The May 2023 issue of the Journal of Environmental Health (Volume 85, Number 9), published by the National Environmental Health Association.
JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional
Volume 85, No. 9 May 2023
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JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 85 No 9 '?
ADVANCEMENT OF THE SCIENCE Lead Source Attribution by Stable Isotope Analysis in Child Risk Assessment Investigations ........................................................................................................... 8 Guest Commentary: A Call for Action to Increase the Scrutiny of Surface Cleaning and Cleaning Agents in Retail Food Establishments ..................................................................... 20 Special Report: Federal Meat and Poultry Inspection Duties and Requirements—Part 1: History and Current Responsibilities ........................................................................................... 22 ADVANCEMENT OF THE PRACTICE Special Report: Increasing Diversity in Environmental Health Graduate Programs ...................... 26 Direct From AAS: Strategic Professional Development ................................................................ 30 Direct From CDC/Environmental Health Services: Here Come the Surf Venues and Artificial Swimming Lagoons ................................................................................................ 32 Direct From U.S. EPA/O ce of Research and Development: Stimulating Innovation Through the Challenges and Prizes Program From the U.S. Environmental Protection Agency ...... 34 Environmental Health Across the Globe: Artificial Intelligence and Environmental Health Teaching: Impacts for the Wider Profession ...................................................................... 38 Programs Accredited by the National Environmental Health Science and Protection Accreditation Council....................................................................................... 40 ADVANCEMENT OF THE PRACTITIONER Environmental Health Calendar ...............................................................................................42 Resource Corner........................................................................................................................ 43 JEH Quiz #6............................................................................................................................... 44 YOUR ASSOCIATION President’s Message: We Are Your Strongest Advocate ............................................................................. 6 Special Listing ........................................................................................................................... 46 NEHA 2023 AEC....................................................................................................................... 48 NEHA News .............................................................................................................................. 50 NEHA Member Spotlight .......................................................................................................... 54
ABOUT THE COVER
Multiple organiza- tions and agencies have called for a more diverse envi- ronmental health workforce. In en- vironmental health practice—taking into consideration the importance
of community engagement—diversity in the workforce is crucial to ensuring a wealth of cultural knowledge that facilitates community relations and builds trust. In this month’s cover article, “Increasing Diversity in Environmental Health Graduate Programs,” the study aimed to determine what motivates and deters students from historically marginalized populations from pursuing degrees in environmental health and to develop recommendations that pro- grams can implement to diversify their student body and, subsequently, the workforce. See page 26. Cover image © iStockphoto: Pekic, Ridofranz, ferrantraite, eyecrave productions, FG Trade, Sabrina Bracher
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Custom Data Processing......................................... 7 Environmental Health and Land Reuse Certificate Program .............................................. 19 Hedgerow Software, US, Inc. ................................ 55 HS GovTech.......................................................... 56 Industrial Test Systems, Inc.................................... 2 JEH Advertising ....................................................41 NEHA Awards ..................................................5, 37 NEHA Credentials .......................................... 31, 45 NEHA Endowment and Scholarship Funds ..25, 29 NEHA Membership .......................................... 4, 41
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May 2023 • our4'l o, 4</ro4me4:'l e'l:.
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in the next Journal of Environmental Health don’t miss Coronavirus Surrogate Persistence and Cross-Contamination on Food Service Operation Fomites Federal Meat and Poultry Inspection Duties and Requirements—Part 2: The Public Health Inspection System, Marks of Inspection, and Slaughter Inspections Unfolding Outbreak Scenarios Can Be a Bite-Size Treat and Other Lessons From New Zealand’s First Online Environmental Health Conference
Official Publication
Published monthly (except bimonthly in January/February and July/ August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802- 2200; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 85, Number 9. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/jeh. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2023, National Environmental Health Association (no refunds). All rights reserved. Contents may be reproduced only with permission of the managing editor. Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/jeh. To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, kruby@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.
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Volume 85 • Number 9
Recognize your colleague! Do you work with someone who is always coming up with creative ways to educate the public or colleagues? Is there someone on your team who has created tools or a practice that has really made a difference in improving environmental health? Nominate them for the Joe Beck Educational Contribution Award and show them how much you value their contribution. Nomination Deadline: May 15, 2023 neha.org/awards Joe Beck Educational Contribution Award
Do you know someone who is walking the walk? When your colleague or team steps up to create a more just, diverse, equitable, and inclusive environment, it matters! Let them know by nominating them today for the Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award. Nomination Deadline: May 15, 2023 neha.org/awards Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award
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May 2023 • our4'l o, 4</ro4me4:'l e'l:.
YOUR ASSOCIATION
PRESIDENT’S MESSAGE
We Are Your Strongest Advocate
D. Gary Brown, DrPH, CIH, RS, DAAS
D r. Martin Luther King, Jr. said, “Courage is an inner resolution to go forward despite obstacles.” My fellow environmental health professionals, every day you show tremendous courage, fortitude, and empathy toward protecting the public. You constantly amaze me by coming up with novel solutions to prob- lems people never realized they had. In our profession, people never speak about being bored. Speaking with environmental health professionals throughout the land, everyone loves our field. Please share your passion for environmental health with ev- eryone you meet just like the individuals on Sesame Street. As Dr. David Dyjack, executive direc- tor of the National Environmental Health Association (NEHA), states, “Environ- mental health is a contact sport.” As such, contact is necessary to get our message out. We share the message of environmen- tal health with our elected ocials and policy makers to improve the profession and provide our members with the tools they need. The NEHA Board of Directors, along with several of our members, spoke with elected ocials and policy makers during our sixth annual Hill Day on Feb- ruary 23, 2023, to educate, enlighten, and hopefully, even entertain. Darwin D. Martin stated, “A teacher’s job is to take a bunch of live wires and see that they are well-grounded.” Doug Farquhar, our director of Government Aairs, does an unbelievable job in preparing us for Hill Day and ensuring we are well-grounded.
