 Welcome. This is Craig Thomas, your host on Much More Medicine, part of the Think Tech Hawaii's live stream program and assisted, as always, by Rich and Ray, our engineers, in joining me today for our welcoming back is Dr. Diana Felton. She is a State of Hawaii toxicologist. And I'm really pleased you're here because last time we had a number of interesting topics related to Hawaii's unique environment, volcanoes mostly. Today, we're going to talk about sort of a sneaky insidious toxin that affects many parts of the world, and at least to some degree here. And that's lead. Tell me about it. Well, thanks for having me, Craig. Happy to talk about lead. Lead is a metal. There's no natural or physiologic use of lead in the human body. So lead is considered a toxin even in very, very small amounts. And it's been a problem of public health focus for a long time. And there is often a misperception that we don't have as much problems with lead poisoning here in Hawaii. But we still do have lead poisoning here in Hawaii. I mean, lead is particularly interesting because it's really most harmful to children. What does it do? So lead interferes with a number of really important processes in the body, in particular at very low levels. It interferes with some of the brain development. And so the problems that occur from exposure to lower levels of lead are really sort of quiet at first, but then show themselves later. So they tend to cause problems with IQ, lowering IQ, poor school performance, hyperactivity, cognitive problems, and really slow executive functioning and higher level development type problems. So that sounds to me like A, bad stuff, and B, tricky to detect because maybe I'm just a little dumb. But maybe it was the lead. And pretty clearly on a population basis, if a whole group of people are exposed to lead and do poorly as a result, this is both an individual and societal problem. That's absolutely correct. And it makes it difficult to detect because many children with lead poisoning that will affect their school readiness or their ability to perform at school may not have obvious symptoms that you would see at times when they're sensitive to the lead, particularly around the ages of one or two years old, which is when the brain is the most sensitive to lead. So because of that, there's been a lot of work with public health agencies of trying to identify kids who are being exposed to lead and decrease their exposure, prevent lead poisoning. You know what, I was trying to decide about recent history and sort of historically. I'd actually like a little picture of where we've been exposed to lead over the years. And then let's talk about some developments of the last couple of years, and then specifically Hawaii. So most lead exposure that has caused problems for kids both in the past and even still today is related to lead-based paint. So paint has historically had lead in it, helps it be durable and shiny, very useful in paint, but it causes this major public health problem. So it was banned in 1978 for most uses, particularly in residential setting. Lead paint is still used in some outdoor structures like bridges used in marine settings like boats. There's still lead paint, but in your house you're not allowed to use lead paint anymore. But plenty of houses that were built before 1978 still have lead paint. So that's traditionally been a big place of exposure and continues to be. And I would point out that even if they got repainted after 1978, if the paint is flaking off, you're getting to the deep layers, which may well contain lead. Exactly. And then traditionally also leaded gasoline was a major source of lead, particularly in cities around roadways and in places where cars were frequent. That has been banned since the late 80s, and so we've really seen a decrease in the ambient lead amounts since that has happened, but that lead never really leaves the environment, it just disperses more. But we don't have lead in gasoline anymore, which is a good thing. So I'm pretty sure lead paint was banned in 1978, is that correct? That's right. I did actually hear an interesting, slightly macabre thing, which is they can tell by your skeleton sort of what era you were born in, because they can detect the tetraethyl lead from gasoline if you were, if your bones developed before it was removed from gasoline, which I guess was the late 80s. Well that's a little macabre, but interesting. And the lead, after the lead gets into your body, it then will end up depositing in the bones. And it stays in the bones, and it can stay for years and decades, and will slowly sort of work its way back out. So the exposures to lead can be really long lasting, even if your source was, you know, short term in the beginning. Got it. So more recently, we all heard about Flint, Michigan. And as I recall, the acute crisis was precipitated by putting some somewhat acidic river water through probably century old pipe that was made out of lead. And this sort of washed off the protective coating on the inside of the pipe and a big spike in lead levels, and took a while and there were some issues about detection. What was all that about? Yeah, that's interesting that you bring that up. It's certainly been in the news a fair bit. And what they found was it was actually detected, I believe by public health authorities who noticed increased in the elevated but not super high levels of lead in large numbers of children in the Flint area. And that was how they picked up on the problem. Unfortunately, there were some problems with some of the communications and some of the public relations that they had during that time. So that sort of became a big issue. But the end result was that there were a lot of children that got exposed to lead to a degree that may harm their school performance. And we're lucky here in Hawaii, we really are not aware of any significant lead problems in our drinking water here in Hawaii. So there was a law passed in a federal law passed in 1988 called the Lead and Copper Rule that