Albaltricitis. So none of the presenters today had any conflicts of interest to disclose, nor did any of them discuss any off-label use of any drugs. Hi, everybody. My name is Albaltricitis. I have to read my brief bio here. It says that I have a residency in family practice. I'm a residency. I'm certified by the American Astronautic Board of Family Practice. I also have a residency in occupational medicine. I'm boarded by the American Board of Preventive Medicine. And I also sat for and passed the DO-ACMED boards, as opposed to having them handed to me. That's a different talk. I'll tell you someday how I really feel about it. I've been practicing exclusively in occupational medicine since 1992. I'm the medical director of the ACMED department for my health care organization, Ascension. And I've been an occupational medicine consultant for Johnson Controls, now Clarios, since about 1995. Now, the title of my talk is Lead Acid Battery Plant. What I'm going to be talking about is more like what information might be helpful for you before you go into the lead acid battery plant. I'm not going to talk about a lot of the health effects of significant lead exposure for a couple of reasons. That's a two-hour talk in and of itself. And plus, you're not going to see that huge lead exposure anymore. It just doesn't happen. I will be talking a lot about the history. And we'll talk about some of the health effects. We'll talk about lead absorption, distribution, half-life. We'll summarize the OSHA lead standard. We'll talk about the US Supreme Court Fetal Protection Decision. And then we'll look at some of the other hazards that you might see in a lead acid battery plant. Some of the references. OK, you've got the lead standard. There's an NTP monograph, which is very, very good. It talks about the health effects of low-level lead. We'll talk about one of the references, the United Auto Workers versus Johnson Controls Supreme Court Decision in 1991. We'll talk about Herb Needleman and his original work about the long-term effects of exposure to low doses of lead. ADSTAR is a very good reference. The latest ADSTAR edition, I think, is 2020. Burgess has a very good chapter. He has lots of chapters regarding various occupational industries. And it is about three pages. If you want to know all about lead acid batteries, it's only three pages in Burgess's book. And then we'll talk about the Merck manual as well, OK? OK, now, history. Lead is extremely abundant in North and South America, Spain, and China. In fact, you know why they call Wisconsin the Badger State? OK, you know why? You know what a badger is? I've never seen one, so I don't know why the hell they would call it the Badger State. The reason they call it the Badger State is because one of the primary, one of the biggest industries in Wisconsin back in the day was lead mining. And the lead miners, instead of making tents for whatever reasons, they would like to burrow into the sides of hills and live in there. They burrowed like badgers. So that's why they call it the Badger State. In fact, the state flag of Wisconsin has a lead miner on it, OK? So that's how important it is. Copper and lead were the first metals discovered and used long before the Metal Age, which began about 3500 BC. In fact, they've done archeologic findings. They found lead and copper beads going back 7000 years BC, OK? The first metallurgic process was called pupillation for silver extraction. Lead is bound to a lot of metals, OK? And in order to get the metal, you have to get rid of the lead. And the way you do that is you subject the mineral to really high heat. What happens is then the high heat oxidizes the lead, and then the lead is mechanically removed. And in the case of silver, the silver, whatever's left is pure silver, pure mass, OK? And in fact, if you like the Old Testament, you just read Jeremiah chapter 6, verse 29, bellows are burned and lead is consumed of the fire, OK? So it goes back to the Old Testament as well. It was used for, lead was used for building the Hanging Gardens of Babylon around 4000 years ago. The interesting thing about lead, it does oxidize, but as soon as you get that top layer of oxidized lead, it's protective for the layers underneath it. So the rest of the lead underneath does not oxidize any further, OK? It's used in enamel, for glazed pottery, glass making, and in cosmetics beginning about 2000 BC. It's still in use in India and Pakistan. There's various cosmetics and nipple balm that is still used today. Hippocrates documented the first cases of lead poisoning in the 6th century BC. Severe outbreaks of colic back in 500 to 600 BC. It was widely used in Rome, water tanks, plumbing, kitchen tools, sweetener, food additives, alcoholic drinks, etc. Now plumbism, P-L-U-M-B-I-S-M, is an old term for lead poisoning. It comes from the Latin word plumbum, where we get plumbing from, OK? The ancient Romans did a lot of work with, they used lead a lot. They made grape syrup, OK? And that grape syrup was then put into wine and fruit preserves. Lead was used as a sweetener, as a preservative. In fact, some of my older, older battery plant workers, they admitted that sometimes, well, back in the day, they could smoke, eat, and drink out on the plant floor. And sometimes they said they would put a little pinch of pure oxide into their coffee as a sweetener. We told them not to do that anymore. It can be used, the ancient Romans used to use it to induce abortions. They have a concoction mixed with lead and onions. I don't think onions had anything to do with it, but, you know, enough lead would be enough to induce an abortion. Now, there was much more documentation of health effects of lead in the first century BC, OK? There was a lot of documentation. And that was not just for occupational exposures. Basically, it was part of life. Now, did lead poisoning contribute to the fall of the Roman Empire? Well, the highest use of lead was about 200 BC, but the decline of the Roman Empire didn't begin until about 300 AD. So it was about 500 years. So it may have contributed a little bit, but not much. I don't think it would have taken 500 years if everyone was lead poisoned. If you look at the history books, you know, you got names like Tiberius, Caligula, Claudius, you know, these Roman emperors. And I think if you look at the history books carefully, what contributed more was the rampant alcoholism you saw at the time. All right. Pharmaceutical. There was a traditional medicine in China, India, and Egypt. It's been traditional medicine in China, India, and Egypt since about 2000 BC. The Romans used it, and it was included in their pharmacopoeia. Paracelsus used lead and opium for diarrhea, and that was still a treatment until the 20th century. Most diseases, at one time or another, were treated with some form of lead, and it's still used as medicine. There's a Mexican ethnic remedy. It's a powdered lead to treat constipation in children. I think it's called empacho. And there's a Laotian ethnic remedy. It's a lead powder used as remedy for fever and rashes. It's called pei luan. Ramazzini noted that it was a cause of serious intoxication, and very, very clearly he documented the various types of health effects from lead, but then he also said it was very effective