ments and might be omitted from the benefits of legislation if not specifically called out. • Environmental health professionals are allies in environmental justice eorts. • Environmental health professionals are on the front lines in climate and health issues. Environmental health services are not a luxury. They are essential to providing the public basic needs, such as safe drinking water, clean air, safe food, healthy hous- ing, climate change adaptation, emergency preparedness, and more. Environmental health has long been recognized as being a crucial service of government at state, local, tribal, territorial, and federal levels. Environmental health professionals are scientifically trained and certified to identify and mitigate environmental dan- gers as well as promote alternatives. We are handling threats on the front lines of public health. Environmental health pro- fessionals form a critical component of the public health delivery system, provid- ing services to curb environmental health threats and prevent adverse health out- comes. We assist communities to prepare for, respond to, and recover from disease outbreaks and natural and anthropogenic disasters. We are on the front lines of public health handling threats such as environmental inequities (e.g., lead expo- sure), climate change (e.g., drought), food safety (e.g., baby food), safe drink- ing water (e.g., perfluorooctanesulfonic acid [PFOS]), and clean air (e.g., ozone).
He even provides a Hawaiian shirt and sneaker wearing fashionista such as myself with professional dress tips such as wearing socks and a tie. We are the profession’s strongest advocate for excellence in the practice of environ- mental health as we deliver on our mission to build, sustain, and empower an eective environmental health workforce. Our mes- sage is to speak about the importance of a robust and well-resourced environmental health workforce. Many people might not know that we represent almost 7,000 gov- ernment and private sector environmental health professionals in the U.S. The messages we shared during Hill Day included: • Environmental health professionals assure healthy, safe, and prosperous communities. • Environmental health professionals often work outside traditional health depart- Our message is to speak about the importance of a robust and well-resourced environmental health workforce.
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Volume 85 • Number 9
Environmental health professionals are strategically positioned to identify and intervene to prevent public health and environmental health threats from a ect- ing local populations. As a nation, the U.S. spends over $3 tril- lion annually on healthcare but lags behind other developed countries in practically every health metric. The lack of investment into the environmental health system is costly for this nation. The top four messages we wanted the congressional sta we met with during Hill Day to remember were to: 1. Fund the National Center for Environ- mental Health within the Centers for Disease Control and Prevention at $300 million and to fund the Agency for Toxic Substances and Disease Registry at $95 million. 2. Fund the Federal and State Initiative of the Food and Drug Administration— which supports food safety inspections— at $140 million and provide $35 million
for states to purchase equipment to serve healthier meals and improve food safety. 3. Encourage the Health Resources and Ser- vices Administration to include environ- mental health within the Public Health Workforce Loan Repayment Program. 4. Share with the congressional oces the importance of environmental health to state and local public health agencies. The author J.K. Rowling said, “No story lives unless someone wants to listen. The stories we love best do live in us forever.” Please share your environmental health stories with your elected ocials and policy makers to improve the profession. Even if you are not comfortable speaking with these individuals, remember what Elmo said, “If you keep practicing, you can do anything.” The more we share our stories with elected ocials, policy mak- ers, fellow scientists, and the public, the greater the impact. When people think of how public health improves their lives, what comes to mind
is what environmental health ensures— clean air, food, and water along with a safe and healthy place to live, work, and play. Environmental health provides the biggest bang for the buck of all of the health fields. As Warren Bu ett stated, “Someone’s sit- ting in the shade today because someone planted a tree a long time ago.” Environ- mental health professionals have planted forests to protect the public. I look forward to seeing you at our 2023 Annual Educational Conference & Exhibi- tion in New Orleans, Louisiana, on July 31– August 3. Thank you for all of your hard work to protect the public every day. Please continue helping me spread the word that environmental health is public health. As Yoda sagely stated, “Try not. Do or do not. There is no try.”
gary.brown@eku.edu
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7
May 2023 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
Lead Source Attribution by Stable Isotope Analysis in Child Risk Assessment Investigations
Summer Shaw, MPH Bureau of Environmental and
Occupational Health, Wisconsin Department of Health Services Sean Scott, PhD Wisconsin State Laboratory of Hygiene Maeve Pell, MPH Bureau of Environmental and Occupational Health, Wisconsin Department of Health Services University of Wisconsin Madison School of Medicine and Public Health Jeff Raiche-Gill Bureau of Environmental and Occupational Health, Wisconsin Department of Health Services University of Wisconsin Madison School of Medicine and Public Health
b9:r'): Lead isotope analysis (LIA) is a promising technique for identifying potential sources of lead exposure among children with lead poisoning that are not revealed via traditional lead risk assessment methods. A total of six Wisconsin children with blood lead levels (BLLs) ≥10 µg/dl were included in this case series. Lead isotope ratios from blood and environmental samples were analyzed using a multicollector inductively coupled plasma mass spectrometer (MC-ICP-MS) to determine exposure source. LIA identified likely sources of lead poisoning: lead-based paint, dust, imported spices, ceremonial objects, or mixtures of these sources. LIA both corroborated findings from standard lead risk assessment and identified novel sources. LIA using high-precision MC-ICP-MS can identify and exclude sources of exposure when interpreted alongside traditional lead risk assessment approaches. Furthermore, LIA can serve as a useful tool in identifying and eliminating lead exposures in poisoning cases, particularly when traditional methods fail to identify the likely cause.
Carrie Tomasallo, MPH, PhD Bureau of Environmental and Occupational Health, Wisconsin Department of Health Services Jonathan Meiman, MD Bureau of Environmental and Occupational Health, Wisconsin Department of Health Services
used to measure isotopic fingerprints have increased discrimination due to higher sen- sitivity and precision compared with earlier applications (Gulson et al., 1995; Gwiazda et al., 2005; Millen et al., 1995; Oulhote et al., 2011; Yae et al., 1983). Given the potential of LIA for lead risk assessment, the Wisconsin Department of Health Services piloted a case series to dem- onstrate the use of high-precision LIA in identifying the primary source and second- ary contributors of lead exposure among Wisconsin children with lead poisoning.
