Despite extensive regulations and preventative efforts, lead poisoning, which can damage the brain, kidneys, and nervous and reproductive systems, still occurs in the United States. Babies are also at risk. Fetal exposure to lead can adversely affect neurodevelopment, decrease fetal growth, and increase the risk for premature birth and miscarriage.
Yet prevention efforts can only accomplish so much and during 2011–2012, the New York City Department of Health and Mental Hygiene (DOHMH) investigated six cases of lead poisoning in foreign-born pregnant women associated with the use of 10 oral Ayurvedic medications made in India. The pregnant women were assessed for lead exposure risk by health-care providers during prenatal visits, as required by New York state law.
Ayurveda is a millennia-old medical system closely connected to traditional culture and religion in India. According to a national survey, an estimated 214,000 adults in the United States visited an Ayurvedic practitioner in 2007, an increase of 39% since 2002. Most Ayurvedic medications are marketed either as dietary supplements or for drug uses not approved by the Food and Drug Administration (FDA). None of the nine medications with labeling information that were used by the patients in this report has been the subject of an FDA import alert. However, in a 2008 update, FDA urged consumers to use caution with Ayurvedic products. Although not all Ayurvedic medications include heavy metals intentionally, all six patients in this report used "rasa shastra" medications. Rasa shastra is a type of Ayurvedic medication that is intentionally prepared with metal, mineral, or gem compounds. These compounds, called "bhasmas," sometimes are indicated on product labels.
The patient blood lead levels (BLLs) ranged from 16 to 64 µg/dL. Lead concentrations of the medications were as high as 2.4%; several medications also contained mercury or arsenic, which also can have adverse health effects. DOHMH distributed information about the medications to health-care providers, product manufacturers, and government agencies in the United States and abroad, via postal and electronic mail. DOHMH also ordered a local business selling contaminated products to cease sales.
Health-care providers should ask patients, especially foreign-born or pregnant patients, about any use of foreign health products, supplements, and remedies such as Ayurvedic medications. Public health professionals should consider these types of products when investigating heavy metal exposures and raise awareness among health-care providers and the public regarding the health risks posed by such products.
CDC also recommends routine testing of pregnant women from at-risk populations - recent immigrants and women who use traditional remedies. Identification and removal of the lead source is the main priority. Women in the second half of pregnancy with BLLs 45–69 µg/dL are considered for chelation therapy. Pregnant women with BLLs ≥70 µg/dL are considered for chelation regardless of trimester. Pregnant women with lead encephalopathy should receive chelation regardless of trimester.
During 2004–2012, through case investigations and agency sweeps of local stores triggered by investigations or published reports, DOHMH identified 22 oral medications, supplements, or remedies containing high levels of heavy metals. Twenty of the 22 products were brought into the United States while one product lacked country of origin information. DOHMH identified 10 of these 22 products during investigations of the six pregnant women with lead poisoning described in this report.
Foreign-born pregnant women might be at increased risk for lead poisoning due to use of certain foreign products and increased bone stores of lead from past exposures. In 2011, of the 205 New York City women reported to DOHMH with BLLs ≥10 µg/dL, 118 (58%) were pregnant, and 98 (83%) of the pregnant women were foreign-born (New York City Department of Health and Mental Hygiene, unpublished data, 2011). More than 70% of pregnant women with elevated BLLs interviewed by DOHMH in 2011 reported using foreign traditional or familiar products from their ancestral countries, such as cosmetics, medications, remedies, food, and pottery, suggesting that health-care providers should question pregnant women about their use of such products.
Pregnant women present a unique concern, because lead exposure can adversely affect the health of both mother and child. Fetal lead exposure increases the risks for low birth weight, developmental delay, reduced intelligence, and behavioral problems. Pregnant women exposed to lead might be at increased risk for gestational hypertension and spontaneous abortion . Exposure to other heavy metals, such as arsenic and mercury, also can have adverse health effects. Two of the six patients miscarried before 20 weeks' gestation. Both patients were taking Ayurvedic medications to promote fertility, and it is unknown whether underlying reproductive problems or heavy metal exposures contributed to the miscarriages.
Reference: Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta, GA: US Department of Health and Human Services, CDC; 2010.
Source: CDC alert