for treating many diseases. Go figure. So you got to think, you know, these people, this was 2,000 years ago. What do they know? They're not modern. They're not smart. They're not intelligent. This, the Merck Manual, okay? Do they still even publish the Merck Manual? Okay, great. Because I started medical school in 1977. I got a copy of it, okay? And I thought it was great. And, you know, our son graduated from medical school four years ago, and he wouldn't know a Merck Manual if it hit him on the head. But having said that, you know how many books he bought through medical school? Zero. None. So the millennial doctors, I guess they don't need books. I'm not saying that's bad. Everything's digital. Everything's electronic. They have the latest and greatest information. But here's our Merck Manual. This is an anniversary copy of the 1899 Merck Manual. All righty? It mentions lead 87 times, as a treatment, 87 times. Everything from aneurysm to treating balanitis to treating yellow fever. Now, that's balanitis, not ulcerative colitis. Do you remember that? All righty. Now, interesting. Now, that was 1899. Well, high-dose lead treatment was still used for cancer treatment until the 1940s. So we're still using lead for cancer treatment here. There have been many, many epidemics of lead poisoning throughout history. There was an outbreak of colic paralysis and death in the 16th century France. Now, lead was added to assist fermentation to improve the taste and prevent contamination. That's what gave them all lead poisoning. There was an epidemic called the Devonshire colic in the 18th century. In fact, in 1772, someone, whoever the epidemiologist was at that time, thought, you know something? These cider presses that people are making cider in, they're lined with lead. Hmm, we kind of sort of know the lead is probably bad, so let's get rid of the lead-lined cider presses. That's one of the first examples of primary prevention, which I thought was pretty cool. There was the Amsterdam colic in the 20th century. At that time, people were drinking rainwater that was collected from the roofs. The problem is the roofs were all covered with lead sheets. There was the golden age of gout in the 18th and 19th century England among the upper classes. And the reason for that is they all were drinking fortified wine and port that was significantly contaminated with lead because they used it to fortify the wine to improve the taste and sweeten it. And at that time, it would be pretty common to get a bottle of wine that would have 1,900 micrograms per liter lead in it. So the Europeans finally decided, no, that's not good. You know, we're going to fix that. So you'd be happy to know that current European wine has a limit of only 300 micrograms of lead per liter. The next time you're drinking your European wine, just kind of remember that, okay? There were epidemics of lead poisoning in the southern U.S. What would happen, almost everybody who was admitted to a hospital in the southern U.S. in the 1960s for gout had some type of lead poisoning, okay? In fact, in 1967, they tested 56 million gallons of confiscated moonshine. 87% of the moonshine had some lead in it. Modern history of lead poisoning began in the 19th century with the Industrial Revolution. All you got to do is start reading Alice Hamilton. She has a lot of good references about lead poisoning. There were more subjects who were occupationally exposed to lead, and there was greater awareness of exposure risk. There was a clearer picture of the spectrum of lead poisoning emerged at that time. There was fatigue, sleep disturbance, constipation, lead lines, Dr. Burton in 1849 said, hey, you know, I'm seeing this funny little bluish line right on the gums of people who are lead poisoned. And it was called lead lines or Burton lines. What it is is these sulfur ions that are present in oral bacteria combined with the lead, and you get deposition of a lead sulfide at the gum line. That's what a lead line is. You get abdominal colic, anemia, kidney disease, peripheral neuropathy. Interesting, it's called painter's palsy. Lead neuropathy is a peripheral neuropathy that's primarily extensor motor. It's sensory sparing. The flexors are okay, but it's called painter's palsy. And you get a foot drop and a wrist drop. That's what that is about. And you can get encephalopathy as well. In the 20th century, added laboratory methods to create a more well-defined diagnostic picture. The most important use of lead regarding modern exposure is addition to motor fuel as an anti-knock agent. So in 1921, they added lead to gas texture, ethyl lead. And, you know, I still remember my dad in the 60s, he finished his little painting project, which probably had lead in it. And then he'd go wash his hands with some gasoline. So, you know, inorganic lead is not absorbed very much, if at all, through the skin. But tetraethyl lead, the organolead compounds are absorbed quite a bit through the skin. Now, U.S. lead consumption peaked in the 70s, okay? There was lead everywhere, okay? And population lead levels have declined over the past 40, 50 years. And interestingly, the CDC lead threshold levels have decreased significantly over the past 30 years as well, okay? There are many studies done regarding the exposure to low doses of lead in children. Now, today, I mean, we don't have lead in paint. We don't have lead in gas. Today, the greatest use of lead in the United States today is in the battery industry. We started decreasing the use of lead. The greatest use of lead in the United States today is in the battery industry. We started decreasing the amount of lead in paint in 1971. It was completely banned in 1978. Now we have graphs. This kind of tells you, it shows you United States lead consumption from 1880 to 1987. On the left is the paint. And then the graph on the right is more the gasoline additives. And, you know, there was a lot of lead in our society, okay? Not just in industry, but, you know, day-to-day in the house, in the home, and in our cars. And this shows lead intake from food. You know, back in the 60s and 70s, anytime you opened up a can of soup or something, there was lead solder in, you know, putting the can together. So we were eating lead too, okay? So it was lead intake from food. And that all started going down. So basically, we've eliminated lead from paint. We've eliminated lead from our gasoline. We've limited our lead intake from food. So things have been getting better. This is an interesting graph right here. The top one talks about median blood lead level every year. This is three-year-olds. These are three-year-olds in Chicago. If you take a look in 1968, you couldn't find a three-year-old whose lead level was less than 30, okay? So then the lead in gas, lead in paint started going down. And the numbers started going down too. So by 1988, the median lead level in a three-year-old was down to 12. And this shows here as the amount of lead in gas went down, population levels of lead in blood have gone down too. Here's what I meant about the CDC. Prior to 1971, CDC wasn't concerned about kids' lead level unless it was greater than 60, okay? It's gone down significantly. I think right now the CDC, maybe somebody knows, is probably down to five. Yes, five, okay. Now, Herb