Introduction Lead exposure early in life can lead to irre- versible harm; even low levels of lead expo- sure can aect the developing central ner- vous system and result in impaired cognitive function (Hou et al., 2013; Reuben et al., 2017). The primary intervention for a child with a case of lead poisoning is to remove the sources of lead from the child’s environment. Finding the sources, however, can be a signif- icant challenge because lead is pervasive and is present in many materials. Environmental health specialists use screening question- naires to identify likely exposure routes and X-ray fluorescence instruments to determine lead concentrations of materials in the home. Confirming the cause of lead exposure requires removing the source and observ- ing a reduction in the child’s blood lead
level (BLL), the latter of which might take months to years depending on peak BLLs and chronicity of exposure. Standard risk assessment methods can fail to identify the primary cause and result in continued lead exposure. Lead isotope analysis (LIA) holds promise for improving the accuracy of child- hood lead investigations. LIA is based on the four stable, naturally occurring isotopes of lead ( 204 Pb, 206 Pb, 207 Pb, and 208 Pb), which all have relative abundances in the Earth’s crust. Isotopes 208 Pb, 207 Pb, and 206 Pb are products of radioactive decay over geologic time. The abundances of isotopes vary given the age of the lead ore due to this radioactive decay. Isotope abundances are analyzed as Pb isotope ratios (PbIR), which are distinct and commonly called isotopic fingerprints. Advancements in technology
Methods
Investigation Protocol To be eligible for this case series, a child with a case of lead poisoning must have met the following criteria: 1) peak venous BLL ≥10 µg/dl, 2) age ≤6 years, and 3) resided in southern Wisconsin. Public health o¥cials identified and conducted data collection among six cases during May 2019–Novem- ber 2021. Local health departments obtained consent from the child’s legal guardian.
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Volume 85 • Number 9
TABLE 1
Case 1: Lead Isotope Ratios With Standard Error and Concentration for Whole Blood and Environmental Sources Sampled for Lead Isotope Analysis
206 Pb/ 204 Pb 2 σ /√n
207 Pb/ 204 Pb 2 σ /√n
207 Pb/ 206 Pb 2 σ /√n
208 Pb/ 206 Pb 2 σ /√n Lead (Pb) Concentration
Sample #
Sample
Sample Type
1 2
5-min flush Tap water
19.1288 0.0007 15.6850 0.0006 0.81997 0.00001 2.02814 0.00003 0.501 µg/L 19.2560 0.0006 15.7004 0.0005 0.81535 0.00001 2.01897 0.00003 0.514 µg/L
Kitchen first draw Living room carpet floor
Tap water
3
Wipe
18.6609 0.0007 15.6362 0.0007 0.83792 0.00001 2.05779 0.00004 1.43 µg/ft 2
4
Child’s bedroom trough
Wipe
20.8818 0.0006 15.8365 0.0005 0.75839 0.00001 1.92719 0.00003 193 µg/ft 2
5
Living room front trough Kitchen floor Child’s carpet floor
Wipe
20.4126 0.0007 15.7959 0.0006 0.77383 0.00001 1.95307 0.00003 10.9 µg/ft 2
6 7
Wipe Wipe
19.0898 0.0006 15.6850 0.0005 0.82165 0.00001 2.03461 0.00003 0.458 µg/ft 2 18.9164 0.0007 15.6667 0.0007 0.82821 0.00001 2.04463 0.00003 0.421 µg/ft 2
8
Solder
Solder (metal)
18.8035 0.0006 15.6916 0.0006 0.83452 0.00001 2.08079 0.00004 36.206 µg/g
9
Soil (side D)
Soil
19.1292 0.0007 15.6883 0.0007 0.82014 0.00001 2.03425 0.00003
136 µg/g
10 Child’s
Paint
20.6180 0.0008 15.8147 0.0006 0.76703 0.00001 1.94195 0.00003 8,696 µg/g
window jamb
11 Living room window jamb 12 Subject initial blood draw 13 Subject second blood draw
Paint
21.5600 0.0008 15.8954 0.0006 0.73727 0.00001 1.89251 0.00003 7,766 µg/g
Whole blood Whole blood
20.4675 0.0012 15.8006 0.0009 0.77199 0.00001 1.95093 0.00004 11.1 µg/dl
20.7182 0.0006 15.8223 0.0005 0.76369 0.00001 1.93683 0.00003 15.4 µg/dl
Note. The report unit for the lead isotope ratio is the atom ratio.
Certified risk assessors conducted a lead- based paint risk assessment and administered the Resident Questionnaire for Investigation of Children With Elevated Blood Lead Lev- els from the U.S. Department of Housing and Urban Development (HUD, Form 16.1). An environmental health specialist from the Wisconsin Department of Health Services obtained environmental samples for LIA. This case series was deemed by the Wis- consin Department of Health Services to con- stitute public health surveillance and prac- tice, thus review by an institutional review board was not required. Lead-Based Paint Risk Assessment Lead in surface coatings was identified using an X-ray fluorescence instrument to determine lead loading in mg/cm 2 . Lead- based paint was defined as ≥0.7 mg/cm 2 and
a lead dust hazard as ≥40 µg/ft 2 on a floor, 200 µg/ft 2 on a windowsill, and 1,200 ppm in soil (Supplemental Text, www.neha.org/ jeh-supplementals).
Soil samples were digested using a combina- tion of nitric and hydrofluoric acids. Lead was purified from samples using the standard anion exchange technique (Strelow & Toerien, 1966). Lead isotopic analysis was performed using Tl-doping on a Nep- tunePlus multicollector inductively coupled plasma mass spectrometer (MC-ICP-MS). Total lead concentrations of the analyzed materials were estimated using the dilution factors and standard concentrations used for the isotopic analysis. Full sample prepara- tion and analytical details are provided in the Supplemental Text. Results from LIA were used to calculate major (ratios not including Pb 204 ) and minor (ratios includ- ing Pb 204 ) isotopic ratios. These ratios were qualitatively compared with isotopic ratios from blood samples to identify the likely source of exposure.