requires the water companies to test water at the taps of a certain percentage of their customers and really don't find exceedances or increases here in Hawaii. So there still is always the question of the pipes that serve the municipal water to your house, particularly if it's built before 1988 when those were no longer allowed to be lead. But for the most part our municipal water particularly here in Oahu with the Board of Water Supply and in other parts of Hawaii did not have significant amounts of lead in them, which is fantastic. Are there any issues with non-municipal water well or catchment or sources like that? It's a very good question. And particularly on the Big Island in areas where the volcanic emissions were affecting people oftentimes there's acid rain related to the sulfuric acid that's created from some of the emissions from the volcano and when the acid was getting into some of some people's catchment systems it was causing lead to leach out of the pipes and can lead to lead in the water in the catchment system. So it's very important if you have private water or wells, catchments that you test frequently for lead and there's information how to do that on the Department of Health website and it's very important, especially during periods of unsettled environmental conditions. So what? Unsettled environment? I think we're going to be looking, have been looking at a lot and we'll be looking at a lot more unsettled environment. So in sort of the mechanism there was actually in some ways similar to the Flint one. Water is acidic, it dissolves the metal and so you get ionic metal basically, metal ions flowing around in the water and drink them. That's exactly right and then we have a few other interesting sort of Hawaii related risks that we are always concerned about. Lead fishing weights are a big source of exposure for kids in Hawaii. They're fun to play with, they're very common, you find them at the beach in the ocean and those are made of lead. So you know kids playing with lead fishing weights, families smelting a bunch of lead down to make weights, those are all also sources of exposure. Ammunition too probably, smelting down. Some people make their own bullets and things so. Absolutely and then we also like to think about some of the more esoteric but still prevalent causes of lead exposure which are things there's often like ceremonial religious equipment, some folk medicine, folk makeup, there are certain supplements and herbs that will contain lead and there's even been significant amount of lead found in certain spices particularly coming from India and Bangladesh. That's not good and I seem to remember a couple years ago I think they were kind of high in wooden toys that were painted with lead, painted had significant lead. Now I don't mean this was legal but in fact I think it escaped notice and got into some distribution. I did hear of a case where a family liked two things, crystal decanter and orange juice, the bad combination. Again the acid leached the lead from the crystal and the lead is what makes crystals so sparkly so there are weird point sources. There are and it's often a big source of mystery for us at the Department of Health when we're trying to investigate these cases and figure out what the exposure is so that we can help the families remove the exposure and decrease the kids blood levels. And interestingly although not the focus of this morning lead affects other vertebrates and possibly invertebrates I don't know but other animals as well and I spent time out at Midway and some of the Northwest Hawaiian Islands and there's a condition out there called droopling which affects albatross chicks and it's related to them getting lead poisoned and they get lead poisoned because their old structures out there the paint is flaking off they peck around in the ground and it's pretty sad the birds look great they grow they look really good except that their wings are droopy and they never fly away and in the end of course they can't survive without flying away so it matters it matters to us and it matters to the creatures we share the state with. That's exactly right. How significant a problem do you think we have and sort of what are the levels we're looking for? Sure. So the honest answer is that we don't know exactly the degree of problem that we have here in Hawaii and the reason for that is a lot of our lead poisoning prevention work has been traditionally funded by the CDC and still is but there was a gap in funding for many years and it's really been in the last year that the program's been refunded to a significant degree and really revamped. Was that the flint effect you think or? You know that's a good question I'm not certain it's possible that that played a role there's certainly been a movement from the federal government about lead poisoning in fact just a few weeks ago the White House released a special report about a federal action plan for investigating lead and reducing lead exposure and lead poisoning. So our program here had through the Department of Health and it's a it's through multiple divisions in the Department of Health has really revamped over the past year and just done some remarkable work in moving forward. In addition to that the CDC recently lowered their level of concern for children so it used to be 10 micrograms per deciliter and has been decreased down by half to five so that's the blood lead level that we start to get concerned about. You know after the break we're going to talk about testing and the fact that I at least probably had a level of 10 when I was a kid given my era and the things that were going on then and we'll talk about these things in a minute so thank you very much. This is a much more medicine we'll look forward to rejoining you after the break. This is Think Tech Hawaii raising public awareness. Choose to treat it with the help of a physical therapist. Physical therapists treat pain through movement and exercise. No warning labels required and you get to actively participate in