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International Journal of Hygiene and Environmental Health 215 (2012) 202–205
Contents lists available at SciVerse ScienceDirect
International Journal of Hygiene and Environmental Health journal homepage: www.elsevier.de/ijheh
Short communication
Lead levels in umbilical cord blood in Belgium: A cross-sectional study in five maternity units Wei-Hong Zhang a,b,∗ , Marie-Christine Dewolf c , Samia Hammadi a , Wendy Fris c , Etienne Noël c , Rosalie Lorenzo d,1 , Sophie Alexander a,d , the PLOMB 6 Group2 a
Perinatal Epidemiology Research Unit, School of Public Health, Université Libre de Bruxelles (ULB), Belgium International Centre for Reproductive Health (ICRH), Ghent University, Belgium c Hygiène Publique en Hainaut (HPH), Belgium d Office de la Naissance et de l’Enfance (ONE), Belgium b
a r t i c l e Keywords: Umbilical cord blood Lead Belgium
i n f o
a b s t r a c t The average blood lead concentration has significantly decreased over the last two decades among the general population. However, in Belgium, there are still high-risk populations such as groups of pregnant women who have shown elevated lead levels. The objective of this study was to evaluate the current situation of lead cord blood levels and identify sources of lead exposure by a questionnaire survey. The study was conducted in 5 maternity units in Belgium; for each, umbilical cord blood samples were collected from 50 consecutive births. At the same time a questionnaire on possible sources of lead exposure was administered to the mother. The dependant variable was a dichotomous lead level variable (<20 ␮g/L vs. ≥20 ␮g/L). The factors associated with elevated lead levels (≥20 ␮g/L) were mother’s country of origin from south Mediterranean and from Sub-Saharan Africa, mother’s educational level, using ‘tagine’ plates for cooking and using khol for make-up, but, after adjusting for potential confounding factors, only the mother’s country origin from south Mediterranean (adjusted odds ratio, 5.51; 95% confidence interval [CI], 1.68–18.08; p = 0.005) and from Sub-Saharan Africa (adjusted odds ratio, 8.14; 95% CI, 2.26–29.40; p = 0.001) were significantly associated with elevated cord blood lead concentrations (≥20 ␮g/L). The results of this study are similar to those found by a previous study in Belgium in 2004. Sources of exposure are difficult to distinguish with this questionnaire, which might be due to other important sources of exposure that were not included in the questionnaire. Confirmation of these risk factors in future studies could lead to new prevention strategies for populations who are at risk for subsequent lead exposure. © 2011 Elsevier GmbH. All rights reserved.
Introduction During the last twenty years, important measures of public health were undertaken in many high-income countries to decrease lead exposure; consequently, the average blood lead levels (BLL) have significantly decreased over the last two decades among the general population. However, in Belgium, five previous
∗ Corresponding author at: Perinatal Epidemiology Research Unit, School of Public Health, Université Libre de Bruxelles (ULB), Belgium, Route de Lennik 808, CP 597, B-1070 Brussels, Belgium. Tel.: +32 2 555 63 68; fax: +32 2 555 40 49. E-mail address: [email protected] (W.-H. Zhang). 1 Deceased. 2 PLOMB 6 (Project Lorenzo for the modification of attitudes with regard to the risk of lead exposure in the childhood and the pregnancy in Belgium) collaborators: Sophie Alexander (Project leader, Belgium), Patricia Barlow (Saint-Pierre Hospital, Brussels), Gilles Ceysens (Ambroise Paré Hospital, Mons), Marie-Christine Dewolf (HPH), Pierre Delvoye (Ath Hospital, Ath), Wendy Fris (HPH), Samia Hammadi (ULB), Christine Kirkpatrick (Erasme Hospital, Brussels), Xavier De Muylder (Saint-Jean Hospital, Brussels), Etienne Noël (HPH), Wei-Hong Zhang (ULB). 1438-4639/$ – see front matter © 2011 Elsevier GmbH. All rights reserved. doi:10.1016/j.ijheh.2011.09.002
studies have shown that there are still high-risk populations such as groups of pregnant women who have been diagnosed with elevated lead levels (Claeys et al., 1992, 1997; Noël, 2002; Heymans et al., 2005; Zhang et al., 2009). Prenatal life is considered to be the most sensitive stage of human development due to the high degree of fetal cellular division and differentiation (Al Saleh et al., 2011). Also, due to differences compared to the adult in many biochemical pathways, the fetus is highly susceptible to teratogens, typically at low exposure levels that do not harm the mother (Wells et al., 2010). The Centers for Diseases Control (CDC, 2009) recommends a follow-up of children above a BLL threshold of 100 ␮g/L, and a concentration of 200 ␮g/L is defined as being the threshold for which a medical intervention is required. According to the French National Institute of the Health and the Medical Research (INSERM, 1999), prevention and medical follow-up must be already envisaged from a BBL of 100 ␮g/L. There is currently a growing concern about the threats on pregnancy outcome or adverse effects in children at levels lower than international guidelines (Schoeters et al., 2006; Holmes et al., 2009). High lead levels are known to cause neurobehavioral effects in infants and children, and the cumulative effects