Isotope Sample Preparation and Analysis
All acid reagents used for laboratory proce- dures were Optima grade purchased from Fisher Scientific. Different sample types required slight modifications to digestion and preparation procedures prior to purifica- tion. Tap water samples (first draw and 5-min flush) were collected in clean 2-L fluorinated ethylene propylene bottles and dried in 1-L polytetrafluoroethylene (PFA) jars. Dust wipes, paint samples, pipes and solder, spices, cosmetics, and whole blood were digested in PFA jars on a hotplate using combinations of concentrated nitric and hydrochloric acids.
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May 2023 • our4'l o, 4</ro4me4:'l e'l:.
ADVANCEMENT OF THE SCIENCE
FIGURE 1
Two-Dimensional Isotope Ratio Plots for Whole Blood and Environmental Lead Sources Sampled for Lead Isotope Analysis for Cases 1–6
Case 1
22.00
2.10
B
21.50
2.05
Child' s Bedroom Trou g h
21.00
Blood Second
Blood Initial
2.00
20.50
Livi ng R oom F ront Trou g h Child' s Window Ja mb
Blood Initial
Livi ng R oom F ront Trou g h Child' s Window Ja mb
20.00
1.95
Blood Second
19.50
Child' s Bedroom Trou g h
1.90
19.00
1.85
18.50
0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86
15.60 15.65 15.70 15.75 15.80 15.85 15.90 15.95
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Tap Water
Wipes
Solder
Soil
Paint
Blood Initial
Blood Second
Tap Water
Wipes
Solder
Soil
Paint
Blood Initial
Blood Second
Case 2
2.12
20.00
A
B
2.10
F ront Porch
19.50
2.08
Street Lateral
R ear Stairwell F loor
D ining R oom Window Sill
2.06
19.00
Child' s Bedroom Carpet
Blood
2.04
Child' s Bedroom Carpet
D ining R oom Window Sill
18.50
2.02
F ront Porch
Street Lateral
Blood
R ear Stairwell F loor
2.00
18.00
1.98
17.50
1.96
15.55
15.60
15.65
15.70
15.75
15.80
0.79 0.80 0.81 0.82 0.83
0.84 0.85 0.86 0.87 0.88
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Tap Water
Wipes
Soil
Pipes
Paint
Blood
Tap Water
Wipes
Soil
Pipes
Paint
Blood
continued
Results
the kitchen window (220 µg/ft 2 ). The HUD questionnaire determined that the child played at her bedroom window and on the living room floor and ate in the living room. LIA indicated that the PbIR of the water (samples 1 and 2), soil (sample 9), solder (sample 8), and floors (samples 3, 6, and 7) did not match those of blood specimens (Table 1). The sample closest to the initial
blood isotope (sample 12) was the wipe from the living room front window trough (sample 5; Figure 1, Case 1). The sample closest to the second blood isotope (sample 13) was the wipe from the child’s window jamb paint (sample 10), with the wipe from the child’s bedroom window trough (sam- ple 4) as a close second match. Samples 5 and 10 remained the best matches to the
Case 1 Case 1 involved a female at 24 months with a BLL of 12 µg/dl. The risk assessment found lead-based paint on the windows, doors, walls, and trim of the home. The highest lead concentrations were from the door- stop in the living room (20 mg/cm 2 ) and
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Volume 85 • Number 9
FIGURE 1 continued
Two-Dimensional Isotope Ratio Plots for Whole Blood and Environmental Lead Sources Sampled for Lead Isotope Analysis for Cases 1–6
Case 3
A 1.90 1.92 1.94 1.96 1.98 2.00 2.02 2.04 2.06 2.08 2.10 0.76 0.77 0.78 0.79 0.80 0.81 0.82 0.83 Livi ng R oom F loor Blood
21.00
B
20.50
F ront Porch E ntry F loor
20.00
Back Stairwell Windowsill
19.50
Livi ng R oom F loor
19.00
Back Stairwell Windowsill Blood
F ront Porch E ntry F loor
18.50
18.00
0.84 0.85 0.86
15.55 15.60 15.65 15.70 15.75 15.80 15.85 15.90
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Tap Water
Wipes
Soil
Pipes
Paint
Blood
Tap Water
Wipes
Soil
Pipes
Paint
Blood
Case 4
2.16
B 17.20 17.40 17.60 17.80 18.00 18.20 18.40 18.60 18.80 19.00 19.20 15.3 5 15.40 15.45 15.50 15.55 15.60 15.65 15.70 15.75 15.80 Black Pepper Tu rmeric Chili Powder Cilantro Powder A saf etida Mang o Powder Blood
A
A saf etida
Mang o Powder
2.14
Tu rmeric
Chili Powder
Blood
2.12
Black Pepper
Cilantro Powder
2.10
2.08
2.06
2.04
0.82 0.83
0.84 0.85 0.86 0.87 0.88 0.89 0.90 0.91
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Tap Water
Wipes
Spices
Blood
Tap Water
Wipes
Spices
Blood
continued on page 12
blood isotopes when all ratios were con- sidered. These items (samples 5, 10, and 4) were also identified as the play areas from the questionnaire. LIA suggested the child ingested deteriorating lead-based paint via hand-to-mouth behavior while playing at the windows. After 6 months, the child’s BLL was 15 µg/dl, and 9 months after the initial BLL, the family’s
home was remediated and passed clearance. Furthermore, 1.5 years after the initial BLL, the child’s venous BLL decreased to 4 µg/dl. Case 2 Case 2 involved a male at 24 months with a venous BLL of 14 µg/dl. The risk assess- ment found lead-based paint above accept- able limits on the windows, doors, walls, and
