors (e.g., pica), and potential environmental exposures such as use of cosmetics (purchased overseas), ceramics, spices, foods, tobacco, or remedies, including the regionally- and culturally-specific items in Table 2. Clinicians should familiarize themselves with local lead resources, as well as state or local recommendations for treatment and prevention.

Pediatric Recommendations

Initial Screening

  • All refugee infants and children <16 years old should be evaluated for lead exposure at the domestic medical screening visit with a blood test.
  • Refugees 16 to < 18 years old should be tested if:
    • there is a high index of suspicion (for example, sibling or household member with BLL at or above 3.5 μg/dL, environmental exposure risk factors),
    • the refugee has a history of lead exposure,
    • the refugee has clinical signs or symptoms of lead exposure, or
    • the refugee is pregnant or lactating.

Capillary screening results at or above 3.5 μg/dL should be confirmed with blood drawn by venipuncture (see CDC's Confirmed Venous Blood Lead Level). Venous or capillary lead levels at or above 3.5 μg/dL should be reported to state or local lead programs.

Follow-up testing with a blood lead test is recommended as follows:

  • A blood lead test should be repeated for all refugee infants and children <6 years old, regardless of initial screening BLL result.
    • For BLLs below 3.5 μg/dL, repeat the blood lead test within 3-6 months after initial screening.
    • For BLLs at or above 3.5 μg/dL, see Table 2 in CDC's Recommended Actions Based on Blood Lead Level for information on confirmatory testing, clinical follow-up, and case management, including recommended testing intervals
  • Refugee infants and children 6 to < 18 years old who had BLLs at or above 3.5 μg/dL at initial screening should have repeat testing in accordance with CDC's Recommended Actions Based on Blood Lead Level.
  • Refugees 6 to <18 years old with risk factors (for example, sibling with BLL at or above 3.5 μg/dL, environmental exposure risk factors), who had BLLs below 3.5 μg/dL at initial screening, consider follow-up testing within 3-6 months after initial screening, based on individual assessment.

Recommendations for Pregnant and Lactating Women and Adolescent Girls

Initial Screening

CDC recommends that all newly- arrived pregnant or lactating women and girls be screened for lead exposure with a blood test at the domestic medical exam.

Follow-up testing with a blood lead test after the initial domestic medical exam is recommended as follows:

Lactating women and girls with BLL ≥ 40 μg/dL should be advised to pump and discard breast milk until the BLL has decreased to < 40 μg/dL. For those with BLLs of 5–39 μg/dL, breastfeeding should continue and be accompanied by sequential testing of infant blood lead level levels to monitor trends.

Clinicians should recommend a prenatal vitamin or multivitamin with adequate iron and calcium to pregnant or lactating women and girls. Clinicians should consider referring refugees with elevated BLLs to a local healthcare provider with expertise in high-risk lead exposure or high-risk obstetrics for treatment and management. Confirmed elevated BLLs should be reported to state or local health departments as determined by local policies.

Additional information on case management and follow-up of an elevated BLL in pregnant or lactating women and girls is available from the CDC Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.

Additional Resources

  1. CDC Lead Website
  2. State and Local Lead Programs
  3. Standard Surveillance Definitions and Classifications: Please refer to the CDC Standard Surveillance Definitions and Classifications and Childhood Lead Poisoning Prevention Program for additional information.
  4. CDC Training: Childhood Lead Poisoning Prevention
  5. CDC Community Education Videos, Childhood Lead Poisoning Prevention
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
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