Needleman, he was an MD pediatrician, clinical psychiatrist. He was like the father of long-term effects of low lead exposure to children. You know, he had some studies back in 1979, 1990. There was another study just published this year, and it said half of the U.S. population is exposed to adverse lead levels in early childhood. But Needleman, let me just, basically what Needleman said was for every, you lose about three IQ points for every 10 micrograms per deciliter of lead in your blood, okay? No ifs, ands, or buts, okay? But then there was no evidence that decreasing lead, like from 20 to 10, would increase your IQ, whatever that means. But you have to, but he also had to admit that socio-demographic factors are much stronger predictors of child development than low lead exposure. But you know, it's, I'm not doubting that people, kids lost that much IQ, okay? Now, so I was three years old in 1958 in Chicago, so I assume my lead level was, let's say, 30-ish. So, what does that mean? That means I probably lost about nine IQ points. So I think, you know, if I hadn't lost those nine IQ points, maybe I would have been smart enough to be a lawyer. Somehow I survived. So, speaking of survival, this has nothing to do with lead, but... The question is, how come kids born in the 80s are stupid as shit? Well, I don't know. There's probably other exposures. Needleman's not alive anymore to figure that one out, sorry. So, I survived lead, but here's, I don't know, some of you may be old enough. In Chicago, I just remember, you know, the DDP truck used to come around. We used to follow the DDP truck up and down the alleys like forever. It was great. He came around every few weeks, and, you know, we were all excited. I ran home. I told my mother, oh, the DDP truck is here. Oh, good. That's great. You know, they'll cut down on the bugs and mosquitoes and stuff like that. So, they didn't care, but nobody knew how bad, you know, DDT was back in the day. But it's relative. It's all relative. You know what I'm saying? My folks were from Eastern Europe. So, you know, there were occasional guests of the German in labor camps, and then they were in refugee camps, and they were deloused and spayed with chemicals all the freaking time, and they survived. So, they had bad exposure. I had some exposure with the lead and DDT. My kids, maybe we spray them with DEET every once in a while, so they're doing okay. But that's an aside. All righty. Effects of high lead exposure on adults are well known. Going back to the days of Ramazzini and Paracelsus, we all know about that. But the effects of low lead exposure remain under study. This is old. This is from ADSTAR, 1990. But it's pretty much, it tells you, you know, you get a lead level of 80, you're going to get anemic. You can get encephalopathy over 100. Female reproductive issues start, these are significant medical adverse effects. So, you know, you're talking about levels that are over 60 or so. You know, at low level, can the blood pressure be affected? Can there be other things that are subclinical? I think they're still studying those, okay? Now, in 1999, I was the plant physician at the Johnson & Johnson Battery Plant in Milwaukee, and we had a NIOSH health hazard evaluation. And the result of the study was that there was no evidence of relationship between hypertension, diastolic pressure, systolic pressure, and lead exposure. But there was a trend, I don't know what that means, between increasing occupational lead exposure and increasing left ventricular mass. So if you've ever gone through a health hazard evaluation, it's really, really interesting, especially if they come up with something. But I think they were a little disappointed that they didn't have a lot to find. Now, Allison Tepler, she was the PhD involved at that time, and I remember having a couple of meetings with her, and she said, there's no safe lead level in the human body. Okay, I didn't disagree with her, but at what point do you have to do something about it? I don't know. They're still studying that. They're still studying that, okay. And pretty much, I think, once the government can get rid of lead, they're going to get rid of lead. And that's my opinion. The NTP, the National Toxicology Program, has a monograph. It's health effects of low-level lead. I've got a copy of it here. It's really an interesting read. It's got a lot of good information in it. And these are just a couple of tables, okay. This table talks about sufficient and limited evidence of principal health effects, okay. And sufficient evidence means that an association is observed between the exposure and the health outcomes in studies in which chance bias and confounding could be ruled out with reasonable confidence. So that's sufficient evidence. Limited evidence means that confounding could not be ruled out. And here's an example. It talks about in adults, if the blood lead is less than five, there's sufficient evidence that you can have decreased cranial filtration rate. Maternal blood lead is associated with loose fetal growth. They talk about bone lead evidence. There's really not a whole lot of data on that. They're not doing a lot of bone lead studies right now. I mean, if you want to, it's available online. You could look at it yourself. I've used this a couple of times to do some specialty consults. Here's, and they talk about neurologic, immune, cardiovascular, renal, reproductive and development. And, you know, some of it is the NTP conclusions are sufficient. Some of them are limited. Remember, these are associations. Now basic lead toxicology. When you talk about lead toxicology, you talk about absorption. We'll talk about that. A little bit about deposition, excretion, metabolic pathways, biological interactions. Lead toxicology, we know it's nephrotoxic. It affects heme synthesis. Now, blood lead is currently the preferred measure of lead exposure and burden in the soft tissue and is regarded as the best indicator of recent lead exposure. Now, due to lead stores in bone, blood lead is not a valid index of cumulative exposure. See, that's what they're looking for. They're trying to figure out how do we determine cumulative exposure? I think someday lead in bone will give us the best picture for that. If you want to talk about basic lead toxicology, you have to talk about lowest observable effect levels, signs and symptoms. We'll talk just a little bit about those. Neurologic and neurobehavioral effects, hematologic effects, endocrine effects, reproductive and developmental effects, cardiovascular effects, and obviously kidney effects. I'm not going to get into those in detail because that's really an hour or two lecture by itself. There's geotoxic effects in cancer. The CDC has set the threshold for children down to five. Kids are five. Now, the lead standard. The lead standard was made law in 1978 to reduce workplace exposure to lead and to prevent frank lead poisoning through early identification and elevated blood lead. Now, employers have certain requirements regarding lead exposure, and engineering controls are required to minimize lead exposure. So why was that a big deal in 1978? Well, because this is the kind of stuff we were seeing back then. This is one of my guys from my old battery