trim of the home. The dust wipes with the highest concentrations were from the living room windowsill (10,000 µg/ft 2 ) and back entry floor (10,000 µg/ft 2 ). Questionnaire responses indicated that the child ate in the dining room and played in the living room. Blood PbIR were similar to the street lateral water pipe (sample 9) but dissimilar to tap water (samples 1 and 2) and the floor lateral
11
May 2023 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
FIGURE 1 continued from page 11
Two-Dimensional Isotope Ratio Plots for Whole Blood and Environmental Lead Sources Sampled for Lead Isotope Analysis for Cases 1–6
Case 5
17.20 17.40 17.60 17.80 18.00 18.20 18.40 18.60 18.80 19.00 19.20
2.16
B
A
Blood
2.14
R ed Chili
2.12
K aj al
2.10
2.08
2.06
K aj al
2.04
Blood
R ed Chili
2.02
0.82 0.83
0.84 0.85 0.86 0.87 0.88 0.89 0.90 0.91
15.55
15.60
15.65
15.70
15.75 15.80
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Tap Water
Wipes
Spices
R ed Chili
K aj al ( Cosmetic)
Blood
Tap Water
Wipes
Spices
R ed Chili
K aj al ( Cosmetic)
Blood
Case 6
2.20
20.50
B
A
Incense Holder
Masala Powder
20.00
2.15
Blood
Ceremonial Bell
19.50
2.10
Small Lamp
19.00
2.05
18.50
2.00
Ceremonial Bell
Blood
18.00
Masala Powder
1.95
17.50
Small Lamp
Incense Holder
1.90
17.00
0.78
0.80
0.82
0.84
0.86
0.88
0.90
15.55 15.60 15.65 15.70 15.75 15.80 15.85 15.90 15.95
207 Pb/ 206 Pb
207 Pb/ 204 Pb
Spices
Toothpaste
Powders
Wipes
Blood
Spices
Toothpaste
Powders
Wipes
Blood
Note. A = 208 Pb/ 206 Pb versus 207 Pb/ 206 Pb; B = 206 Pb/ 204 Pb versus 207 Pb/ 204 Pb.
pipe (sample 10; Table 2). Other samples closest to the blood PbIR were dust from the child’s bedroom carpet (sample 4), dust from the rear stairwell floor (sample 7), dust from the dining room windowsill (sample 6), and front porch paint (sample 11) by all ratios (Figure 1, Case 2). The dust wipe sample ratios fell within the upper and lower ratio limits of suspected paint contributors. This
pattern was consistent with the deterioration of chipping paint from the walls and win- dowsills, which accumulated as lead-contam- inated dust inhaled or ingested by the child (Figure 1, Case 2). LIA supported the exposure pathway of hand-to-mouth behavior in play areas iden- tified by the questionnaire and lead concen- tration measurements from the risk assess-
ment. Although there was no remediation completed, increased cleaning was recom- mended. After 5 months, the child’s second BLL decreased by one half to 7 µg/dl. Case 3 Case 3 involved a female at 19 months with a venous BLL of 18 µg/dl. The risk assessment found lead-based paint on the windows,
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Volume 85 • Number 9
TABLE 2
Case 2: Lead Isotope Ratios With Standard Error and Concentration for Whole Blood and Environmental Sources Sampled for Lead Isotope Analysis
206 Pb/ 204 Pb 2 σ /√n
207 Pb/ 204 Pb 2 σ /√n
207 Pb/ 206 Pb 2 σ /√n
208 Pb/ 206 Pb 2 σ /√n Lead (Pb) Concentration
Sample #
Sample
Sample Type
1 5-min flush
Tap water
19.8351 0.0006 15.7582 0.0006 0.79446 0.00001 1.97195 0.00003 0.361 µg/L 19.0985 0.0004 15.6843 0.0004 0.82123 0.00001 2.01598 0.00003 0.798 µg/L 18.3052 0.0005 15.6115 0.0004 0.85284 0.00001 2.07685 0.00002 57.6 µg/ft 2
2 Kitchen first draw Tap water
3 Child’s bedroom windowsill 4 Child’s bedroom carpet 5 Master bedroom floor 6 Dining room windowsill 7 Rear stairwell floor
Wipe
Wipe
18.4668 0.0004 15.6265 0.0005 0.84619 0.00001 2.06621 0.00004 11.5 µg/ft 2
Wipe
18.6236 0.0005 15.6444 0.0005 0.84004 0.00001 2.05522 0.00003
9.0 µg/ft 2
Wipe
18.5622 0.0004 15.6333 0.0004 0.84221 0.00001 2.06086 0.00003 1,272 µg/ft 2
Wipe
18.4468 0.0006 15.6291 0.0005 0.84726 0.00001 2.06730 0.00003 181 µg/ft 2
8 Backyard
Soil
18.8866 0.0006 15.6614 0.0005 0.82924 0.00001 2.04108 0.00003
248 µg/g
9 Street lateral 10 Floor lateral 11 Front porch 12 Living room wall (side A) 13 Living room window jamb 14 Child’s bedroom window jamb 15 Rear stairwell 16 Subject initial blood draw
Pipe 18.5256 0.0003 15.6284 0.0004 0.84361 0.00001 2.06981 0.00003 128,683 µg/g Pipe 19.7667 0.0005 15.7650 0.0004 0.79756 0.00001 1.98448 0.00002 32,438 µg/g
Paint Paint
18.4497 0.0005 15.6255 0.0005 0.84692 0.00001 2.06890 0.00004 2,659 µg/g 18.2564 0.0004 15.5862 0.0004 0.85374 0.00001 2.08100 0.00003 38,033 µg/g
Paint
18.0086 0.0004 15.5817 0.0004 0.86524 0.00001 2.09786 0.00003 37,011 µg/g
Paint
17.8365 0.0004 15.5680 0.0005 0.87282 0.00001 2.10845 0.00003 53,193 µg/g
Paint
19.1132 0.0004 15.6884 0.0004 0.82081 0.00001 2.01580 0.00003 25,993 µg/g 18.4896 0.0005 15.6273 0.0005 0.84520 0.00001 2.06345 0.00003 13.2 µg/dl
Whole blood
Note. The report unit for the lead isotope ratio is the atom ratio.