your care. Choose to improve your health without the risks of opioids. Choose physical therapy. Aloha I'm Wendy Lowe and I'm coming to you every other Tuesday at two o'clock live from Think Tech Hawaii and on our show we talk about taking your health back and what does that mean? It means mind, body and soul. Anything you can do that makes your body healthier and happier is what we're going to be talking about whether it's spiritual health, mental health, fascia health, beautiful smile health whatever it means let's take healthy back. Aloha. Welcome back this is Craig Thomas your host on Much More Medicine and with me is Dr. Diana Felton who is the state toxicologist and it's great to have you here and before the break we were talking in general about issues about lead and we were just getting to what's the state doing and where's your focus? What are you concerned about? How can we implement prevention measures? So where are we at? Sure so it's pretty exciting the work that the state has done over the last year with being sort of revamping the childhood lead poisoning prevention program so it's the Hawaii version of that so we call it high clip is the acronym and high clip is a multidisciplinary effort within the Department of Health to really has sort of multiple components one is identifying children that are poisoned with lead with lead then tracking them and tracking looking for any sort of patterns in the public health matter and then following up with them making sure that the source is identified trying to help families understand how to reduce the source and then also oftentimes referring these children to treatments that we know work for lead poisoning such as early intervention sometimes individualized education plans or whatever else the kids may need going forward to try to compensate for the for the lead exposure on their school preparedness and school performance. So how big a problem is there anything but what kind of testing are we doing looking for kids? Obviously if you know there's a source and there's a child there it makes sense to look but I suspect that often there isn't an obvious source. Yeah and we have guidelines based on the CDC recommendations and the guideline is a questionnaire that the patient's pediatrician or child primary care provider would ask would go over with the family and it's recommended at nine months and two years and it goes through a list of things that would make a child at risk for lead poisoning so has another sibling ever had a positive lead level? Are there any exposures in the home such as old paint? Is the house built before 1978? It's also zip codes that are considered higher risk for lead poisoning so do you live in a high-risk zip code? Does a family member work in any industry that might expose you to lead? And a number of other things on the questionnaire and then if the children screen into that questionnaire then it's recommended they get a blood blood level test done but we do not have universal testing of kids in Hawaii which is something different from many other states so many other states recommend or actually require testing of all children at ages one and two. In addition Medicaid if you're on Medicaid you're supposed to be tested at nine months and two years however tested not screen correct however in Hawaii even among our Medicaid population only about 30% of the kids are getting tested so we really have a problem in that we don't know how big our problem is because we haven't had enough testing done so that's been a big push from the Department of Health and the Childhood Lead Poisoning Prevention Program to really encourage more testing so we can get a sense of what we're dealing with. Yes I mean it seems to me that relying on a screen is dependent on the sensitivity of the screen and based on the fact we don't have a big baseline level of testing is I think that's probably hard to know and it makes me wonder if instead of devoting effort to the screen we just did the test for a while to see where we are at I think we'd probably have some surprises. I think you're absolutely right and certainly test doing the blood test on more kids would really advance our understanding of the problem and help us understand how best to help the kids and prevent the poisoning cases. To me this is an important area to focus on because you won't find it if you don't look and the long-term impacts are real but hard to trace back to the issue and so you kind of have to look to find out. What in general can people do to minimize the risk of exposure themselves, their kids, even their albatross? Well that's probably not a problem. Well that's a great question Craig and it really helps just to think a little bit about your environment and how a kid around you or even yourself might be exposed to lead. So particularly if you live in an older home think about the paint is it paint peeling on the inside and even a lot of another big source in Hawaii particularly is the soil around houses so if the exterior paint is peeling and which often does because of our environment and the lead in the paint has gotten into the soil it's then in the soil and in the dust and that soil and dust gets on kids hands gets tracked into the house the kids run around on the floor etc. So even just really good wet mopping keeping surfaces clean of dust making sure there's no peeling pain or paint chips and washing hands really carefully before eating and drinking can really help decrease the exposure to lead for everyone in the family. You know I'd forgotten about something until just now years ago we had a wonderful little parakeet that flew into our lives from flying out of somebody else's life no doubt and we had it for some years and we went on a trip and we gave the bird to some friends while we're gone and by the time they're back the bird was really sick and so we took the vet took an x-ray bird was full of lead chips and it had been pecking away at the windowsill which it was an old home which clearly several layers down had lead paint sadly