An Analysis of Occupational Blood Lead Trends in Manitoba, 1979 Through 1987

Annalee Yassi MD, MSc, Mary Cheang, MMath, Milton Tenenbein, MD, Geoffrey Bawden, Jerny Spiegel, MA, MSc, and Ted Redekop, MD

Introduction Although lead poisoning has been documented since antiquity, occupational lead intoxication continues to occur.1-3 Moreover, there is growing consensus that lead causes toxic injury to humans at levels of exposure that only a decade ago were thought to be safe. As Landrigan notes,' these subclinical changes represent truly harmful outcomes and are not merely homeostatic or physiologic "adjustments" to the presence of lead. The US Occupational Safety and Health Administration (OSHA) standard, since 1978, has required the removal from exposure of workers who have confirmed blood lead levels of 2.9 ,mol/L (60 ,ug/dl) or higher, an average of 2.4 ,umolVL (50 jig/dl) or higher on three tests, or a medical condition contraindicating continued exposure to lead. Once removed, workers cannot return to a job where they will be exposed to lead until the blood lead level is 1.93 ,umoVL (40 ,ug/dl) or less or the employee no longer has a medical contraindication to lead exposure.2 Environmental monitoring is also required, to ensure a permissible exposure limit of 50 ,ug/ m.3

Evidence is lacking as to the effectiveness of any regulation with respect to lead poisoning. While some states maintain heavy metal registries, these only required the reporting of blood lead concentrations above 1.93 FLmol/L (40 pg/dl) (until recently when some states dropped their required reporting level to 1.21

,umol/L [25 ,ug/dl]). Hence, longitudinal follow up of individuals, as well as by workplace, is not possible. Manitoba, a Canadian province with a population of one million, has a list of high-risk workplaces that are under gov-

emnment surveillance, as well as a centralized provincial laboratory where all occupational blood lead samples are analyzed. With over 11,000 blood lead concentrations recorded in this data base for more than a decade, linked by individual as well as by workplace, it is possible to evaluate trends in the province overall, as well as by individual company. It is also possible to assess concurrent tumover or

rotating

of staff (administrative controls). Utilizing this blood lead data base, we address specifically the following questions: * What is the extent of occupational lead intoxication? * Have mean blood lead concentrations decreased following govemment improvement orders and tighter standards? * What has been the role of administrative measures and engineering controls in any such decrease?

Methods Lead Measurements A total of 10,190 blood lead tests were performed as a result of regulatory surAddress reprint requests to Annalee Yassi, MD, MSc, Director, Occupational and Environmental Health Program, Department of Community Health Sciences, University of Manitoba, S113-700 Bannatyne Avenue, Winnipeg, Manitoba, R3E OW3. Coauthor affiliations: At the University of Manitoba, Ms. Cheang is with the Biostatistical Consulting Unit, Dr. Tenenbein is Associate Professor, Departments of Pediatrics, Pharmacology, and

Community Health Sciences, and Dr. Redekop is Community Medicine Resident, as well as Medical Officer of Health with Manitoba Health; in the Manitoba Department of Labor, Mr. Bawden is Director of Field Operations, Division of Workplace Safety and Health; in the Manitoba Department of Environment, Mr. Spiegel is Director of Planning. This paper, submitted to the Joumal February 26, 1990, was accepted for publication October 19, 1990.

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Occupational Blood Lead Trends, Manitoba

veillance reported from 10 high-riskworkplaces. Five workplaces had regular medical monitoring programs throughout the period 1979-87 inclusive, and five conducted comprehensive and continuous programs for at least two years during this period. In other workplaces the medical monitoring was sporadic and voluntary. All blood lead analyses were conducted at the provincial government's Technical Services Laboratory located in Winnipeg, Manitoba. The laboratory is accredited by the American Industrial Hygiene Association and participates in the Blood Lead Proficiency Testing program of the Centers for Disease Control in Atlanta, as well as the program conducted by the Centre de Toxicologie in Quebec. Blood leads are analyzed using the Fernandez Method.4 Those whose blood lead concentrations exceeded 2.41 p,mol/L (50 ,ug/dl) on at least one occasion, had an annual frequency of testing ranging from one to 21, median of four and mode of four, whereas those whose blood lead concentrations were always less than 1.93 p,mol/L (40 ,g/ dl) had an annual average testing frequency ranging from one to nine, with median of one and mode of one. To adjust for this variation, a quarterly median was taken for each individual. If an individual had only one blood lead test in a given year, the same result was entered in all four quarters for that year. If an individual had blood tests monthly, only the median of each quarter was entered for analysis. As measures of blood lead concentrations tend to be skewed, most of the analyses were smoothed (using a median quarterly or annually as the case may be) and the overall medians analyzed. Contingency table analysis allowed the comparison of aggregated distributions of blood lead concentrations, while linear regression analysis assessed company trends over the nine-year period, and Mantel-Haenszel trend tests evaluated specific target proportions over shorter time segments (i.e. proportion of values over 70 ,ug/dl during the three years following 1979 and proportion over 60 pg/dl in the three years following 1983). To gain insight into the mechanism underlying the longitudinal variations of individual blood lead concentrations, first order auto correlations to assess the influence of one result on the next among individual workers and testing the run of signs of first differences for randomness to assess individual patterns were performed.5-6 The overall effect of administrative controls as hypothesized by a negative association between last blood lead

