Madhav P. Bhatta, PhD, MPHAssociate Professor, Epidemiology & Global HealthCollege of Public HealthKent State UniversityKent, OH 44242

High Lead Levels in Refugee Children Resettled in US Interview with:

Madhav P. Bhatta, PhD, MPHAssociate Professor, Epidemiology & Global HealthCollege of Public HealthKent State UniversityKent, OH 44242

Dr. Bhatta

Madhav P. Bhatta, PhD, MPH
Associate Professor, Epidemiology & Global Health
College of Public Health
Kent State University
Kent, OH 44242 What is the background for this study?

Response: Lead exposure, especially in children, in any amount is harmful. Lead poisoning is a growing global environmental health problem with increasing lead-related diseases, disabilities, and deaths.  While exposure to lead in US children, in general, has significantly declined in the last three to four decades certain sub-groups of US children such as African Americans, immigrants and resettled refugees, and those from lower socioeconomic backgrounds are still vulnerable to environmental lead exposure.

Previous studies among resettled refugee children in the United States had found 4- to 5-times higher prevalence of elevated blood lead level (EBLL) when compared to US-born children. However, most of the studies were conducted when EBLL was defined as blood lead level ≥ 10 µg/dL. In 2012, the US Centers for Disease Control and Prevention changed the reference value for EBLL to ≥ 5 µg/dL. Moreover, because the countries of origin for US resettled refugees change over time, it is important to have epidemiologic studies that provide the current information on EBLL among these vulnerable new US immigrant children.

Using blood lead level data from the post-resettlement medical screening, our study examined the prevalence of elevated blood lead level at the time of resettlement among former refugee children who were settled in the state of Ohio from 2009-2016. We had a large and diverse sample (5,661 children from 46 countries of origin) of children for the study, which allowed us to assess EBLL in children from several countries of origin that had not been previously studied. What are the main findings? 

Response: We found that overall 22.3% of children under 18 and 27.1% of children under 6 years of age had elevated blood lead level at the time of post-resettlement medical screening. For 97.1% of the children, the screening was done within 3 months of arrival in the United States. The EBLL figures in these children are remarkably high compared to US-born children. For example, observed EBLL in children younger than 6 years in the new immigrant children is almost 4- to 7-folds higher than US national prevalence and Ohio state prevalence for the same age group.

In children younger than 6 years of age, we observed EBLL prevalence 12% or greater in children from 12 of 14 countries of origin that we were able to assess elevated blood lead level individually. Children from a South Asia region, particularly, had very high prevalence of EBLL. For example, children younger than 6 years of age from Afghanistan, Nepal, Bhutan, and Burma respectively had elevated blood lead level prevalence of 75.7%, 43.6%, 39.7%, and 30.9%, respectively. What should readers take away from your report?

Response: There are three things that the readers should take away from this report. First, while in general the US resettled refugee children have a higher elevated blood lead level at the time of resettlement compared to US-born children, they are also a diverse group with differing geographical and sociocultural characteristics and varying levels of lead exposure risk. Therefore, clinical, public health, and social service professionals should be aware of the disparity as well as diversity when providing services addressing the issue to these groups.  Furthermore, lead awareness and prevention programs should be tailored to each of the sub-groups to account for sociocultural and linguistics differences.

Second, since we know from previous studies the resettled refugee may also be at a higher risk of environmental lead exposure after US resettlement, resettlement agencies  must be cognizant of the risk of lead poisoning while arranging housing for these new immigrant children who already have EBLL and should not continue to be exposed to environmental lead in the United States.

Third, while we cannot be fully certain, we believe that most, if not all, of the observed blood lead levels in these children are likely due to their prearrival exposure. Therefore, this study provides a window into the risk of environmental lead exposure among children in low- and middle-income countries in Asia and the Pacific region, Africa, and Latin-America and the Caribbean, where most of the children have their countries of origin. The use of lead in many consumer and commercial products such as paints and lead-acid batteries continues to globally put millions of children at risk of lead exposure and its adverse health effects. What recommendations do you have for future research as a result of this work?

Response: We found a high prevalence of elevated blood lead level among US resettled refugee children when they were screened for lead within three months of arrival. Since we could not fully delineate the contribution of the postresettlement exposure to the EBLL prevalence in our study, longitudinal studies with this population are needed to answer that question.

Since lead poisoning is a problem in the resettled refugee children, studies on parental awareness and knowledge about the issue are needed for designing prevention programs appropriately tailored for various subgroups of the population.

Finally, studies of lead exposure in children and its contribution to morbidity and mortality in low- and middle-income countries and needed to understand the growing global problem of lead poisoning in children. This study provided a glimpse of the possible burden of EBLL in various countries but studies with representative samples of children in those countries are needed to truly understand the scope of the problem. Is there anything else you would like to add?

Response: While lead in gasoline is now banned from practically every country is the world, the use of lead in various consumer and commercial products such as lead-acid-batteries (LABSs) is growing. The production processes and improper recycling and disposal of LABs is likely contributing to the environmental contamination by lead. Similarly, the production and the use of lead-based paints continues in many countries. To address this widespread problem, there is a need for serious global commitment and action.

Nothing to disclose.


Refugees, Environment, Screening, Lead, Prevention, Child and Adolescent Health, Epidemiology, Other Child and Adolescent Health
Ahead of Print
18 Apr 2019

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Last Updated on April 20, 2019 by Marie Benz MD FAAD