Australian federal and state and territory responses to lead exposure cases

By Elizabeth O’Brien, Lead Advisor at The LEAD Group Inc, April 2016.

New (federal) NHMRC Lead Guide for Health Practitioners (WHO)

On 27^th April 2016, the Australian federal Health Department’s National Health and Medical Research Council (NHMRC) published Managing Individual Exposure to Lead in Australia - A Guide for Health Practitioners ; PDF (AT BOTTOM OF PAGE) ACCESSIBLE VIA: https://www.nhmrc.gov.au/guidelines-publications/eh58

The Lead Project Team at the NHMRC advised me by email (mid-April 2016):

The Guide, Managing individual exposure to lead in Australia - a guide for health practitioners is a companion document to the Statement and Information paper: evidence on the health effects of lead. It aims to provide general information on the detection and management of individuals with elevated blood lead levels in non-endemic areas from which State and Territory health authorities can develop specific advice for health practitioners, including clinicians and environmental health officers.

The management of exposure in communities where lead is endemic (such as lead mining and smelting communities) is the responsibility of State/Territory health authorities who run tailored programs to address local needs. If you receive enquiries from individuals living in these areas I suggest you refer them to their local state/territory health authority.

The publication of the Guide on the NHMRC website will also be advertised in the NHMRC Health Tracker newsletter, which is a free monthly e-newsletter. Details of how to subscribe are available at: https://www.nhmrc.gov.au/media/newsletters/health-tracker

The NHMRC’s Lead Working Committee concluded on 30 November 2015 and it fulfilled its Terms of Reference. Details of its terms of reference and membership are available here

[end of NHMRC Lead Project Team email]

Prior to the NHMRC Lead Guide being published, I web-searched or surveyed each State and Territory Public Health section in order to ask whether they’d incorporated into policy, the May 2015 NHMRC recommendation:

“If a person has a blood lead level greater than 5 micrograms per decilitre, their exposure to lead should be investigated and reduced.” Reference:

NHMRC Information Paper: Evidence on the Effects of Lead on Human Health

That is, the NHMRC was recommending Public Health action to be taken in every case where a blood lead level exceeds 5 micrograms per decilitre (µg/dL). Since 1993, the blood lead “action” level had been 10 µg/dL. Here are the results of the survey:

Queensland

On 17th July 2014, Queensland became the first Australian state to announce the proposed halving of the blood lead notification level, in media release which included:

“Chief Health Officer Dr Jeannette Young said Health Minister Lawrence Springborg had advised the Government would accept a recommendation from her to reduce the current mandatory blood lead notification level from 10 micrograms per decilitre (ug/dL) to 5 ug/dL…

“Dr Young said the 5 ug/dL blood lead level was adopted in 2012 by the United States under advice from that country’s Centres for Disease Control and Prevention.” Reference: https://www.health.qld.gov.au/news-alerts/doh-media-releases/releases/140717-lead-levels.asp

Queensland’s Health Legislation Amendment Regulation (No. 3) 2015 notes:

Part 6 of the Regulation commences on 1 January 2016.

Part 6 Amendment of Public Health Regulation 2005

…Amendment of sch 1 (Notifiable conditions)

Clause 19 amends schedule 1 ‘Notifiable conditions’, to ensure that all condition names and case definitions are consistent with contemporary terminology.

Blood lead level

The Regulation will amend schedule 1 of the Public Health Regulation to change the notification level for lead exposure, blood lead level, from 10 ug/dL (0.48umol/L) to 5 ug/dL (0.24umol/L) or more, to allow greater identification, management, reduction and if possible, elimination of lead exposure sources.

…the Public Health Regulation 2005 (Public Health Regulation) to:

…allow greater identification, management, reduction and if possible, elimination of lead exposure sources, by identifying persons who have lead exposure with blood lead levels of 5 μg/dL or more,

…An amendment to the Public Health Regulation is required to change the notification level for lead exposure (blood lead levels) from 10 ug/dL (0.48umol/L) to 5 ug/dL (0.24umol/L) or more. As a result of this revision, laboratories will be required to notify results that indicate a blood lead level of 5 ug/dL (0.24umol/L) and above.

“The objective of the intervention is to identify persons who have lead exposure higher than background levels to allow greater identification, management, reduction and if possible, elimination of lead exposure sources. This will ensure that potential adverse health effects are better managed.” Reference: https://www.legislation.qld.gov.au/LEGISLTN/SLS/RIS_EN/2015/15SL154E.pdf 

Australian Capital Territory (ACT)

Emailed response:

Thank you for your enquiry.