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concentration nearing the target level and current blood concentrations was tested using the Mantel-Haenszel chi-square stratified by regulatory period. Industrial hygiene observations and measurements were gleaned from the records ofthe provincial government's workplace safety and health inspectorate.

essentially established a blood lead concentration of 2.41 ,umol/L (50 p.g/dl) as a compensable level.7 Sixty-three claims for lead poisoning had been allowed by the Manitoba WCB prior to 1986; 54 were allowed in the two years following this policy statement.

Occupational Lead Exposure and Regulatory Process

Results

Workplace safety and health is a provincial responsibility in Canada, with each province enacting its own legislation and regulations. The Workplace Safety and Health Act in Manitoba, proclaimed in 1977, empowers the minister to issue an order requiring an occupational health service at designated workplaces, with penalty of fine for noncompliance. This permitted the minister in charge of occupational health for the province to issue an order to five companies in 1979 to reduce blood lead concentrations to below 3.86 ,umol/L, (80 j±g/dl). There was no mention of environmental monitoring in the order. An individual was to be removed from the plant when his blood lead concentration exceeded 3.86 Fmol/L or transferred to a low lead exposure area when the blood lead ranged from 3.383.86 ,umoV/L (70-80 ,ug/dl). In 1983, after considerable debate, the 1979 order was revised reducing the blood concentration removal level to 3.35 ,umol/L (70 p,g/dl), with workers to be transferred to low lead areas when the blood concentration ranged from 2.90-3.38 ,umol/L (60-70 ,ug/ dl). There was no mention of differential levels for women, or of environmental

monitoring. The five firms that received this order consisted of one battery manufacturer, two primary lead-using industries, one secondary lead smelter, and one combined battery breaking/secondary smelter operation. These companies all operated continuously from 1979 to 1987 with the exception of the combined battery breaking/secondary smelter operation which was shut down briefly for economic reasons during 1983. Three other companies conducted biological monitoring over part of the same period; a primary copper smelter with additional production of zinc and lead concentrate (1982-87), a battery breaking operation in a reclamation yard (1985-87), and an aluminum forging operation (1985-86) with incidental lead exposure.

In 1986 following years of controversy and no written policy, the Workers' Compensation Board (WCB) in Manitoba

Table 1 contains the 10,190 blood lead concentrations of employees who worked in the 10 designated plants between 1979 and 1987 inclusive. The proportion of values over 3.86 ±mol/L (80 ,g/dl) has steadily decreased; there is a statistically significant difference in the distribution of lead concentrations over the years, (p < .0001). There were no essential changes in this distribution when one entry per quarter for each worker is included regardless of the number of tests performed on that worker during that particular year (data available from author on request). Figure 1 illustrates the trends in median blood lead concentrations over time in each of the five companies that operated throughout this period (with the exception of a brief plant closure in 1983 in one). Median blood lead levels by year and type of plant are given in the Appendix. A separate analysis was conducted to assess the proportion of blood lead concentrations over 3.38 pmol/L (70 p,g/dl) in the three years following the 1979 order which required a reduction to below this level. Both the overall trend as well as the trend within each of the five firms subject to this order showed a highly significant decrease in the proportion of blood leads over this level (overall from 7.9 percent in 1979 to 0.8 percent in 1982). When a similar assessment was done for the 1983 order, only one of the then six companies showed a statistically significant decrease in proportion of blood leads over 2.90 ,umol/L (60 p,g/dl), the new target level (data available from author on request). Two companies, a secondary smelter and a combined battery breaking/secondary smelter operation, which had 11.2 percent and 11.8 percent of blood levels over 2.90 ,mol/L (60 ,ug/dl), respectively, at the time of the 1983 order, had 13.9 percent and 16.9 percent over 2.90 pmol/L (60 ,Lg/ dl), respectively, three years later. Industrial hygiene investigation revealed that after the first government intervention, some hygiene and/or engineering controls were implemented in all ofthe firms in question with each firm adopting a unique strategy depending on its condi-