plant. You take a look, 1974, lead level was 102. And you see a lot of 70s, 80s, couple of 90s. The lead index, that was basically they divided the lead by the hemoglobin. I don't know why they did that. I can't find that reference. I always meant to talk to Dr. Fishburne, my predecessor there, but he used it for something. But this was back in the day when they were smoking on the job. They were eating their lunch there, drinking their sodas, putting their lead in their coffee. So good old days. Well, you know, it's interesting. I did this guy's retirement physical. Nothing. This guy, no high blood pressure. Kidney function was fine. No problems at all. No problems at all. But, you know, everyone's different. Back in the day, yeah. Back in the day. I don't know why. If you're not going to do anything, what's your cutoff? I mean, it's like you cut them off at 100? Obviously they didn't. They didn't take them off. So I have no idea. You know, but there's other sources of lead. You know, when I have someone with an elevated lead level, I always ask them about, you know, what do they do for an occupation? You know, are there any environmental issues as far as lead exposure? What hobbies or other related activities might be contributing to it? As far as folk remedies, that's kind of important. That's kind of important. Folk remedies are really important. Now, the lead standard, the employer must provide certain workplace conditions. You know, people have to have a respirator. They have to be able to take a shower after work. They have to have clean uniforms. They have to have a clean area to eat. Employer must perform environmental and medical monitoring. And medical monitoring is required if the worker is exposed to lead in the air at or above 30 micrograms per cubic meter. Now, the employer must enter into a formal ongoing relationship with a licensed physician. This is where I have a problem. Not every one of my plants has a local OCDOT. Or they have a local Ocmed clinic where the doctor may do the physical, or the PA or MP might do the physical, and they basically, they clear them. But the thing is, we give them information. We give them a copy of the lead standard. We try to educate them. And in the lead standard, it says the employer needs to get a physician opinion as to whether or not the employee has any detected medical condition, which would place the employee at increased risk of material impairment of the employee's health from exposure to lead. So probably every three months, I get a call from one of the plants. Hey, we got this guy. He's been here a month. We found out that his hemoglobin is down to nine. He started with a nine. Or this guy's got kidney failure. What do we do? It's like, well, why the hell was he cleared in the first place? I mean, we do so much. I try to teach my local plants. If there's a red flag, you got to call me right away. It's usually a month later. By that time, the guy's working. There's not much we can do. So, you know, sometimes I used to call the local clinics. I tried to educate them. The California Department of Public Health has a nice PowerPoint presentation. I think it's called Adult Occupational Lead Poisoning in California for Occupant Providers. And we try to give them as much education as possible. And I said, well, why did you clear this guy? Well, it's under the ADA. I can't do that. It's discrimination. Well, yes, you can, because the lead standard says you've got to clear these people. So, you know, I remind them of the Chevron versus a Cosibel case. This guy was, I think, had hepatitis C and some type of liver disease. And Chevron fired him or didn't let him work because exposure to solvents would certainly aggravate his liver disease. And they went to the Supreme Court, I think, and they won. So you can't do that. OK, so what do I do now? It's a lot more difficult because the guy's been hired. He's been there for a month. So we try to do a lot of education. We try to give the employee information. We try to get them to go see their nephrologist. Most nephrologists will say, no, you shouldn't be doing this. Every once in a while, I get a nephrologist that says, ah, that's not going to hurt him, which is kind of scary. But, you know, these are kind of some of the things that we have to worry about, OK? Now, the lead standard says there are no recommendations made for treatment beyond cessation of exposure. And this is important. Prophylactic chelation therapy to prevent the rise in blood lead is forbidden under the standard. The problem is, on the internet, these guys can get anything. They, oh, it's just scary. Whenever I, you know, I do a lot of interviews when I talk to people when their lead levels are elevated. Maybe 25% of the time, you know, I get them to admit that, yeah, I got something online. It's like, you know, that stuff's going to rot your kidneys, rot your liver. Don't do that. So if you need to be chelated, you got to call your doctor. But you understand, the lead levels now, 30, 31. OK, not like back in the day when I was seeing 50, 60, 70, 80, 90, and 100, OK? Biological monitoring, what do we do? We do a CBC with a differential. It should be a manual differential. Why a differential? We need to check for basophilic stippling. I've never seen basophilic stippling, but that's why the standard requires us to do it. We do urinalysis with micro, a BUN creatinine, a blood lead, and we do a ZPP. Now, as we all lucidly recall from medical school, the formation of hemoglobin results from protoporphyrin 9 being turned into heme and hemoglobin. What happens is there's an enzyme called ferrohelatase, and that helps absorb iron into the protoporphyrin. It results in heme and hemoglobin. What happens if there's not enough iron? The ferrohelatase then incorporates zinc, and you get ZPP. What happens if something interferes with the ferrohelatase-assisting iron? You wind up getting zinc protoporphyrin. Now, is zinc protoporphyrin the same as FEP, free erythrocyte protoporphyrin? Kind of, sort of, no. A lot of people use it interchangeably. The numbers will be about the same. The numbers will be very much, very close to the same. FEP, originally, a method was used to convert ZPP to FEP, but it required a chemical extraction and use of fluorescence spectrometry. It's a tedious process. It's a more expensive process, and I think the reason they did it back then was sometimes you'd get ZPP affected by the bilirubin levels and carboxyhemoglobin and a couple of other things, but they found that's very rare, so it's a lot easier to do a ZPP. It's easier to use a hematophorometer to direct measurements of ZPP, and you can do it from a finger stick, okay? Protoporphyrin complex with iron creates heme. Heme-containing proteins include hemoglobin, which is found in red blood cells. Ferrohelatase is responsible for inserting iron to the protoporphyrin in a normal, healthy person to create heme. When the iron supply is limited, ferrohelatase inserts zinc to create zinc protoporphyrin, and elevated ZPP is an indicator of iron deficiency and or iron deficiency anemia. Children and menstruating women have higher ZPP levels than men. It's a lousy task. I don't like it. You know, I've got a lot of slides on ZPP. I'll try to go through them as quickly as