W.-H. Zhang et al. / International Journal of Hygiene and Environmental Health 215 (2012) 202–205
of low levels of lead exposure in utero and after birth can have similar detrimental effects (Gardella, 2001). Jedrychowski showed that a prenatal lead cord blood level below 16.7 ␮g/L could result in a development delay in infants by about 20% at age 6 months (Jedrychowski et al., 2008). Mattison suggested that the impact of environmental exposures on pregnancy outcome or development may have no threshold, and the only reasonable approach is to keep exposure as low as possible (Mattison, 2010). The present paper is one component of the project Project Lorenzo for the modification of attitudes with regard to the risk of lead exposure in the childhood and the pregnancy in Belgium (PLOMB 6) that aims to evaluate the current situation of cord blood lead levels and identify sources of lead exposure by using a questionnaire. Methods Study design A cross-sectional study was conducted from May 2008 to August 2008 in 5 maternity units in Belgium including two in the Hainaut Province and three in the Brussels Region. In each maternity unit, umbilical cord blood samples were collected from 50 consecutive births at the time of delivery. At the same time a questionnaire on possible sources of lead exposure was administered to the mother. This questionnaire included demographic, socioeconomic, lifestyle, environment data, possible sources of lead exposure and women’s knowledge regarding lead exposure. The questionnaires were completed by the maternity investigators in paper form. Data entry (Epi-6) has been performed in the Université Libre de Bruxelles (ULB).
203
Table 1 Baseline characteristics of participants. Variables
n
Valuesa
Mother’s age (years), mean (range) Parity Primiparity Multiparity Mother’s country of origin Western Europe Eastern Europe South Mediterranean Sub-Saharan Africa Othersb Education Primary school Junior/middle school Senior school College or university Umbilical cord blood lead concentration (␮g/L) < LOQc 10 to <20 20 to <50 ≥50
218
30.4 ± 4.9 (17–45)
81 116
36.8 63.2
133 11 42 20 7
62.4 5.2 19.7 9.4 3.3
11 45 65 89
5.2 21.4 31.0 42.4
116 74 25 5
52.7 33.6 11.4 2.3
a Mean ± standard deviation [SD] for continuous variables and counts (percentages) for categorical variables. b Japan (1), China (1), Philippines (1), Pakistan (2), Paraguay (1), Brazil (1). c Limit of quantification [LOQ] is 10 ␮g/L.
Ethical aspects Ethical approval was obtained from local ethics committees in each maternity unit and from central research ethics committees at the Université Libre de Bruxelles on 13th February 2008.
Analysis of umbilical cord blood sample All of the samples of umbilical cord blood (5 mL) were collected in the delivery room with a vacutainer tube (ethylenediaminetetraacetic acid – EDTA). All measurements of blood leads were performed by the laboratory of Hygiene Publique en Hainaut (HPH). The samples were first diluted with a Triton X-100 solution containing a matrix modifier (ammonium dihydrogen phosphate). The analytical method for blood determination was Graphite Furnace Atomic Absorption Spectrophotometry (GFAAS) with Zeeman background correction (Perkin Elmer Analyst 600). The limit of quantification (LOQ) was 10 ␮g/L. The validity of the analytical method was performed through internal and external quality control samples. Statistical analysis Baseline characteristics of maternity units and individual women were summarized with mean (standard deviation [SD]) for continuous variables and counts (percentages) for categorical variables. The analysis of the association between the answers to questionnaires and the lead concentration concerned only the women for whom we had a complete questionnaire and had a measurement of cord blood lead (n = 220). A threshold of 20 ␮g/L of lead cord blood concentration was used to categorize two exposure groups: <20 ␮g/L and ≥20 ␮g/L. In order to determine the predictors of any differences between the two groups, crude odds ratios [OR] and 95% confidence intervals were calculated. Furthermore, logistic regression was used to adjust for potential confounding factors such as age of mother, parity, mother’s education and living in a traffic area. All statistical tests were two-sided at the 5% significance level. Statistical analyses were performed using IBM SPSS statistics 19.
Role of the funding source This study was funded by the Fonds Houtman, Belgium. Fonds Houtman had no role in the design, management, data collection, analyses, or interpretation of the data. Fonds Houtman had no role in the writing of the manuscript or in the decision to submit for publication.