American Journal of Public Health 737

Yassi et al.

tion. Thereafter, companies seemed to be making greater use of administrative controls, i.e. removing workers to lower leadin-air areas when blood lead concentrations approached the action level, only to return them to the higher areas after their blood lead concentration had fallen. Industrial hygiene inspections found for example, that while the lead-in-air levels had dropped from 300 pg/M3 to less than 150 pg/M3 in a primary lead using company, between 1979 and 1983, such a decrease was not observed in the inspection of a secondary lead smelter where environmental levels continued to exceed 300 p3gm/M. A second secondary smelter demonstrated a reduction of near 150 Rg/3on average but some areas, notably the fumace area, demonstrated no substantial reduction in air-borne lead with concentrations approaching 400 pgfM3 and personal protection being used as a protective strategy. No ongoing environmental or personal monitoring programs were in place and government monitoring was generally complaint-based. Environmental data are thus incomplete. To further investigate the apparent failure of the 1983 order to produce a continuing decrease in blood lead concentrations, longitudinal analysis was performed for all workerswho ever had values of 2.90 ,umol/L (60 p,g/dl) or greater. A graph for these workers individually showed a marked "titration" pattern, indicating use of administrative controls. Figure 2 shows two typical examples of this pattern. It demonstrates that as a worker's blood lead concentration approaches the action levels he is removed to a lower lead area, and after his blood lead concentration falls, he is probably retumed to a higher lead-in-air concentration since his blood lead level rises. This titration pattern in individual workers was present throughout the period of data collection. Its exis-

738 American Journal of Public Health

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nificant (p = 0.0001) finding that if a worker's blood lead was less than 2.41 ,umoVL (50 pLg/dl) his next blood lead would be higher and vice versa. This indicates that an overall decrease in lead exposure in the plant was not occurring because the lead exposure was being averaged over a pool of employees. Four of the eight companies still in operation in 1985 had 18-50 percent of blood lead concentrations over 2.90 prmol/L (60 p,g/dl); one other company brought its percentage down to 1.9 percent, while the remaining three companies had had less than 1 percent even prior to the 1983 order. The workforce turnover rates were higher in the four companies with poor compliance than in the four with lower proportion of concentrations over 2.90 p.mol/L (60 ,ug/ dl) (data available from author on request). There was much less evidence of titration

in the four with better compliance (data available from author on request).

Dicussion The prevention of lead poisoning requires: 1) knowledge of dose response relationships with establishment of an acceptable target blood lead "threshold" to reduce the potential for subclinical lead toxicity, 2) effective surveillance of the environment and of the at-risk population, and 3) action to reduce lead exposure at the source. Considerable knowledge exists with respect to "threshold" levels of exposure for different adverse effects, as summarized elsewhere.2 There is a need to intensify the monitoring of lead levels in the at-risk population in order to take action which would result in a safer workplace. Methods used to monitor trends of occupational illness and injury8-13 are usu-

June 1991, Vol. 81, No. 6

Occupational Blood Lead Trends, Manitoba

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ally developed primarily for other purposes, making them less useful for occupational health surveillance. Most states have reporting systems specifically for occupational disease,9 but the completeness of reporting is rarely satisfactory due to a lack of effective centralized monitoring, and disincentives for physicians and others to report occupational disease.8,9 One of the main purposes of surveillance systems is to evaluate the effectiveness of worksite control programs.1' However, there is little information addressing the effectiveness of government regulatory strategy in controlling workrelated illness and injury, and there has certainly been controversy14 in this regard. This study illustrates an overall decrease in the extent of lead poisoning over the last decade. However, on careful examination it is apparent thatwhile the 1979 government order to reduce blood lead concentrations to below 3.38 ,umol/L (70 ,ug/dl) was effective, the 1983 order to reduce blood leads to below 2.90 ,umol/L (60 p,g/dl) was less so. Thus the conclusion regarding the effectiveness of Manitoba's regulatory strategy is mixed. Our findings show that when biological monitoring is the only criterion for compliance, utilization of administrative