possible. Antitoxin disease, genetic disorder, or other medical issue that interferes with ferrohelatase may disrupt the normal process of inserting iron in a protoporphyrin and will result in the production of ZPP. Infection, inflammation, hemolytic anemia all cause significant elevation of ZPP. Genetic blood defects, such as porphyria, will cause elevated ZPP. Anemias of chronic disease will result in elevated ZPP. G6PD deficiency may result in anemia, which will elevate the ZPP. I've pretty much seen most of those. Sickle cell anemia will result in elevated ZPP. Sideroblastic anemia will result in elevated ZPP. Thalassemia, cancer, vanadium exposure, all those things can elevate and result in an elevated ZPP. Okay, so lead interferes with ferrohelatase. Lead poisoning causes significant elevation of ZPP. If the person already has iron deficiency or some other blood dyscrasia, almost any lead exposure will have a much greater effect on ZPP levels as compared to the effect of lead by itself. So I get calls all the time. Somebody's got a ZPP of 120 and the lead level is 5. It's not from the lead. Okay. In fact, I create a letter saying, you know, and I tell them, you know, go to the doctor. It says your recent ZPP elevation has been reviewed and does not appear to be consistent with lead poisoning. There are many other reasons for an elevated ZPP, including anemia or other medical conditions that affect red blood cell formation. These conditions may result in elevated ZPP levels with minimal lead exposure. Please follow up with your primary care physician to determine the need for further elevation. Attach your most recent blood lead and ZPP results. Please sign below acknowledging that you're aware of the recommendation. So basically, I sent them off to their own doctors. Okay. Now, here's the one and only time that I thought ZPP was helpful is I had a lady whose blood lead level was always, let's say, 30. Okay. Not too low, not too high. And her ZPP was always 50, 50, 50, 50. One day she comes in and her ZPP was up to like 150. But I noticed her hemoglobin was down to 11. So, you know, she had anemia. And I said, well, you know, you got to go see your doctor. And she did. She went to see her doctor. And she came back and she said, well, my doctor says my ZPP is elevated because of my lead. It's like, well, your lead hasn't changed in 15, 20 years. But your hemoglobin has decreased. Oh, he just gave me iron pills. So I was, you know, persistent. And I said, no, you got to go back. And, you know, it turned out she had colon cancer. That's one time lead saved a person's life. So if it wasn't for that, who knows what would have happened. Okay. ZPP is usually low. Increase in ZPP indicates a disruption of normal heme production. But it's not specific as to its cause. That's why it's allowed to test. So you as a clinician, you have to figure out, is this from the lead? Or is this from something else? Okay. The main reasons are iron deficiency and lead poisoning. It's important that ZPP levels be evaluated in the context of a person's history, clinical findings, and results of other tests, such as ferritin, lead, CBC. It's possible that the person may have both iron deficiency and lead poisoning. Okay. Now, there's a lag in cases of chronic lead poisoning. ZPP reflects the average lead level over the previous three to four months. However, the amount of lead currently present in the blood and the amount in the organs cannot be determined on the ZPP test. Values for ZPP rise more slowly than blood lead concentrations following exposure and take longer to drop after the exposure to lead. Why is that? What's the lifespan of a red blood cell? 120 days. Okay. So, in other words, if you have a high lead level, let's say if there's a big exposure today, lead level is high, the ZPP is not going to go up for a few weeks. And once it does go up, even if the lead level goes down, the ZPP is not going to go down until those red blood cells are gone. Okay. So, OSHA talks a lot about ZPP. I won't spend too much time on this. The second paragraph talks about ferrochelatase is inhibited at low blood lead levels. It leads to increased free erythrocyte protoporphyrin. Zinc is incorporated and results in zinc protoporphyrin. So, at a blood lead level of 50, nearly 100% of the population will have an increase in FVP or ZPP. There's also an exponential relationship between blood lead levels greater than 40 and the associated ZPP levels. So, what they're talking about, you're not going to see significant changes in ZPP purely from lead poisoning unless your lead levels are, you know, getting up there. Okay. Oregon, in 2016, Oregon said, hey, you know, this is stupid. Why are we doing ZPP levels? Because there's so many other things that can contribute to it. Okay. So, Oregon actually petitioned OSHA saying, hey, do we really need to do that? Okay. So, in 2009, the state of Oregon requested an exemption to discontinue ZPP monitoring as part of a medical surveillance of employees with a low prevalence of elevated blood lead levels. So, why do ZPP if someone's lead level is only 5, 10, 15, 20, knowing that you're not going to see a significant change in the ZPP unless your lead levels are over 30, 40, something like that. And the short answer to this slide, no, OSHA said you have to do it. My OSHA, Michigan OSHA, they amended their lead in general industry standard in 2018. They did a lot of things. One of the things they did is right now OSHA said you have to take someone out of the lead environment if the lead level is 60 or an average of 50. Okay. And that's the current, the current standard is if you have a lead, one time lead level of 60 or an average of 50, they have to take you out of the lead environment. What they did in Michigan, they said, well, you know, we're going to be testing you. And if your lead level is over 30, we're not going to let you go back until you have two consecutive blood samples below 15. Okay. And that's pretty much what we do at Clarios. The Lead Industry Association had bargained with OSHA saying that, hey, we're going to do a, we're going to have a voluntary lead reduction program across the board and all the battery plants are doing this. And pretty much they've adopted like, you know, if you get a lead level of 30, you're out of the plant. Okay, if you're out, and then you don't, you don't go back, what Clarios does, you can't go back until you have two consecutive readings of 20 or below. And then what they do is if someone is put on medical removal protection, I get to talk to them. I give them a call. And I, and, you know, I introduce myself and first thing I ask is, well, your lead level is going up, it's over 30, you know, here's your numbers over the last couple of years, what do you think happened? Most of the time, they'll tell you what happened. You know, it's you, it's stuff like there's a huge oxide exposure. If there's an oxide spill, there's an oxide spill, the room is going to be so cloudy, you could barely see through it. And it's really hard, no matter what type of respirator you're wearing. It's going to be difficult. Okay. Most of the times I get the maintenance guys seem to have higher lead levels because even though they're wearing pampers, it's, if you're in the under machine, if