doors, walls, and trim of the home. The high- est lead concentrations were the interior win- dowsills (mean of 1,158 µg/ft 2 ), the porch entry floor (54 µg/ft 2 ), and the backyard play area (4,874 ppm). The HUD questionnaire indicated that the child ate and played in the living room and at the windowsills. The main suspected sources of exposure were interior windowsills and floors with soil tracked from the backyard. LIA excluded tap water (samples 1 and 2) and the lateral service line (sample 9) as the primary source of exposure given the poor match with blood PbIR (sample 15; Table 3). Samples closest to the blood PbIR were the paint in the back stairwell windowsill (sample 10), wipe from the living room
floor (sample 7), and wipe from the front porch entry floor (sample 6) by both major and minor ratios. Dust sample (samples 3–7) isotope compositions were similar to each other and plotted within the upper and lower limits of the isotope ratios of the sam- ples from paint (samples 10–14) and soil (sample 8), which suggested that the dust samples were likely a result of paint dete- rioration and soil tracked inside the home (Figure 1, Case 3). LIA excluded potential sources so that priority could be given to the floors and points of entry to the home. Even though remediation work was not performed, clean- ing was increased. Overall, 2 months after the initial BLL, the second BLL decreased
to 9 µg/dl. The child’s family moved 15 months after first blood draw and 2 months after the move, the child’s BLL decreased further to 4 µg/dl. Case 4 Case 4 involved a male at 15 months with a venous BLL of 10 µg/dl. The risk assessment did not find any lead hazards in the walls, floors, or points of entry of the home. Based on the questionnaire, the main suspected sources of exposure were spices and pressure cookers purchased in India. Lead concentra- tions in turmeric, asafetida, teething powder, and kajal with aela (a cultural eye cometic) were 99, 180, 97, and 98 ppm, respectively. The spices turmeric and asafetida were then
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ADVANCEMENT OF THE SCIENCE
TABLE 3
Case 3: Lead Isotope Ratios With Standard Error and Concentration for Whole Blood and Environmental Sources Sampled for Lead Isotope Analysis
206 Pb/ 204 Pb 2 σ /√n
207 Pb/ 204 Pb 2 σ /√n
207 Pb/ 206 Pb 2 σ /√n
208 Pb/ 206 Pb 2 σ /√n Lead (Pb) Concentration
Sample #
Sample
Sample Type
1 5-min flush
Tap water
19.9770 0.0003 15.7713 0.0003 0.78947 0.00001 1.96219 0.00002 1.090 µg/L 19.7307 0.0004 15.7469 0.0004 0.79810 0.00001 1.98160 0.00003 9.008 µg/L 19.2338 0.0005 15.6970 0.0004 0.81612 0.00001 2.00743 0.00003 60 µg/ft 2
2 Kitchen first draw Tap water
3 Child’s bedroom floor carpet 4 Living room windowsill 5 Kitchen floor
Wipe
Wipe
19.2135 0.0007 15.6936 0.0006 0.81680 0.00001 2.00960 0.00003 443 µg/ft 2
Wipe Wipe
19.2393 0.0005 15.6952 0.0005 0.81578 0.00001 2.01453 0.00002 37 µg/ft 2 18.9651 0.0006 15.6662 0.0006 0.82606 0.00001 2.03770 0.00003 313 µg/ft 2
6 Front porch entry floor
7 Living room floor
Wipe
19.0367 0.0007 15.6786 0.0006 0.82361 0.00001 2.02807 0.00003 250 µg/ft 2
8 Backyard
Soil 19.3163 0.0004 15.7040 0.0004 0.81300 0.00001 2.01272 0.00003 3,261 µg/g
9 Service lateral 10 Back stairwell windowsill 11 Kitchen window trough 12 Living room window jamb 13 Front porch door 14 Window sash by bed 15 Subject initial blood draw
Pipe
20.6057 0.0005 15.8491 0.0004 0.76915 0.00001 1.91982 0.00003 19,483 µg/g 18.9586 0.0005 15.6716 0.0005 0.82662 0.00001 2.02849 0.00003 3,116 µg/g
Paint
Paint
19.4228 0.0004 15.7114 0.0004 0.80892 0.00001 2.00226 0.00003 63,318 µg/g
Paint
19.8662 0.0004 15.7560 0.0005 0.79311 0.00001 1.97517 0.00003 36,975 µg/g
Paint Paint
19.4478 0.0004 15.7190 0.0004 0.80827 0.00001 1.99512 0.00002 34,821 µg/g 18.3150 0.0007 15.6114 0.0006 0.85239 0.00001 2.07881 0.00003 14,675 µg/g
Whole blood
19.0458 0.0008 15.6809 0.0007 0.82333 0.00001 2.02366 0.00003 16.8 µg/dl
Note. The report unit for the lead isotope ratio is the atom ratio.
Case 5 Case 5 involved a female at 16 months with a BLL of 23 µg/dl. The risk assessment did not identify potential lead hazards in the walls, floors, or points of entry of the home. Based on the HUD questionnaire, suspected hazards included items manu- factured in India, such as pressure cookers, spices, and kajal. The sample closest to the blood (sample 20) isotope composition was kajal (sample 19) and red chili (sample 15; Table 5). Even though the kajal material was insoluble, a sig- nificant amount of lead (approximately 500 ng) was present in the leachate, suggesting this material was rich in lead (Supplemental Table). The kajal isotope ratios were con- sistent with the blood isotopic composition by both major and minor ratios. The wipes
sent for isotopic analysis along with other environmental samples. LIA did not indicate lead-contaminated dust (samples 3–10) or tap water (samples 1 and 2) as potential sources of lead exposure by both the major and minor ratios (Table 4). Samples closest to the blood isotope composition (sample 22) were black pepper (sample 11), cilantro powder (sample 16), and turmeric (sample 13; Figure 1, Case 4). Although black pepper was the closest in isotopic composition to the child’s blood, tur- meric and asafetida had the highest levels of lead concentration out of the spice samples (Supplemental Table). The family stopped using the spices and pressure cookers and were advised to buy locally sourced food items and cookware. After 7 months, the child’s BLL decreased to 4 µg/dl.
