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US: Health alert about the risk of heavy metal poisoning from folk remedies

3 August, 2012
Folk remedy linked to baby’s high lead levels.US issues alert based on Boston case. By Kay Lazar. bostonglobe.com.  August 02, 2012. The specialists at Boston Children’s Hospital were stumped. Usually when they encounter children with high levels of lead in their blood, the problem is traced to chipped, lead-based paint in families’ homes or yards. But disease trackers found no problematic paint or other obvious source of lead at the home of the 6-month old.  Additional probing revealed that since the boy was 2 weeks old, his family had been applying a Nigerian eye cosmetic and folk remedy that is 83 percent lead to his eyelids. His family believed that the powder, Tiro, would make the boy more attractive and improve his vision.
US: Health alert about the risk of heavy metal poisoning from folk remedies
Now federal health officials are issuing an alert, prompted by the case, about the risk of heavy metal poisoning from folk remedies found in many immigrant cultures.

A report Thursday from the federal Centers for Disease Control and Prevention details the case and highlights the large number of cultures in Asia, ­Africa, and the Middle East that use similar eye cosmetics that may contain lead. The products include kohl from Arab countries and surma or kajal from India and Pakistan.
In the case of the Nigerian eye powder, also known as tozali or kwalli, the CDC said it has been used in that country to “ward off the evil eye”; to ­relieve eye strain, pain, or soreness; and to prevent infection in infants after the umbilical cord is severed.
CDC officials advised obstetricians, pediatricians, midwives, and other health care professionals to discuss potential health risks with patients during prenatal and early childhood medical visits.
Lead can harm the brain, kidneys, and nervous system, and children are particularly sensitive. Even low levels of lead can make it hard for them to learn, pay attention, and ­behave, health officials said.
Dr. Alan Woolf, a coauthor of the report whose Children’s Hospital clinic treated the Nigerian child last year, said immigrant families who use these products typically get them from relatives who bring them from their native countries when they visit. He said some also buy them at ethnic specialty shops and on the Internet.
The baby boy was treated, and doctors said he suffered no apparent harm.
The state Department of Public Health is contracting with local agencies across ­Massachusetts that have staff of Nigerian, Asian, Indian, and other backgrounds who can ­explain the cosmetics’ health risks to immigrants in their own languages.
“People don’t want to believe that something that is so impor­tant for religious and cultural reasons would have a harmful effect on them,” said Suzanne Condon, director of the state Bureau of Environmental Health. “If we don’t send the message the right way, then there is the potential for the practice to go underground.”
The CDC recently halved the blood levels of lead considered safe for children, and state health officials have been sending letters alerting physicians to the changes and advising them that they may want to recheck children who tested at levels that were previously considered safe but are above the new threshold, Condon said.
A Massachusetts law ­requires all children to be screened for lead poisoning ­annually up to age 3, and it was through this routine test that the infant’s pediatrician detected the problem. The family was referred to Children’s Hospital.
“The parents said it is quite common in some parts of their section of Nigeria for some families to use this as a beauty aid,” said Woolf, a pediatrics professor at Harvard Medical School and director of the hospital’s Pediatric Environmental Health Specialty Unit. “They said darker eyes add to the infant’s appearance, but there is also a belief that this will improve their vision.”
Given the global crossroads that the Boston region has ­become, Woolf said his clinic is increasingly seeing families from cultures that routinely use folk remedies and herbs that are unfamiliar to physicians trained in Western medicine and that contain high levels of lead and other heavy metals, such as arsenic, that are harmful.
One case involved a child whose family was from Thailand and had been using a traditional Thai treatment on their infant son to remove white spots on his tongue sometimes caused by breastfeeding.
“Their belief . . . was that applying this powder to his tongue daily would enhance his health by drawing toxins out of the body,” Woolf said.
The 1-year-old’s lead levels were so high that he needed to be hospitalized to have the chemical leached from his body. Woolf said he did not appear to have developmental delays, but the family did not continue with treatment in his office, so he does not know whether the child developed problems later.
“We want to be sensitive to the idea that these families have strong beliefs and some of those beliefs may be grounded in good health practices,” Woolf said, “but there should be a special awareness by health care providers” of potential risks.
At Boston Medical Center, which cares for many immigrant patients, Dr. Rob Saper directs a program called Integrative Medicine and Health Care Disparities, which combines Western medicine with evidence-based alternative therapies.
“Eighty percent of the world’s population uses [alternative] medicine of some form,” said Saper, an associate professor of medicine at Boston University School of Medicine. “What we consider to be alternative in the United States is often mainstream in other cultures.”
Saper said he has encountered patients from India who use kohl, another eye cosmetic with high lead levels, for religious or ceremonial purposes on children and adults. He tells patients that some alter­native therapies, such as yoga for lower back pain, can be helpful, but that others can be harmful.