there's an oxide spill, the stuff can get past the valve. It really can. And also, when you're a maintenance guy, you have to fix the machine, it's very noisy. Guess what, you're always flipping the thing up to talk to people. And if you absorb, roughly you absorb about 90% of the oxide that you breathe in and you figure if you have a mask off for about 60 seconds, that's about 14 breaths, you're absorbing 90% of all the oxide that you've taken in. And then sometimes when you're crawling in a machine, it's hard to wear a pamper, it just doesn't work, they take it off. So we do a lot of time educating them. Plus, a lot of the machines are filthy dirty. I've tried to improve the lead hygiene of the of the machines, they really should be cleaning them up a little bit better. And I tell all the maintenance guys, I said, before you start working on the machine, clean it up. So you spend 10 minutes. Though the pappers, the hoses frequently are cut, they get holes in them. And so you're breathing in lead that way. So we started putting sleeves on the hoses. So there's a lot of it, you know, and then sometimes you get people who just they don't take their shower, they go home without taking a shower, which they're not supposed to. We've had calls from health departments, you know, we've got, we had one guy, he just wouldn't take a shower, he'd go home, he'd plop his feet up on that you wouldn't change, you know, he plopped his foot up on a little coffee table, and all of a sudden, his kids have lead levels of 20 and 30. So, you know, it's sometimes, you know, the company needs to improve the hygiene. But ultimately, the employees have a certain responsibility as well. And then the other thing that the other thing that my my my OSHA did is they pretty much they stopped using the ZPP. Okay, they just they just don't do it anymore. Okay. And one of the one last reason for and I'm going through some of these quickly, you know, for the sake of time, one last reason for elevated ZPP is a false positive reading. So if I get if I get a reading that doesn't make any sense at all, I just say, well, let's just repeat it. Let's see what the heck is going on here. Now, absorption, if you breathe it, it's about 90% absorption. Okay. That's why you got to wear respirators. You can eat it. Okay. If the people who aren't breathing it, they're eating it, you get about 50% 50% absorption and kids and pregnant women. But it could and especially in kids, you can get up to 100% absorption on an empty stomach. So that's why little kids chewing on old paper chips. That's a huge problem. In adults, it's anywhere from 10 to 30% absorption in adults, but good enough. But if you have an empty stomach, it could be 60 to 80%. So that's why when I talk to these guys, you know, I asked him, do you come to work on an empty stomach? Well, yes, I do. So at least have a glass of milk or sandwich or something because there's increased absorption. I kind of go through that with them when I call them. Now, lead is an element found in concentrated and easily accessible lead ore deposits. And they're widely distributed through the world. You find lead on almost every continent. The general population could be exposed to lead in air, foods, drinking water, soil, dust. For adults, exposure to levels of lead beyond background are usually associated with occupational exposures today in America. In America, it's going to be primarily an occupational exposure. Other segments of the general population with an increased exposure include individuals living near sites where lead was produced or disposed. Okay, some of the more important lead exposures have occurred as a result of living in urban environments, especially near stationary emissions sources like smelters. Renovation of homes containing lead-based paint, we see a lot of that, pica, contact with interior lead paint dust, occupational exposure. I had a couple cops with elevated lead levels because they would use the indoor shooting range, which wasn't very clean. And they weren't wearing gloves, and they weren't washing their hands, and they were smoking, and they did all kinds of silly things, okay. The primary source of lead in the environment has historically been anthropogenic emissions to the atmosphere. In 1984, combustion of leaded gasoline was responsible for 90% of all lead emissions. The United States gradually phased out the use of lead, alkalizing gasoline, and by 1990, auto emissions accounted for only 33% of the annual lead emissions. So that wasn't that long ago. Domestic mines produced 368 metric tons of recoverable lead. Secondary recycled lead was derived from mainly scrapped lead acid batteries accounted for all the domestic refined lead production in 2014. So the plant in Canby, Oregon, uses 36 million pounds of lead. Tampa is a little place, it's only, they only use about 3 million pounds of lead, okay. And there's a lead exposure outside of work, auto repair, manufacturing, bridge reconstruction, bridge reconstruction, plumbers, pipe fitters, firing range instructors, police officers, glass manufacturers, printers, lead miners, shipbuilders, I mean, yeah, there's, there's lead pretty much everywhere, you just have to know where to look. Adults can be exposed during certain hobbies. I had one stained glass shop, they had, they had a lot of lead there. In fact, one of the, one of the workers actually lived in an apartment associated with the, with the shop. And it was, we did some lead, lead wipes, there was lead everywhere. Car repairs, radiator repairs, soldering, molding bullets, people who reload, reloaders, there's a lot of exposure to that if they're using lead shot, okay. Moonshine production, that's a big, I, especially with my southern class, I always ask them if they're drinking moonshine. Tobacco smoke is a source of lead, interestingly enough. You know, it's also interesting, the, the, most of my, not most, many of the battery guys, I ask them if they smoke, they say yeah. So what they do is they have, they have what's called a smoke shack outside, and during their breaks, they let them go have a cigarette or two. I go, where do you keep your cigarette? In my pocket. Well, guess what, by the time you get to the, get to the smoke shack, you know, it's covered in lead oxide, and you're smoking your cigarette, and you're breathing, breathing lead, and I, I kind of recommend a selfie. You're going to smoke, you're going to smoke, you shouldn't do it, but if you're going to do it, I recommend at home, in a clean environment, put three, four, five, six cigarettes in a little plastic baggie, put the bag in your pocket, so when you go out, hopefully it doesn't get, doesn't get contaminated, hopefully your hands are clean by that time, okay. People who use the following items also increase their lead exposure, paints, pigments, facial makeup, hair coloring, lead or lead acetate, you have to know what you're using, certain, some cosmetics contain lead from foreign countries, there's some traditional folk remedies may contain lead, these are used in Indian, Middle Eastern, West Asian, or Hispanic cultures, I always ask, are you using any ethnic remedies? Some ethnic medicine practitioners believe that lead and other heavy metals have healing qualities, look at the Merck manual