(samples 3–11), tap water (samples 1 and 2), and spices (samples 12–18) except red chili (sample 15) had isotope ratios that were not consistent with the blood composition (Fig- ure 1, Case 5). Intervention included use of alternative and locally sourced eyeliners, spices, and pressure cookers. Over the next 6 months, five additional blood lead measurements demonstrated a slow decrease in BLLs: 16, 15, 15, 14 (isotope-analyzed result for sample 20), and 13 µg/dl, respectively. Case 6 Case 6 involved a male at 10 months with a BLL of 14 µg/dl. The child was 16 months at the first isotope-analyzed blood draw (8 µg/dl). The risk assessment found one lead hazard: a bell with a lead concentration of 93 µg/ft 2 . The
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Volume 85 • Number 9
TABLE 4
Case 4: Lead Isotope Ratios With Standard Error and Concentration for Whole Blood and Environmental Sources Sampled for Lead Isotope Analysis
206 Pb/ 204 Pb 2 σ /√n
207 Pb/ 204 Pb 2 σ /√n
207 Pb/ 206 Pb 2 σ /√n
208 Pb/ 206 Pb 2 σ /√n
Sample #
Sample
Sample Type
Lead (Pb) Concentration
1 Kitchen first draw 2 5-min flush (kitchen)
Tap water
18.3581 0.0006 15.6356 0.0005 0.85170 0.00001 2.07985 0.00003
3.388 µg/L
Tap water
18.4378 0.0009 15.6373 0.0008 0.84810 0.00001 2.07245 0.00003
0.105 µg/L
3 Living room rug 4 Bedroom carpet 5 Large pressure cooker 6 Small pressure cooker
Wipe Wipe Wipe
17.8841 0.0006 15.6131 0.0006 0.87301 0.00001 2.11131 0.00003 17.7869 0.0004 15.6057 0.0005 0.87737 0.00001 2.11856 0.00003 17.3334 0.0005 15.5811 0.0005 0.89890 0.00001 2.14941 0.00003
0.1 µg/ft 2 0.2 µg/ft 2 43.7 µg/ft 2
Wipe
18.2844 0.0025 15.6383 0.0022 0.85528 0.00003 2.08393 0.00008
0 µg/ft 2
7 Bathtub
Wipe Wipe
17.9773 0.0003 15.5985 0.0003 0.86768 0.00001 2.10208 0.00003 18.6121 0.0005 15.6562 0.0005 0.84119 0.00001 2.05947 0.00003
1.6 µg/ft 2 1.3 µg/ft 2
8 Bedroom windowsill 9 Halloween pumpkin 10 Entry carpet 11 Black pepper
Wipe
18.2618 0.0008 15.6385 0.0006 0.85634 0.00001 2.08272 0.00003
0.1 µg/ft 2
Wipe
18.4166 0.0006 15.6520 0.0005 0.84988 0.00001 2.07266 0.00003
0.2 µg/ft 2 0.2 µg/g 0.4 µg/g 2.3 µg/g 0.7 µg/g 0.1 µg/g 0.1 µg/g 0.1 µg/g 1.7 µg/g 0.1 µg/g 0.3 µg/g
Kitchen spice 17.5736 0.0029 15.5855 0.0029 0.88686 0.00004 2.13096 0.00018 Kitchen spice 19.0658 0.0006 15.7676 0.0005 0.82702 0.00001 2.06173 0.00004 Kitchen spice 17.5815 0.0005 15.6032 0.0005 0.88748 0.00001 2.13628 0.00003 Kitchen spice 17.4722 0.0006 15.5942 0.0007 0.89252 0.00001 2.13718 0.00003 Kitchen spice 18.9118 0.0033 15.7701 0.0031 0.83387 0.00003 2.05695 0.00015
12 Pink salt 13 Turmeric
14 Chili powder
15 White salt
16 Cilantro powder Kitchen spice 17.7199 0.0028 15.6279 0.0028 0.88199 0.00003 2.12744 0.00015 17 Cumin seeds Kitchen spice 18.0285 0.0039 15.6482 0.0036 0.86804 0.00004 2.11106 0.00015
18 Asafetida
Kitchen spice 17.4226 0.0005 15.5828 0.0005 0.89440 0.00001 2.14508 0.00003 Kitchen spice 18.4908 0.0075 15.6962 0.0068 0.84886 0.00007 2.09457 0.00028
19 Rai
20 Mango powder Kitchen spice 17.5334 0.0018 15.6214 0.0018 0.89095 0.00003 2.13850 0.00011
21 Wheat flour 22 Subject initial blood draw
Kitchen spice 17.5323 0.0424 15.4015 0.0374 0.87845 0.00020 2.12633 0.00053 Whole blood 17.6207 0.0008 15.5910 0.0008 0.88482 0.00001 2.13053 0.00004
0 µg/g
10.3 µg/dl
Note. The report unit for the lead isotope ratio is the atom ratio.
Discussion Our study demonstrates the application of LIA for source attribution among lead- poisoned children. In the six homes investi- gated, LIA identified lead-based paint, lead- contaminated dust, kajal, foreign ceremonial objects, and imported spices such as turmeric and black pepper as likely sources of lead poisoning. This technique was useful in rul- ing out exposures when interpreted along- side measurements of lead concentration and questionnaires about behavioral risk factors.