Kay Lazar can be reached at [email protected]

Read also: infant Lead Poisoning Associated with Use of Tiro, an Eye Cosmetic from Nigeria — Boston, Massachusetts, 2011WeeklyAugust 3, 2012
Lead is highly toxic and can damage the brain, kidneys, bone marrow, and other body systems; high levels can cause convulsions, coma, and death (1). Young children are especially susceptible to lead exposures because of their floor-hand-mouth activity, greater gut absorption, and developing central nervous systems. In June 2011, a male infant aged 6 months of Nigerian descent was referred to the Pediatric Environmental Health Specialty Unit (PEHSU) at Boston Children’s Hospital because of an elevated blood lead level (BLL). An investigation found no lead exposure except for "tiro," a Nigerian cosmetic that also is used as a folk remedy to promote visual development. The tiro applied to the infant’s eyelids contained 82.6% lead. Products similar to tiro, such as "surma" and "kajal" in Asia and kohl in the Middle East, also might contain lead. This case adds to the medical literature documenting nonpaint lead sources as causes of elevated BLLs in children (2,3) and highlights persons of certain immigrant populations as a risk group. Educational efforts are needed to inform immigrants from Africa, Asia, and the Middle East that tiro and similar products can cause lead poisoning in children. Health-care providers and public health workers should ask about eye cosmetics and folk remedies when seeking a source of exposure in children with elevated BLLs from certain immigrant populations.
In June 2011, during a well-child visit of a male infant aged 6 months born in the United States to Nigerian parents, the physician noted that an imported cosmetic had been applied to the child’s eyelids. Capillary blood testing performed by the physician indicated a BLL of 13 µg/dL, more than twice the CDC’s reference value of 5 µg/dL, based on the 97.5th percentile of the BLL distribution in U.S. children aged 1–5 years. The next day, a confirmatory venous BLL measured by graphite furnace atomic absorption spectroscopy was 12 µg/dL. Additional laboratory evaluation revealed a normal hemoglobin level and 2+ erythrocyte microcytosis on an automated blood smear. In accordance with CDC recommendations aimed to help reduce the absorption of lead and mitigate the severe adverse health effects of lead exposure,* the pediatrician prescribed supplemental iron, contacted the Massachusetts Department of Public Health, and referred the family to the regional PEHSU.
When the infant was brought to the PEHSU 1 week later, his venous BLL, as measured by the same laboratory, was 13 µg/dL. His whole blood zinc protoporphyrin (30 µg/dL whole blood [normal: 0–35 µg/dL]), hemoglobin (12.1 g/dL [normal: 10.4–12.5 g/dL]), erythrocyte mean cell volume (74.2 fL [normal: 68.0–83.1 fL]), plasma iron (81 µg/dL [normal: 40–100 µg/dL]), and ferritin (65.0 ng/mL [normal: 10.0–75.0 ng/mL]) were in the normal range for his age. A manual blood smear showed 2+ erythrocyte microcytosis. The parents reported no health concerns for the infant, and a detailed review of systems was normal. The infant had no relevant past medical history, was growing well, and had met all developmental milestones. No other children lived in the home. Both parents had sickle cell trait; the infant had a normal hemoglobin electrophoresis. No abnormalities were noted on the physical examination.
Since 2008, the family had lived in a townhouse originally built in 2004. PEHSU staff members inspected the residence and found it to be in excellent condition, without lead hazards. Other sources of lead exposure were ruled out, including take-home exposure from parental occupations, kitchenware, family hobbies, and diet. The infant was breastfed exclusively and did not consume any imported herbs, spices, or dietary supplements. Additional questioning revealed that since age 2 weeks, a Nigerian cosmetic and folk remedy had been applied to the infant’s eyelids three to four times weekly to improve attractiveness and promote visual development. A grandparent had purchased the powder, called tiro (Figure 1), from a street vendor in Ilorin, a city in Kwara State, Nigeria. The PEHSU recommended immediately discontinuing the use of tiro on the infant and continuing iron supplementation. The parents agreed to submit the suspected tiro powder for laboratory analysis.
Quantitative analysis by the PEHSU showed that the tiro consisted of 82.6% lead. A single application of 10 mg of tiro would deliver 8 mg of lead to the infant’s eyelids. The most likely routes of exposure were eyelid-hand-mouth and absorption from the conjunctival surfaces of the eyes or in ingested tears. Analysis of the tiro by the U.S. Geological Survey, using scanning electron microscopy (SEM), showed that the sample was dominated by lead sulfide, known as galena (Figure 2), which has relatively low bioavailability (1). No other minerals were observed by SEM, although small amounts of other minerals commonly found as microscopic inclusions in lead sulfide might have escaped detection.
Three months after the family stopped applying tiro to the infant’s eyelids, his venous BLL had fallen from 13 µg/dL to 8 µg/dL.
Reported byAbdulsalami Nasidi, MD, Nigeria Centre for Disease Control. Mateusz Karwowski, MD, Alan Woolf, MD, Pediatric Environmental Health Specialty Unit; Mark Kellogg, PhD, Terence Law, Dept of Laboratory Medicine, Boston Children’s Hospital, Boston, Massachusetts. Marissa Scalia Sucosky, MPH, Rose M. Glass-Pue, MA, Mary Jean Brown, ScD, Div of Emergency and Environmental Health Svcs, National Center for Environmental Health; Behrooz Behbod, MBChB, EIS Officer, CDC. Corresponding contributor: Behrooz Behbod, [email protected], 770-488-0788.