Results Study participants Table 1 shows the characteristics of participants in the study. The mean of mother’s age was 30.4 years old (SD = 4.9). The number of values below the limit of quantification was 116 (52.7%). The percentage of cord blood samples with lead levels ≥20 ␮g/L was 13.7% (30/220); among them, 5 cases had excessive lead levels (50 ␮g/L).
Factors associated with elevated cord blood lead concentration The factors associated with elevated lead levels (≥20 ␮g/L) were mother’s country of origin from south Mediterranean and from SubSaharan Africa, mothers educational level, using ‘tagine’ plates for cooking and using khol for make-up, but, after adjusting for potential confounding factors, only the mother’s country origin from south Mediterranean (adjusted odds ratio, 5.51; 95% CI, 1.68–18.08; p = 0.005) and from Sub-Saharan Africa (adjusted odds ratio, 8.14; 95% CI, 2.26–29.40; p = 0.001) were significantly associated with the elevated cord blood lead concentration (Table 2).
204
W.-H. Zhang et al. / International Journal of Hygiene and Environmental Health 215 (2012) 202–205
Table 2 Crude and adjusted odds ratios (95% CI) of risk markers associated with elevated cord blood lead concentration in five Belgian maternity units in 2008. Cord blood lead concentration (␮g/L) Variables
Mother’s country of origin Western Europe Eastern Europe South Mediterranean Sub-Saharan Africa Mother’s education Less than college/university College or university Mother living in traffic area Yes No Using ‘tagine’ plates for cooking Yes No Mother’s Kohl using Yes No a
≥20
<20
Crude OR (95% CI); p-value
Adjusted ORa (95% CI); p-value
n
%
n
%
9 0 15 6
30.0 0.0 50.0 20.0
124 11 27 14
70.5 6.3 15.3 8.0
1 – 7.65 (3.03–19.30); p < 0.001 5.91 (1.83–19.05); p = 0.01
1 – 5.51 (1.68–18.08); p = 0.005 8.14 (2.26–29.40); p = 0.001
23 7
76.7 23.3
98 82
54.4 45.6
2.75 (1.12–6.73); p = 0.02 1
2.49 (0.82–7.59); p = 0.11 1
11 18
37.9 62.1
64 117
35.4 64.6
1.12 (0.50–2.51); p = 0.79 1
1.07 (0.38–3.05); p = 0.89 1
12 18
40.0 60.0
41 141
22.5 77.5
2.29 (1.02–5.15); p = 0.04 1
1.56 (0.51–4.80); p = 0.44 1
9 20
31.0 69.0
23 153
13.1 86.9
2.99 (1.22–7.37); p = 0.01 1
1.49 (0.49–4.54); p = 0.48 1
Adjusted for age of mother, parity, mother’s country of origin, mother’s education, living in traffic area, using ‘tagine’ plates for cooking and mother’s Kohl using.
Discussion
Conclusions and policy implications
Strengths and limitations of study
There is evidence from the Belgian data, but also from other counties, that some cultural habits are linked to a risk of high cord blood lead levels. These habits include traditional medicines, cosmetics and also the use of lead glazed earthenware. Additional research with larger sample sizes is needed to explore factors such as diet, lifestyle and cultural habits contributing to lead exposure. Future health and environmental actions are needed, not only to remediate known areas of lead pollution, but also to investigate these other sources of potential risks in order to ensure effective interventions and health promotion.
In this study, among 220 newborns, about 13.7% had a cord blood lead concentration ≥20 ␮g/L and 5 cases (2.3%) had a cord blood lead concentration ≥50 ␮g/L. This result was quite similar to those found in a previous study which had similar study design and data collection in four Belgian maternity units in 2004 (Heymans et al., 2005). In both studies the migrant mothers from North and Sub-Saharan Africa were at increased risk of lead exposure, and a positive association was found between cultural determinants (khol) and cord blood lead concentration The study has much strength. The births were consecutive births, with less than 5% refusal, making the sample truly representative of the hospital population. The different population mix of the five hospitals gives credit to the lack of association between old housing and increased cord blood lead levels. The main weaknesses of the study were small sample sizes and lack of follow-up of women and children who had elevated lead levels by investigating the details related to their diet, lifestyle and cultural habits.