in 1899, we did too. Lead may also contaminate products during grinding and coloring or leaching from the package equipment, there's some ethnic, some ethnic remedies are known to contain lead, there's Hispanic, Indian, Chinese, and, and, and other countries still have lead in their ethnic remedies. Now who's this guy? Isn't he cute? I just want to kiss those little pudgy cheeks, okay, that's our granddaughter, I'm sorry, our daughter-in-law presented him to us two months ago yesterday, so why, why is that picture here? For two reasons, number one, I want to brag, number two, his mom is Indian, okay, she was born there, she came over to this country when she was three years old and grew up in Chicago, I dare say her English is better than mine and, and, and she, she has no hint of a Chicago accent unlike me, but so why is this here? Well, she's from India, all relatives are from India, so when she became pregnant, you know, she, some of her relatives sent a couple of ethnic remedies, so I did a deep dive right away and, and it's interesting, all the, all the ethnic remedies, there's, right, one of the first things they mention when you do the literature review is that they, they, they do, they evaluate for the presence of heavy metals, okay, so I guess they must know that that's important to people, so the, the ethnic remedies that she had appeared not to have any lead in it, so I said, okay, that's good. Gunshots, this, you know, gunshots are really, really interesting, okay, there was a study in the MMWR between, from 2003 to 2012, retained bullet fragment cases accounted for 0.3 percent of all blood leads greater than 10 and about 4.9 percent of all blood leads greater than 80, interestingly enough, there's about 115,000 firearm injuries every year, 70 percent are non-fatal, so you get about 80,000 people walking around with bullet fragments every year, so after 13 years, you had about a million people in the population that have retained bullet fragments, okay, now I would love to do a study to see how many of them have high lead levels, in my experience, they generally don't, okay, now you can't have an elevated blood lead if the, the bullet fragment migrates to a joint space or something like that, okay, so it can happen, and so I get calls from the plants all the time, they say, well, you know, Joe has a retained bullet, that's why we can't get his blood lead down, I said, no, you know, neither Joe's being a goofball, you guys aren't watching him carefully, that's not, or, you know, it's not happening, well, should we chelate him, no, you don't want to chelate him, now, it can happen, but would I, would I, would I tell people, I said, look, you see, what was Joe's blood lead when he started working, okay, if it was two, and now it's 25, he's working in a high lead environment, that's where it's coming from, if you, if you take him out of the lead environment, you want to put him on medical removal protection for two months and see what happens, if his lead level still stays up there, well, maybe it's from the bullet, but then you got to refer him to his own doctor to see if they'll take the bullet out, okay, um, I did have one case that I did a consult for, he was a, is a Wisconsin teenager, 19-year-old, he and his buddy were out hunting, and alcohol may have played a role, the one buddy said, look, duck, the other guy didn't duck, he got about 200 buckshot in his, in his leg, and his side, and I know it was 200, because I did an x-ray, I counted them all, his blood lead was 14, I don't know, I don't know, so, so that was a case where just the sheer volume, see, normally what happens, you get a bullet fragment or some type of shrapnel, the body encapsulates it, it, it, it puts it in some type of scar tissue, it's no big deal, but this kid had, this kid had a huge, huge volume, huge volume of stuff, okay, all righty, redistribution, okay, total body burden is defined, is distributed as follows, two to five percent of the blood lead, of lead is in the blood, 99 percent is bound to red blood cells, one percent of plasma, it's free to exchange with soft tissues, including kidney, brain, peripheral nerves, heart, liver, bone marrow, and placenta, two to eight percent in blood tissue, in soft tissues, and 90 percent goes to the bone, okay, the half-life of lead in blood is about one to two months, this, this, the slow compartment of lead is in the skeleton, with an estimated half-life of years to decades, of note, the half-life for elimination of lead from the body increases with increasing intensity of lead exposure, since red blood cells become saturated, and a greater proportion of lead accumulates in the slow skeletal compartment, you get rid of lead primarily through the kidneys, the half-life, basically the, according to Maureen Alvarez, half-life of lead in blood is 28 days, half-life of lead in soft tissue is 40 days, half-life of lead in bone is 10 years or longer, okay, according to ADSTAR, lead is excreted primarily in the urine and feces, regardless of the route of exposure, you have some excretion through sweat, saliva, hair, nails, breast milk, and seminal fluid, elimination is multiphasic, it varies with age and exposure history, and ranges from one week to two years, half-life of lead in bone is about one to two decades, two physiologic compartments appear to exist for lead in cortical and trabecular bone, there's an inner compartment for lead for decades, and a labile component readily exchanges bone lead with the blood, that's the trabecular bone, under certain circumstances, this apparent, this apparently inert lead will leave the bones and re-enter the blood and soft tissue organs, you have bone to blood lead mobilization can increase during periods of advanced age, broken bones, chronic disease, hyperthyroidism, immobilization, kidney disease, lactation, menopause, physiological stress, and pregnancy, calcium deficiency exacerbates or worsens bone to blood lead mobilization and all the above instances, consequently the normal inert pool poses a significant risk because it is a potential endogenous source of lead that can that can maintain blood leads long after exposure has ended, let's talk a little bit about the UAW versus Johnson Controls, Johnson Controls makes batteries, the lead exposed jobs were the highest paid in the factory, due to concern that children of workers who are outside the exclusive remedy of workers cop would sue the company, they decide Johnson Controls decided to exclude pregnant and potentially fertile females from the most lead exposed jobs, these are some of the ladies that work with me at Johnson Controls, I know all of them, and they there was a lawsuit, they said hey listen the one lady said I got I you know I got some kids at home, I want to make more money, they said no no you can't you can't work in a high lead area, you have to take a job that pays five six bucks an hour less, you can't work, we'll let you come back if you if you get your show us your infertile, so she went got a tubal ligation so she could start making more money, and of course then she got married and her husband wanted to have kids and that was one of the reasons that they sued okay, so what happened was the Supreme Court said that they said fetal protection policies are