Editorial NoteAlthough the primary source of lead exposure in the United States is lead-based paint, nonpaint sources of lead increasingly are being identified in lead poisoning cases (2,3). These nonpaint exposures include recent travel to a foreign country, take-home exposure when persons exposed to lead at their workplace contaminate their homes or vehicles, and use of imported products such as spices, food, candy, cosmetics, health remedies, ceramics or pottery, and jewelry.
This report describes an eye cosmetic and folk remedy as the source of lead poisoning in a child of Nigerian descent; a similar case has been reported in the United Kingdom (4,5). Although Nigeria switched to unleaded gasoline by the end of 2003, Nigerian children might also be exposed to the lead that remains in the soil from years of use of leaded gasoline. In addition, lead contamination resulting from gold mining has caused many child deaths in Nigerian villages where artisanal gold ore processing takes place (6,7).
Tiro is the Yoruba name for this eye cosmetic implicated in the case described in this report. In another Nigerian language, Hausa, it is called "tozali" or "kwalli." Similar products intended to darken the eyes are known as kohl in English and Arabic and as "surma" or "kajal" in languages spoken in India and Pakistan. These preparations are not standardized, and not all contain lead. One alternative to lead sulfide is another toxic compound, antimony sulfide. Imported cosmetics are one of the relatively few sources of significant lead exposure for infants too young to crawl or walk; however, exposure to lead in tiro represents an additional burden to groups who might be exposed to other sources of lead. The contribution that tiro might make to the cumulative burden of lead poisoning should not be overlooked.
This fine powder is applied to the dermal surfaces of the eyelid. In addition to its use by the patient’s family for improving attractiveness and promoting visual development, tiro has been used to ward off "the evil eye"; to relieve eyestrain, pain, or soreness; to prevent infection of the umbilical stump or a circumcision wound by local application; and to prevent sun glare (8,9).
This case identifies tiro as a potential lead exposure among not only Nigerians living in the United States, but also among African, Asian, and Middle Eastern populations who use similar products. Public health educational campaigns can help identify and prevent further cases (10).† Obstetricians, pediatricians, midwives, and allied health-care professionals should discuss this potential risk factor during prenatal and early childhood medical visits by families for whom these cultural practices might apply. Although CDC recommends blood lead testing for internationally adopted and refugee children,§ blood lead testing in children of certain immigrant populations also might be important because of the increased risk for exposure to lead-containing foreign products.
The Nigeria Centre for Disease Control is working with the vendors of products such as tiro to find possible safer alternatives. Discussions involve the perceived benefit of tiro, and evidently, strong beliefs are attached to its use. The Nigeria Centre for Disease Control plans to launch a national public health awareness campaign.
AcknowledgmentGeoffrey S. Plumlee, PhD, US Geological Survey, Crustal Geophysics and Geochemistry Science Center, Denver, Colorado.
ReferencesAgency for Toxic Substances and Disease Registry. Toxicological profile for lead. Atlanta, GA: US Department of Health and Human Services, CDC, Agency for Toxic Substances and Disease Registry; 2007. Available at http://www.atsdr.cdc.gov/toxprofiles/tp13.pdf . Accessed July 26, 2012.Gorospe EC, Gerstenberger SL. Atypical sources of childhood lead poisoning in the United States: a systematic review from 1966–2006. Clin Toxicol (Phila) 2008;46:728–3.CDC. Childhood lead poisoning associated with tamarind candy and folk remedies—California, 1999–2000. MMWR 2002;51:684–6.Warley MA, Blackledge P, O’Gorman P. Lead poisoning from eye cosmetic. Brit Med J 1968;1:117.Healy MA, Aslam M, Bamgboye OA. Traditional medicine and lead-containing preparations in Nigeria. Public Health 1984;98:26–32.CDC. Notes from the field: Outbreak of acute lead poisoning among children aged <5 years—Zamfara, Nigeria, 2010. MMWR 2010;59:846.Dooyema CA, Neri A, Lo YC, et al. Outbreak of fatal childhood lead poisoning related to artisanal gold mining in northwestern Nigeria, 2010. Environ Health Perspect 2012;120:601–7.Al-Hawi SA, Wafai MZ, Kalaagi MR, Al-Ugum WA. Light of the eyes and the collector of arts, vol. 1286. Riyadh, Saudi Arabia: King Faisal Center for Research and Islamic Studies; 1980:142.Hardy AD, Vaishnav R, Al-Kharusi SSZ, Sutherland HH, Worthing MA. Composition of eye cosmetics (kohls) used in Oman. J Ethnopharmacol 1998;60:223–34.Woolf AD, Hussain J, McCullough L, Petranovic M, Chomchai C. Infantile lead poisoning from an Asian tongue powder: a case report & subsequent public health inquiry. Clin Toxicol (Phila) 2008;46:841–4.

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