HUD questionnaire identified imported pow- ders and spices as main suspected hazards. LIA demonstrated that not only the bell (sample 3) but also other objects (samples 12 and 13) located on a religious altar where the family burned incense were similar to the blood in isotope concentration, suggesting lead expo- sure near the altar contributed to the child’s BLL. LIA indicated that the powders (samples 1 and 2) were not the primary suspected haz- ards because their isotopic compositions were dissimilar to the blood PbIR. The samples
closest to the blood isotope composition were dust wipes from the small lamp (sample 12), incense holder (sample 13), and masala pow- der (sample 9; Table 6). These samples were also most similar to the blood isotope composi- tion by minor isotope ratios (Figure 1, Case 6). After getting the LIA results, the family was advised to buy locally sourced spices and restrict access to the entire altar area. The child’s BLLs at 7, 8, 9, and 22 months decreased after the initial BLL and were 8, 7, 6, and 5 µg/dl, respectively.
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May 2023 • our4'l o, 4</ro4me4:'l e'l:.
ADVANCEMENT OF THE SCIENCE
TABLE 5
Case 5: Lead Isotope Ratios With Standard Error and Concentration for Whole Blood and Environmental Sources Sampled for Lead Isotope Analysis
206 Pb/ 204 Pb 2 σ /√n
207 Pb/ 204 Pb 2 σ /√n
207 Pb/ 206 Pb 2 σ /√n
208 Pb/ 206 Pb 2 σ /√n Lead (Pb) Concentration
Sample #
Sample
Sample Type Tap water Tap water
1 First draw 2 5-min flush 3 Elephant wipe 4 Bracelet wipe
18.5807 0.0034 15.6494 0.0011 0.84225 0.00013 2.06144 0.00021 0.022 µg/L 18.5219 0.0174 15.6737 0.0150 0.84625 0.00008 2.07268 0.00014 0.002 µg/L
Wipe Wipe
18.7607 0.0007 15.6776 0.0006 0.83566 0.00001 2.05194 0.00003 17.6595 0.0004 15.6009 0.0004 0.88342 0.00001 2.12768 0.00003 18.7060 0.0006 15.6671 0.0006 0.83754 0.00001 2.05626 0.00003 18.9088 0.0005 15.6826 0.0004 0.82939 0.00001 2.04150 0.00003 18.9274 0.0005 15.6892 0.0004 0.82892 0.00001 2.03924 0.00002 18.6116 0.0004 15.6625 0.0004 0.84154 0.00001 2.05890 0.00002 18.5758 0.0005 15.6337 0.0005 0.84162 0.00001 2.06975 0.00003 17.9282 0.0005 15.6125 0.0004 0.87083 0.00001 2.11286 0.00002 17.7830 0.0004 15.6074 0.0005 0.87765 0.00001 2.11914 0.00003 18.8568 0.0005 15.7673 0.0005 0.83617 0.00001 2.07926 0.00003
0.1 µg/ft 2 0.9 µg/ft 2
5 Gold charm wipe Wipe
0 µg/ft 2
6 Living room sill wipe 7 Floor dust wipe 8 Metal cart wipe 9 Bathtub wipe 10 Old cooker wipe
Wipe
0.4 µg/ft 2
Wipe Wipe Wipe Wipe
0.9 µg/ft 2 0.2 µg/ft 2 1.8 µg/ft 2 4.1 µg/ft 2 2.6 µg/ft 2 0.08 µg/g
11 New cooker wipe Wipe
12 Chunky chat masala 13 Dal makhani masala 14 Sabzi masala
Kitchen spice Kitchen spice Kitchen spice Kitchen spice Kitchen spice Kitchen spice Kitchen spice
18.0354 0.0006 15.6493 0.0006 0.86769 0.00001 2.11559 0.00003
0.09 µg/g
18.3446 0.0004 15.6885 0.0004 0.85521 0.00001 2.09903 0.00003
0.15 µg/g
15 Red chili
17.3785 0.0004 15.5843 0.0005 0.89675 0.00001 2.14614 0.00003
22.8 µg/g
16 Black pepper
18.3640 0.0025 15.6853 0.0024 0.85412 0.00003 2.10746 0.00012
0.01 µg/g
17 Turmeric
17.7062 0.0007 15.5994 0.0006 0.88102 0.00001 2.12986 0.00004
0.01 µg/g
18 Coriander
17.7070 0.0005 15.6178 0.0006 0.88201 0.00001 2.12803 0.00003
0.05 µg/g
19 Kajal
Cosmetic 17.4047 0.0010 15.5811 0.0005 0.89522 0.00004 2.14390 0.00006
–
20 Subject initial blood draw
Whole blood
17.4400 0.0006 15.5834 0.0006 0.89355 0.00001 2.14124 0.00003 10.1 µg/dl
Note. The report unit for the lead isotope ratio is the atom ratio.
Similar to previous studies, cases 1–3 dem- onstrated that LIA was able to identify the most common household exposure: legacy lead-based paint exposure via hand-to-mouth behavior (Becker et al., 2022; Gulson et al., 1995; Manton et al., 2000). BLLs decreased among these cases after intervention on sources identified by LIA. Cases 4–6 involved nonpaint-related sources more commonly identified in recent years (Forsyth et al., 2019; Gorospe & Ger- stenberger, 2008; Mohta, 2010; Smith et al., 2017) and demonstrate at-risk groups for
lead poisoning among immigrant popula- tions (Angelon-Gaetz et al., 2018; Centers for Disease Control and Prevention, 2012; Shakya & Bhatta, 2019). A questionnaire can identify a foreign spice as a potential hazard, but LIA can provide additional evidence that the spice contributed to blood lead through matched PbIRs. Unlike other recent isotopic analyses, water was also investigated in our case series due to the historical use of lead pipes in the U.S. (Triantafyllidou et al., 2009). Contami- nated water might be a significant contribu-
tor to overall lead exposure among young children even at low concentrations (Zartar- ian et al., 2017). Environmental health spe- cialists extensively sampled water sources by testing tap water, pipes, and solder for five out of six cases. Water was not observed as the dominant or likely source in our cases. The PbIRs of the tap water samples for cases 1–5 were dissimilar to the children’s blood samples (Figure 1). For case 2, the PbIRs between street lateral pipe (sample 9) and child’s blood (sample 16) appeared similar but could be due to the lead street lateral pipe
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Volume 85 • Number 9
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