prohibited by title nine, the OSHA lead standard concluded that lead was harmful to both males and females, and title I've said title seven title title seven forbids illegal sex discrimination as a method of diverting attention from an employer's obligation to police the workplace, the court rejected Johnson Controls professed moral and ethical concerns and decisions about the welfare of future children must be left to the parents who conceive bear support and raise them rather than to employers who who hire those parents okay, so OSHA established a series of the Supreme Court said OSHA established a series of mandatory protections which taken together should effectively minimize any risk to the fetus and newborn child if under if under general tort principles title seven bans specific fetal protection policies and the employee fully informs the woman of the risk and the employer has not acted negligently the basis for holding an employer liable seems remote at best, so what they said was the Supreme Court said you have to comply with safety and health laws and regulation you have a duty to warn, I understand duty to warn is an educational activity we do not counsel our employees, counseling is a physician a patient activity so general information including resources and data may be provided to the employee and the employee's physician and we tell them go talk to your doctor about this okay and we have a duty not to be negligent okay now got a couple minutes almost so the what are the implications employers cannot protect fetuses more than its workers um but a ruling in California in 1998 by the California Supreme Court brought to eight the number of states where employers can be held liable for injuries suffered by their children in utero while their mothers are at work you know so we can't protect the women against their will but their babies can sue us so there's you can't ask for waivers no medical certifications we can't force them to get tubal ligations or hysterectomies we cannot discourage certain jobs but we do not we cannot minimize or ignore reproductive risks to males either okay we have to educate everybody and basically we give as much as we do as much education as we can and we tell them go talk to your doctor uh other further implications we have to reduce exposure to level safe for all we need to provide warnings to male workers uh we can't just say oh well they're assuming the risk um and we if we do all this stuff we may protect the company from legal actions from the employee but not necessarily from the kids okay state work comp laws may bar employees from suing their companies for injuries but some courts have upheld the rights of their offspring that's the point i want to make there the mother may have been informed and may have been given state-of-the-art ppe and may have agreed to the risk but the fetus did not agree to that risk okay there's real history i want a couple more slides johnson controls reform in 1883 they've made the first patent for the first electric room thermostat your thermostat at home may have something that says johnson controls okay in 1978 they acquired a battery company called globe union 1985 they acquired automotive seating companies hoover universal so basically there was three divisions the controls division for air conditioning and stuff battery division and then the automotive division where they made car seats and stuff like that so in 2016 johnson controls merged with tyco international from ireland tyco makes like fire extinguishers and other home safety issues and and they said well we we like the controls division but we don't know anything about batteries or cars so they spun off the automotive division the adian in 2019 they spun off and they sold the battery division to clarios and clarios currently has 57 plants globally that doesn't include sales offices there's 19 battery plants in the u.s there's 16 000 employees globally and lead acid battery basically you know you have lead oxide production you have pasting casting finishing formation you'll see all that at the tour today uh what are the explosions well you got lead obviously there's noise great noise the sulfuric acid uh sulfuric acid it's you worry about that if it's misting or at high temperatures we don't have that issue there uh the ergonomics are obviously an issue i mean they they roboticize a lot of the a lot of the uh jobs i'm really interested to see what interested to see what they do in tampa i've not been to the tampa plant before a lot of pinch points a lot of people lose a finger or two arsene gas and stymie gas it's really interesting you you uh you they use arsenic and antimony um to uh make the the lead a little bit stronger so that the grids aren't so malleable okay um and and uh if you subject arsene to hydrogen gas you can get i'm sorry if you subject arsenic to hydrogen gas you get arsene gas and if you subject antimony to hydrogen gas you get stymie and both those because of the hemolytic anemia back in the 70s they did some studies and there and there was there were some levels of arsene gas and stymie gas they've changed the process a little bit right now it's not an issue they haven't done i mean i have i had one anecdotal uh a case of stymie poisoning years and years years ago uh it's not an issue because of the uh because of the industrial hygiene but anyway just in case you're in the formation area don't sniff the batteries okay so anyway so we have it's a battery plant is an interesting place you have you have the lead export you have lead standard to deal with the here uh audiometric standard respiratory protection you got sulfuric acid there's OSHA regulations you have all the organelle it's a fascinating place to go if you ever if you've never been in one if you have an opportunity to work with one there's so many different things for many different aspects of occupational medicine that you can do so and it's 20 after we have to get ready any questions if you if you haven't looked at it and you had some questions i'd be more happy to talk to you about it on the bus okay i'm going to give all these so what's interesting in the in the msds on lead acid batteries they talk about lead and sulfuric acid as a compound but somewhere on page 22 they said well you know you might you might be exposed to arsine gas if the arsenic is uh it's combined with the with the hydrogen but they don't mess it they don't mesh they don't mention the arsenic or the antimony in the msds up front okay make sure you know All right, thank you all so much. That'll conclude our day. For those of you online, as I mentioned, if they're able to pick up any types of videos or other learning resources from the lead plant, we'll certainly augment Dr. Baltresaitis' talk and publish that for your later viewing pleasure. We'll start again at the same time in the morning. I believe it's an eight o'clock start and appreciate you very much. Tomorrow we'll be on the exact same Zoom channel, okay? So have a great afternoon. Quickly, we're going to leave promptly at 1.30, so you've got about seven minutes.

occupational medicine

lead acid battery

toxicological impact

OSHA standards

lead exposure

fetal protection

workplace safety

zinc protoporphyrin

female workers' rights

battery industry