Lead notification level reduction letter to stakeholders

Reduction in the notifiable lead absorption level in the Health Act 1956 Dear colleagues The Ministry of Health is writing to advise of a change to the notification level at which lead absorption is a notifiable condition under the Health Act 1956. 1 The existing notification level of 0.48 (or greater) micromoles per litre of blood (µmol/l) is to be reduced: • • • •

The new notification level will be 0.24 µmol/l.

The new notification level comes into effect on 9 April 2021.

Notifications are made by health practitioners and medical laboratories to their local medical officers of health.

Public health units follow up notifications and manage non-occupational exposures. If medical officers of health reasonably believe that any given case arises from workplace exposure then they must advise WorkSafe New Zealand for follow-up 2.

The change to the Health Act is being made by the Notifiable and Infectious Diseases Order 2021. 3 What the change means for you If you (or your organisation) is involved in making blood lead notifications, then you need to be aware of the change in the notification level (and ensure other relevant people in your organisation are also aware).

Likewise, if you are responsible for subsequent follow-up and management of cases (ie, public health unit staff), or provide related functions (such as data collation and reporting of blood lead notifications) can you please ensure that your relevant staff are aware of this change.

The Ministry has updated the Environmental Case Management Guidelines for Leadexposed Persons 4. These Guidelines focus on the management of risks to health from exposure to lead in non-occupational settings. They outline a recommended graded response protocol to indicate appropriate responses to the results of the most recent blood test from the affected child or non-occupationally exposed adult.

Some organisations may need to update their relevant systems and processes, or staff guidance or procedures to reflect the change. The Ministry has engaged with our surveillance and reporting colleagues at Massey University’s Environmental Health Intelligence NZ programme and BPAC Clinical Solutions (who run the HSDIRT 5 Tool). If you use BPAC’s patient management software, updates to the Tool’s supporting guidance will be made by BPAC.

The notification level is prescribed in Section B of Schedule 2 of the Health Act 1956.

Section 199 of the Health and Safety at Work Act 2015 requires medical officers of health to advise WorkSafe New Zealand of work-related notifiable disease notifications made under section 74 Health Act, or notifications of injuries caused by hazardous substances made under section 143 of the Hazardous Substances and New Organisms Act 1996.

3 https://www.legislation.govt.nz/regulation/public/2021/0035/latest/whole.html#LMS454194 4 https://www.health.govt.nz/publication/environmental-case-management-lead-exposed-persons 5 Hazardous Substances Disease and Injury Reporting Tool (HSDIRT) is a GP-based system for reporting hazardous substances injuries and diseases.

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Rationale for the change Lead exposure, even at a low level, is well known for its harmful effects on children. With the removal of lead from petrol in 1996, the main source of non-occupational lead exposure in New Zealand is from lead-based paint on and around pre-1980s houses.

The Ministry of Health has continued to monitor international evidence and approaches since the notification level was last changed in 2007. Multiple studies and reviews have concluded that blood lead levels below 0.48 µmol/l are associated with several health effects, which include: • decreased IQ and academic achievement in children • adverse behavioural effects (attention, impulsivity and hyperactivity) in children • delayed sexual maturity or puberty onset in adolescents • increased blood pressure and risk of hypertension among adults and pregnant women.

Children under six years are the group within the population that is most susceptible to lead exposure.

• their activities and behaviour (eg, hand-to-mouth) result in greater exposure • they absorb about 50% of ingested lead compared to 10-15% in adults • their developing nervous system is sensitive to lead • their diet may be low in calcium or iron thus increasing lead absorption in the body.

The change is consistent with other jurisdictions. The Centers for Disease Control and Prevention (CDC) in the United States adopted 0.24 µmol/l as their reference value to identify children with elevated blood lead levels. In Australia, the National Health and Medical Research Council recommends investigating and reducing lead exposure if a person’s blood lead level is greater than 0.24 µmol/l, particularly if the case is a child or pregnant woman.

Further information • • •

Guidelines for public health units - The Environmental Case Management Guidelines for Lead-exposed Persons (updated March 2021) Massey University’s latest factsheet on Lead Absorption Notification (October 2020) is available on its Environmental health Indicators NZ website. 6 The Ministry has also updated its relevant pages on its website to reflect this change. 7

Further information about lead and exposures in the New Zealand situation is provided in Attachment 1. Please also feel free to circulate this letter to others as you see fit. If you have any questions, please email notifyenvhealth@health.govt.nz Yours sincerely

Dr Caroline McElnay Director of Public Health Ministry of Health

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https://www.ehinz.ac.nz/assets/Factsheets/Lead-absorption-notifications-October-2020.pdf https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/lead-poisoning https://www.health.govt.nz/your-health/healthy-living/environmental-health/hazardous-substances/removing-lead-based-paint https://www.health.govt.nz/publication/guidelines-management-lead-based-paint

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Attachment 1 - Further information •

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Lead is a global public health concern: Lead is a persistent environmental pollutant, and the World Health Organisation ranks lead among the 10 chemicals of major public health concern.

In New Zealand, lead-based paint accounts for most cases of elevated blood lead levels: With the removal of lead from petrol in 1996, the main source of nonoccupational exposure to lead in New Zealand is lead-based paint on and around houses built before about 1980, but particularly before 1945. On many older houses, the old paint may still be in place, painted over or flaking off. When old paint is removed, the lead in it may settle in dust or soil.

Elevated blood lead in children is of greatest public health concern: Young children, particularly under six years are much more at risk from lead exposure than adults because of: their activities and behaviour (eg, hand-to-mouth) result in greater exposure; their developing nervous system is sensitive to lead; they absorb more ingested lead than adults. Exposure of pregnant women to high levels of lead can cause miscarriage, stillbirth, premature birth and low birth weight.

Rates of elevated blood lead levels in adults have increased between 2017 and 2019: The notification rate of lead absorption in adults increased by 100% from 2017 (2.5 per 100,000) to 2019 (5.0 per 100,000).

Most elevated blood lead levels in adults occur from exposures at work, and painters are the occupational group most frequently reported: In 2019, there were 120 occupational lead absorption notifications (59% of all lead notifications). Of these, 49 were painters, who are the most common occupational group identified since 2014. The majority of the occupational lead notifications were below the 1.50 µmol/l Biological Exposure Index blood lead level for occupational exposure.

Rates of elevated blood lead levels in children are similar each year: Notifications of elevated blood lead levels in children (0 to 14 years) has remained relatively constant from 2014-19.

Most non-occupational lead exposures were due to lead paint: During 2014-19, nonoccupational lead exposure was due to: lead based paint (150 cases), indoor shooting ranges (90 cases), bullet/sinker manufacture (20 cases) or unknown/other causes (170 cases).

Rates of elevated blood lead levels are highest in the most deprived areas: Overall, in 2014–19, the lead absorption notification rates were higher in the most deprived areas (26.3 per 100,000) than in other quintiles (for example the least deprived area had a notification rate of 13.9 per 100,000) Rates of elevated blood lead levels are highest in Pacific people: For 2014–19, Pacific people had the highest lead absorption notification rate (4.1 per 100,000; 75 notifications), followed by European/Other (2.7 per 100,000; 483 notifications). However, a large number of notifications listed ethnicity as ‘unknown’.

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