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controls enables companies to comply with stricter regulations without decreasing overall lead exposure. The practice of administrative controls is problematic for several reasons. It results in subjecting more people to lead exposure, thereby failing to reduce overall lead exposure; it often causes employment disruption with its consequent socioeconomic consequences; it usually fails to reduce individual body burden of lead. The oscillations observed below the action level (Figure 2) do not represent lead exposure followed by lead excretion. Rather, due to man's relative inability to excrete lead, the downstrokes represent lead storage within the body. The end result of this process is chronic lead poisoning. This finding is supported by the clinical observations of the clinician authors (AY and MT) in which modest blood lead elevations in several long-term employees have been noted to be accompanied by marked increases in erythrocyte protoporphyrin concentrations. In 1987 the minister responsible for occupational health in Manitoba issued a further order requiring ". . . a worker to be removed from the lead containing environment until his/her lead level returns to acceptable levels below 2.41 ,umol/L

(50 ,ug/dl). The worker may work in a job with minimal lead exposure (30 ,ug/M3) considered as an 8 hour average ..." Moreover, the order stated that the exposure to the worker shall be "no greater than 50 ,g/3 ... Only upon a detailed engineering assessment by a qualified engineer can consideration be given to permit exposure levels ... to exceed 50 ,g/ M3." As most Canadian jurisdictions utilize the American Conference of Governmental Industrial Hygienist (ACGIH) level of 150 pg/M3, this order was considered quite progressive by some and draconian by others. Regardless of the appropriateness of the lead-in-air concentration chosen, the data presented here demonstrate that the inclusion of an environmental target level was a needed addition. Nonetheless, biological monitoring must continue, with the data base described above serving an important role in monitoring the effectiveness of this new regulation. In conclusion, while appreciation of lead as a subclinical toxin is essential, and a comprehensive blood lead surveillance system for high risk industries is crucial, unless biological monitoring is in conjunction with environment monitoring and measures to decrease exposure at the source, the overall goal of reducing occupational lead poisoning will not be achieved. El

Acknowledgments This research was funded in part by the University of Manitoba Research Development Fund. We acknowledge with thanks the cooperation of Will Grieve and staff of the William M. Ward Technical Services Laboratory, Department of Environment, Manitoba.

References 1. Landrigan PJ: Toxicity of lead at low dose. Br J Ind Med 1989; 46:593-596. 2. Goldman RH, Baker EL, Hannan M, Kamerow DB: Lead poisoning in automobile radiator mechanics. N Engl J Med 1987;

317:214-218.

3. Cullen MR, Robins JM, Eskenazi B: Adult inorganic lead intoxication: Presentation of 31 new cases and review of recent advances in the literature. Medicine 1983; 62:221-247. 4. Fernandez FJ: Micromethod for lead determination in whole blood by atomic absorption with use of the graphite furnace. Clin Chem 1975; 21:558-561. 5. Edgington ES: Probability table for number of runs of signs of first differences in ordered series. J Am Stat Assoc 1961; 56:156-159. 6. Gibbons JD: Nonparametric Statistical Inference. New York: McGraw Hill, 1971; 62-66.

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Yassi et al. 7. Workers' Compensation Board (WCB) Manitoba. Board Order No. 198/86. Criteria for Acceptability of Claims for Lead Toxicity. Manitoba: WCB, 1986. 8. Baker EL, Melius JM, Millar JD: Surveillance of occupational illness and injury in the United States: Current perspectives and future directions. J Public Health Policy 1988; 9:198-221. 9. Muldoon JT, WintermeyerLA, EureJA,et at Occupational disease surveillance data

sources, 1985. Am J Public Health 1987; 77:1006-1008. 10. Seligman PJ, Halperin WE, Mullan RJ, Frazier TM: Occupational lead poisoning in Ohio: Surveillance using workers' compensation data. Am J Public Health 1986; 76:1299-1302. 11. Baker EL, Honchar PA, Fine LI: Surveillance in occupational illness and injury: Concepts and content. Am J Public Health 1989; 79(Suppl):9-11.

12. Melius JM, Sestito JP, Seligman PJ: Occupational disease surveillance with existing data sources. Am J Public Health 1989; 79(Suppl):46-52. 13. Blanc PD, Rempel D, Maizlish N, Hiat P, Olson KR: Occupational illness: Case detection by poison control surveillance. Ann Intern Med 1989; 111:238-244. 14. Mendeloff JM: The Dilemma of Toxic Substance Regulation: How Overregulation Causes Undergraduation. Cambridge, MA: MIT Press, 1988.

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June 1991, Vol. 81, No. 6

An analysis of occupational blood lead trends in Manitoba, 1979 through 1987.

While regulations for workplace lead exposure become more strict, their effectiveness in decreasing blood lead concentrations and the method by which ...
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