Comparison with other studies In terms of prevalence, the results are of the same order of magnitude, albeit higher than what is reported in recent published studies in other high income countries or regions: Spain (Llop et al., 2011), Maryland (Wells et al., 2011), Taiwan (Lin et al., 2011), Austria (Gundacker et al., 2010) and Tennessee (Jones et al., 2010). Regarding determinants, this study departs from the standard risk factors for high cord blood levels. Classically occupational exposure, smoking, homes with lead paint and proximity to traffic are the main determinants. None of these were found in our data. However, belonging to an ethnic minority, and specifically cultural habits such as using khol were found to be significant determinants. This is in line with the results of a study which described migrant status as the major risk in France (Yazbeck et al., 2006) and higher umbilical cord blood concentration associated with surma (an eye cosmetic) daily users in Karachi, Pakistan (Janjua et al., 2008).
Acknowledgements The project was funded by the Fonds Houtman, Belgium. We would like to thank all the women who participated in this study and the staff of the five Belgian maternity units. References Al Saleh, I., Shinwari, N., Mashhour, A., Mohamed, G.D., Rabah, A., 2011. Heavy metals (lead, cadmium and mercury) in maternal, cord blood and placenta of healthy women. Int. J. Hyg. Environ. Health 214, 79–101. CDC, Centre for Disease Control, 2009. Why Not Change the Blood Lead Level of Concern at This Time?, http://www.cdc.gov/nceh/lead/faq/changeBLL.htm. Claeys, F., Limbos, C., Ducoffre, G., Sartor, F., 1992. Saturnisme infantile à Bruxellesdépistage 1991–1992: étude de prévalence et des facteurs étiologiques. Institut d’hygiène et d’épidémiologie Press, Brussels. Claeys, F., Gulbis, B., Lorenzo, R., Sykes, C., Van Humbeck, R., Vertongen, F., 1997. Saturnisme infantile, carence martiale, hémoglobinopathies-thalassémie: Dépistage 1995–1996 à Bruxelles. Scientific Institute of Public Health (IPS) Press, Brussels. Gardella, C., 2001. Lead exposure in pregnancy: a review of the literature and argument for routine prenatal screening. Obstet. Gynecol. Surv. 56, 231–238. Gundacker, C., Fröhlich, S., Graf-Rohrmeister, K., Eibenberger, B., Jessenig, V., Gicic, D., Prinz, S., Wittmann, K.J., Zeisler, H., Vallant, B., Pollak, A., Husslein, P., 2010. Perinatal lead and mercury exposure in Austria. Sci. Total Environ. 408, 5744–5749. Heymans, I., Colar, F., Lagasse, R., 2005. Rapport de l’analyse des données: l’intoxication au plomb chez le nouveau-né et les facteurs de risque de sa mère. Recherche dans les 4 maternités bruxelloises, 2003–2004. ESP Press, Brussels. Holmes, P., James, K.A., Levy, L.S., 2009. Is low-level environmental mercury exposure of concern to human health? Sci. Total Environ. 408, 171–182. INSERM, Institut National de la Santé et de la Recherche Médicale, 1999. Plomb dans l’environnement: quels risques pour la santé?, http:// www.ladocumentationfrancaise.fr/rapports-publics/064000679/index.shtml. Janjua, N.Z., Delzell, E., Larson, R.R., Meleth, S., Kabagambe, E.K., Kristensen, S., Sathiakumar, N., 2008. Maternal nutritional status during pregnancy and surma use determine cord lead levels in Karachi, Pakistan. Environ. Res. 108, 69–79.
W.-H. Zhang et al. / International Journal of Hygiene and Environmental Health 215 (2012) 202–205 Jedrychowski, W., Perera, F., Jankowski, J., Rauh, V., Flak, E., Caldwell, K.L., Jones, R.L., Pac, A., Lisowska-Miszczyk, I., 2008. Prenatal low-level lead exposure and developmental delay of infants at age 6 months (Krakow inner city study). Int. J. Hyg. Environ. Health 211, 345–351. Jones, E.A., Wright, J.M., Rice, G., Buckley, B.T., Magsumbol, M.S., Barr, D.B., Williams, B.L., 2010. Metal exposures in an inner-city neonatal population. Environ. Int. 36, 649–654. Lin, Y.Y., Leon Guo, Y.L., Chen, P.C., Liu, J.H., Wu, H.C., Hwang, Y.H., 2011. Associations between petrol-station density and manganese and lead in the cord blood of newborns living in Taiwan. Environ. Res. 111, 260–265. Llop, S., Aguinagalde, X., Vioque, J., Ibarluzea, J., Guxens, M., Casas, M., Murcia, M., Ruiz, M., Amurrio, A., Rebagliato, M., Santa Marina, L., FernandezSomoano, A., Tardon, A., Ballester, F., 2011. Prenatal exposure to lead in Spain: Cord blood levels and associated factors. Sci. Total Environ. 409, 2298–2305. Mattison, D.R., 2010. Environmental exposures and development. Curr. Opin. Pediatr. 22, 208–218.
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