Lead poisoning still occurs in the United States despite extensive prevention efforts and strict regulations. Exposure to lead can damage the brain, kidneys, and nervous and reproductive systems. Fetal exposure to lead can adversely affect neurodevelopment, decrease fetal growth, and increase the risk for premature birth and miscarriage.
In 2011 and 2012, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) investigated six cases of lead poisoning associated with the use of ten oral Ayurvedic medications made in India. All six were foreign-born pregnant women assessed to be at risk for lead exposure and tested by providers during routine prenatal visits per New York State law. Their blood lead levels (BLLs) ranged from 16 to 64 micro gram/deciliter. Lead concentrations of the products were as high as 2.4 percent. Several also contained mercury or arsenic. Heavy metal exposure can increase the risk of adverse health effects for both mother and child. All but two of the products were purchased in India.
Public health professionals and health care providers should consider imported medicines, supplements, and remedies such as Ayurvedic medications when investigating heavy metal exposures, especially among foreign-born or pregnant patients. The six patients in this report all were asymptomatic pregnant women whose health-care providers assessed them to be at risk for lead exposure. New York state law requires assessment of patients for risk of lead exposure during the first prenatal visit and testing of those determined to be at risk. The CDC also recommends routine testing of pregnant women from at-risk populations (e.g., recent immigrants and women who use traditional remedies). The New York State Department of Health forwards all blood lead test results from New York City residents to DOHMH, which conducts follow-up interviews and case investigations for adults identified with BLLs ≥10 µg/dL. 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 (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.
The cases of lead poisoning described in this report were associated with the use of Ayurvedic medications. 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 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, the 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 cases of lead poisoning among the six pregnant women underscore the importance of risk assessment for lead exposure and blood lead testing in at-risk populations. Health-care providers should 1) be aware that users might not readily disclose use of health products; 2) ask patients about their use of prescription and nonprescription medications and supplements, including Ayurvedic medications and other traditional remedies; 3) advise patients to stop using suspect products; and 4) consider testing patients for exposure to lead or other heavy metals if use is reported.
Public health workers and health-care providers should consider the use of foreign supplements, medications, traditional remedies, or other health products as potential risk factors when investigating lead and other heavy metal poisonings, especially in foreign-born populations, and particularly among pregnant women. Risk assessments and testing conducted during prenatal visits are critical to identifying and intervening in heavy metal poisoning cases. Public health measures, such as blood lead testing and surveillance in the United States and elsewhere, are necessary to assess the extent of lead exposure and develop appropriate interventions.
See the CDC Report