Elevated blood lead levels are not notifiable in the Australian Capital Territory (ACT). The Environmental Health unit within the ACT’s Health Protection Service works closely with clinicians to investigate any referred cases with elevated lead levels as warranted. In the event that we became aware of cases of elevated blood lead levels, a public health investigation would be initiated and we would utilise the NSW Health Guidelines for lead poisoning which can be found here: http://www.health.nsw.gov.au/factsheets/guideline/lead.html [Editor’s note: this URL is broken and there are no Lead fact sheets on the NSW Health Department website, but perhaps the NSW Environment Protection Authority (EPA) fact sheets at http://www.epa.nsw.gov.au/mao/leadbasedpaint.htm - which links to http://www.epa.nsw.gov.au/resources/epa/140693-lead-your-health-fact-sheet.pdf - are utilised in the ACT... or they will soon utilise the guidance mentioned below, at http://www.health.nsw.gov.au/Infectious/controlguideline/Pages/lead.aspx ]

ACT pathology refers blood lead level testing to QML pathology in Queensland. The pathology testing reports lead levels to as low as <2 micrograms/dL, with levels of 5 micrograms/dl or greater identified as elevated.

There are no identified areas of high risk of lead exposure in the ACT, with most cases being related to occupational exposure.

I hope this information is of use to you and answers your query.

Health Protection Service, Population Health, ACT Health

Victoria

After receiving no response to my email, I phoned and was advised that: From 4^th April 2016 the notifiable blood lead level in Victoria will be 5 ug/dL or greater. A later web-search revealed:

Chief Health Officer Advisory

02 March 2016

“From 4 April 2016 doctors and laboratories are required to notify the Department of Health and Human Services (DHHS) of:

“• all blood lead level test results greater than 5 micrograms per decilitre (replacing the current threshold of 10 micrograms per decilitre). You must provide notification to the DHHS in writing within five days of diagnosis.”

Reference: https://www2.health.vic.gov.au/Api/downloadmedia/%7BB33DCBD5-6FE4-44C2-AD42-98C64B48DD96%7D

Tasmania

Having received no response to my phone message, my websearch revealed no change to the Tasmanian guidelines which lists the following as a notifiable condition:

Lead [Demonstration of blood level in excess of 10 µg/dL (0.48 µmol/L) in any person not known to be occupationally exposed to lead], with PERSON OR ORGANISATION REQUIRED TO NOTIFY: Laboratory. Reference: Guidelines for Notification of Notifiable Diseases, Human Pathogenic Organisms and Contaminants, Public Health Act 1997. Issued 1 February 2010, at https://ablis.business.gov.au/TAS/resource/COP7953.pdf

South Australia

Emailed letter:

Thank you for your email of 19 February, 2016 regarding blood lead test notifications. As this matter falls within my portfolio of responsibilities, the Chief Executive has asked me to respond to you on his behalf.

There is no legal requirement for notification of blood lead test results in South Australia. SA Health’s lead abatement policies and programs have always aligned to, and reported against, the NHMRC guidelines. Further details of how NHMRC guidelines are implemented in the Port Pirie Lead Implementation Program can be found here:

Doctors or members of the public who require aid in identifying sources of lead exposure are encouraged to contact SA Health for advice and resources for exposure investigations. Resources are also available here on the SA Health web site

Thank you for your interest in this matter.

Yours sincerely

Public Health Services, Public Health & Clinical Systems, SA Health, Government of South Australia

Western Australia (WA)

I emailed the Health Department in Western Australia and then they phoned in mid-March 2016 to report progress in answering my questions, which were:

I am aware that WA Health follows up and investigates children under 5 yrs who have PbBs of 5 ug/dL or more so I’m really asking how do you know when a young child has an EBLL? How are you notified or more specifically, is any category of person required under your public health regulations to notify the Department? Do you also receive notifications for older people and do you also investigate those older children and adults if the blood lead level is above 5 or above 10 ug/dL or does the GP still have to notify the Department that a patient is “lead poisoned” by diagnosis, as in the old days?

On the same day as the phonecall in mid-March 2016, I received the following excellent news by email:

…as discussed by phone today we have been sorting out the processes required to be able to update our lead notification system.

The Health Act does currently list lead as a notifiable disease. I can confirm that the Department of Health will be moving towards incorporating a blood lead level of of greater than or equal to 5 micrograms/decilitre for the general population (excluding occupational testing) as notifiable.

The link to the NSW Health’s recent changes is:

http://www.health.nsw.gov.au/Infectious/controlguideline/Pages/lead.aspx or http://www.health.nsw.gov.au/Infectious/controlguideline/Documents/lead-in-blood.pdf

Cheers

ENVIRONMENTAL HEALTH DIRECTORATE, PUBLIC HEALTH DIVISION, DEPARTMENT OF HEALTH

New South Wales (NSW)

As noted above, NSW Health published Lead in Blood: Control Guideline for Public Health Units, on 22 February 2016 http://www.health.nsw.gov.au/Infectious/controlguideline/Pages/lead.aspx or http://www.health.nsw.gov.au/Infectious/controlguideline/Documents/lead-in-blood.pdf  (last updated on Tuesday 5 April 2016) and it has the most useful Public Health follow-up guidance I’ve ever found in Australia so I’ve pasted quite a bit of it below:

Managing single notifications

Response time

Investigation

Within 3 working days of notification of a confirmed case, begin follow-up investigation. 