the bird died but it demonstrates how ubiquitous this can be and it also makes a good point in that even if your house is new you might want to consider other places where your kids spend significant amount of time such as the family member's house or a friend's house um there are you know lots of places throughout the community where lead could be present so important to think about all those possibilities when evaluating if your child might be at risk. To me this is all an argument for screening I by screening I mean testing I don't mean questionnaire because maybe the questionnaire is all benign but as you say child spends a significant time in a house like my friends we're living in at the time and um you would never find that on a questionnaire. And fortunately the technology for lead testing is getting better so a lot of times it can be done just in the doctor's office briefly quickly it's not a perfect test and there are some problems they have to then be confirmed with a true blood test if they're elevated but the screening the basic screening can be done fairly quickly and easily in many situations. So is it what sample is required so currently for the screening test for the quick screening test they're using point-of-care test for just capillary testing so it's just a finger print a poke yeah and that makes it a lot easier to do the screening do have to be careful because there can be some problems with false positives so the test will come out high and then you'll verify it with a true venous test and it will be normal but it's still useful in screening because you can eliminate a lot of kids when it's normal. And false positives although alarming sometimes and require an additional test are not that huge a deal so you tell the parent we're going to do this test sometimes it's inaccurate on the positive side in which case we do a confirmative test and if it's normal there's no issue. So for a screening test that's okay what would it take do you think to screen all nine little children? Good question so probably would take a change in the law through the legislature and also I think really important would take the buy-in of the pediatric community here in Hawaii so you know having some further discussions with pediatricians family care practitioners and talking about the usefulness not only to their individual patients but also to the collective good and the data set and the importance of the public health part of it would be interesting one idea that's been tossed out would be to try to require a brief period of time where we did universal testing so three years or so to see where you're at to see where you are and this has been piloted in some other states with a lot of success they've really found some problems they did not expect found other places where they thought there was a problem and there wasn't so really help them refine their both their prevention strategies and also their treatment strategies and pretty clearly the underlying rate of whatever it is you're looking for in the end drives whether it's worth testing for but if you don't know it you have to do some sort of baseline analysis just thinking about the pediatricians family practitioners nurse practitioners who are caring for these children I suspect buy-in could be facilitated if the program was supported by infrastructure perhaps the point of care devices to support to facilitate the process because what doctors tend to resist are sort of unfunded mandates but which you know you wish we all did the right thing for our patients but the truth is if there are barriers it's harder to get it to happen but I would love to see at very least a baseline statewide testing of small children at least till we know where we should be looking and where we shouldn't and does the questionnaire screen work or not my sense is it must miss some you know if it's a crystal decanter or a religious device or a I don't know herb from Bangladesh probably not going to find those on a screening questionnaire so or just staying at somebody else's house in the last couple minutes let's talk about where you'd like to see this go and what people can do both personally but also as a voice in their community for trying to increase lead awareness and abatement and impact the health of our community that's a great question I think awareness is number one particularly for people with young children talking with their healthcare providers about lead talking with their friends and other family members and some of the things we talked about earlier about you know keeping a lower dust environment making sure the paint isn't deteriorating on your wall and just kind of being conscious of the potential risk of course regular health checkups with your child are very important and then in addition there is you know there's work to be done through the legislature and there's a couple of bills about lead poisoning prevention currently in this year's legislative session that if this is of interest to people they can talk to their legislatures about and for more information there's a kind of really excellent resources and information on the department of health website it's actually on the website related to the childhood lead poisoning prevention program what's the url for the overall website I'm sure people can click down to the menu yeah so it's doh.hawaii.gov perfect is the department of health and then the subtext would be the high clip website and they've just revised it somewhat and it's just got a ton of information handouts brochures studies everything that can help you figure out where things might be at risk and also where what to do about it you know I really appreciate you coming today it's nice to hear that that you're focusing on a problem that affects our cakey and especially one that's not visible but is real so thank you all for joining us this is Dr. Diana Felton a state toxicologist and if you're interested in the pursuing this on the website again it was doh.hawaii.gov perfect thank you very much thanks for joining us