Data entry

Within 5 working days of notification enter confirmed cases on NCIMS.

Response procedure

The response to a notification should be carried out in collaboration with the case's health carers and/or SafeWork NSW. Regardless of who does the follow-up, PHU staff should ensure that action has been taken to:

Confirm any symptoms associated with exposure, including onset date

Confirm whether the case or relevant care-giver has been provided with the results before beginning the interview

Seek the doctor's permission to contact the case or relevant care-giver

Review case management

Identify household contacts who may also be at risk of elevated blood lead levels

Response protocol for single elevated blood lead level notifications in non-endemic areas

[For endemic areas, refer to existing local protocols and programs for managing lead notifications in children].

The protocol outline below is for new notifications. If the notification relates to follow up from a previous notified blood lead level within the last 12 months (BLL), the PHU response can be modified according to the circumstances of the case.

Table 1. New Lead Notifications Procedure

Lead in Blood: Control Guideline for Public Health Units, NSW Health

Investigation and Treatment of Cases
The main treatment for adults and children involves:

Reducing or preventing the case's exposure to lead sources

Reducing the impact of exposure or eliminating it

Ensuring that exposure to other sources does not occur.

Education
The case or relevant care-giver should be informed about the effect of the blood lead level and the likely causes. In particular, emphasis should be placed on minimising the exposure of young children and pregnant women to sources of lead.

Lead exposure in children for community members and health care professionals is available from PHUs.

The Office of Environment and Heritage Pollution or telephone 131555

Other information on lead is also available from the NSW Environment Protection Authority

Exposure Investigation

The case or relevant care-giver should be asked about sources of lead contamination such as:

Lead paint on houses built before 1970 (including the case's and neighbouring houses), and in particular (i) any renovation or demolition of these houses and (ii) whether a young child is known to engage in eating soil and paint (pica).

Involvement in high risk occupations, including lead mining and smelting, metal repair or foundry work, painting and decorating, automotive (including radiator) repairs or breaking down old car batteries

Engaging in high risk hobbies involving lead or lead paint, including casting metal sinkers, antique furniture restoration, lead soldering, lead lighting and indoor shooting

Living in an area associated with large and small lead industries or areas with historic high traffic flow

Household pets which may provide an exposure pathway for lead dust

Use of traditional medicines such as Ayurvedic or Burmese remedies.

Infants who regularly chew or suck on painted toys, cots, window sills, paint chips, etc.

Other potential sources such as sandpits, vegetable gardens or domestic poultry 

Further information on occupational sources of lead can be obtained from SafeWork NSW on 13 10 50.

…Environmental Evaluation

If the source of the exposure is not clear after the initial investigation has taken place, the PHU should arrange for an environmental assessment of the residential area if the case's blood lead level is in excess of 25 µg/dL (1.2 µmol/L) and/or the implicated source may affect the broader community.

Environmental Control measures

The Public Health unit response to any exposures identified will need to be tailored to the specific risks identified. General advice can be provided by telephone or the provision of information such as factsheets, or advice on managing lead paint in the home (for example refer to Lead Safe Blitz video)

In some instances an EHO may provide an assessment through a home visit. Householders (or the landlord of the property) may also be advised to engage the services of an independent assessor or remediator to advise or assist with exposure risk reduction.

[end of extract of NSW Health’s Lead in Blood: Control Guideline for Public Health Units.]

The only advice I would add in that last paragraph (above) is that independent assessors of residential/non-occupational lead contamination are as rare as hens teeth for most of the NSW population but a Public Health Officer, armed with a LEAD Group DIY-Sampling Lab-Analysis Kit, could make an excellent assessment of lead sources in a home and yard, childcare centre, Council property such as a library or hall, pre-school, school, park or playground, etc.

The huge advantage of a LEAD Group Kit (available for purchase only from www.leadsafeworld.com/shop ) is that the Kit price/s include a report with recommendations on lowering blood lead levels of those exposed to the samples that have been tested, including lowering blood lead levels in pets and poultry, and thus in eggs.

A LEAD Group Kit can even be used by a professional remediator to check whether their lead abatement work or lead removal (of paint, ceiling dust, soil, lead flashings or paint from rainwater collection rooves, etc) has indeed made the premises lead-safe.

Northern Territory (NT)

Emailed response:

An elevated lead level is not a notifiable condition in the Northern Territory.

The making of an elevated lead level to be formally notifiable is currently under consideration within the NT.

The NT Dept of Health is developing a public health response framework for cases of elevated lead levels.