Lead Exposure among Adult Temporary Residents in Eastern
Europe: Should Blood Lead Levels Be Monitored?
Thomas R. Eng, Thomas Matte, Charles Dodson, and Dan Paschal
Background:The risk of lead exposure among temporary residents i n Eastern Europe is unknown. We monitored blood
lead levels (BLLs) of Peace Corps Volunteers serving in Albania, Bulgaria, the Czech Republic, Hungary, Poland, Romania,
and Slovakia from June 1991 through June 1994.
Methods: BLLs were analyzed before the Volunteers left the United States (Sample I), at mid-service (median of 15 months
in-country, Sample 2). and at end-of-service (median of 22 months in-country, Sample 3).
Results: Among 425 study participants who provided at least one follow-up blood sample, BLLs were significantly higher
at Samples 2 and 3 compared to the U S . baseline (paired t-test, p<.OOOI); however, the mean increase i n BLL was only
1.0 ug/dL (range = -9.6 to 10.7). Overall, 74% of Volunteers experienced an increase in BLLs, 24% a decrease i n BLLs, and
2% no change in BLLs at Sample 3 compared t o their U.S. baseline. The highest increases in BLLs were among Volunteers
i n Albania, Bulgaria, and Romania (analysis of variance, pe.0001). In addition, men had higher mean increases i n BLLs
at Samples 2 and 3 compared t o women (t-test, p=.017 and ,029).
Conc1usions:The risk of significant lead exposure among our study population was low, and monitoring of BLLs among
adult short-term residents i n Eastern Europe does not seem t o be indicated.
Hazardous exposure to lead is a common environmental problem in both developed and developing countries.’ Among adults, the health effects of excess lead
exposure include damage to the hematologic, neurologic,
reproductive, and gastrointestinal systems.’ Studies suggest that women who are exposed to lead during pregnancy are at increased risk for spontaneous abortion, their
offspring are at risk for minor congenital malformations, and that young children are at risk of mental
impairment.*
After the fall of their socialist governments, health
officials and scientists in Eastern Europe reported substantial and widespread environmental contamination
from both industrial and nonindustrial sources of pollution.”’ However, there is currently limited information
avdable on environmental health risks to travelers to Eastern Europe,’ and no data regarding the risk of lead
exposure among temporary residents in that area. It is
unclear whether temporary residents living in areas
where leaded gasoline is widely used or where industrial
sources of lead are common, such as in Eastern Europe,
should be monitored for lead exposure during their stay.
The Peace Corps is a U.S. government-funded
international development agency that sponsors more than
6000Volunteers who serve approximately 2 years in one
of more than 90 developing countries. From 1990
through 1992, Peace Corps initiated programs in Albania, Bulgaria, the Czech Republic, Hungary, Poland,
Romania, and Slovakia. Peace CorpsVolunteers live and
work at a level comparable to their native counterparts,
and share sirmlar sources of food, water, and housing. Interviews with country health officials revealed that lead exposure from industrial and motor vehicle emissions was a
major health concern in these countries.To examine the
risk of lead exposure among temporary residents in Eastern Europe and Albania, we monitored blood lead levels (BLLs) ofvolunteers serving in the region from June
1991 through June 1994.
Thomas R. Eng, VMD, MPH: Office of Medical Services,
Peace Corps, Washington D.C., and International Health
Program Office, Centers for Disease Control and Prevention,
Atlanta, Georgia, USA; Thomas Matte, MD, MPH, Charles
Dodson, MS and Dan Paschal, PhD: Division of
Environmental Hazards and Health Effects, Centers for
Disease Control and Prevention, Atlanta, Georgia, USA.
Allvolunteers who were serving in Eastern Europe
and Albania between June 1991 through June 1994 were
informed of potential exposure to lead and other environmental hazards in their new country before leaving
the United States.The objectives of the lead nionitoring program were explained and study participants gave
informed consent.At the time that the program was initiated, three groups of Volunteers were already serving
in Poland and HungaqcTheseVolunteers were enrolled
in the program by Peace Corps medical staff overseas.
Preliminary data from this study were presented at the
Fourth International Conference on Travel Medicine,
Acapulco, Mexico, April 23-27, 1995.
Reprint requests: Dr. Thomas R. Eng, Social & Health
Services, Ltd., 11426 Rockville Pike, Suite 100, Rockville, MD
20852.
J Travel Med 1997:4:132-135.
132
E n g et a l . , L e a d L e v e l s a m o n g T e m p o r a r y R e s i d e n t s
133
A 3-mL whole blood sample was collected &om each
study participant during three time periods.The first sample was collected 1 to 2 days before the participant left
the United States and was considered the baseline (Sample 1).The second sample (Sample 2) was collected during the participant's mid-service medical examination
which occurs approximately 15 months in-country. The
third sample (Sample 3) was collected during theVolunteer's end-of-service medical examination, which
occurs approximately 27 months in-country. In cases
where thevolunteers did not complete their term of service, we attempted to obtain a blood sample before they
left their Peace Corps country. Volunteers who were
already in-country when the study was started did not
have a US. baseline sample drawn. Their BLLs were
used only in calculation of geometric group means.
All lots of blood tubes and venipuncture equipment used were pretested for lead contamination in the
United States and shipped overseas.Al1 samples collected
in Eastern Europe were shipped to the United States and
analyzed by the lead laboratory at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.All blood samples were analyzed using electrothermal
atomization atomic absorption spectrometry."
Group BLLs were natural log-transformed so that
these data approximated a normal distribution. Then
t-tests were used to compare group means. Changes in
BLLs over time were not log-transformed because examination of these data showed them to be normally distributed.
in BLLs, 24% a decrease in BLLs, and 2% no change in
BLLs at Sample 3 compared to Sample 1.BLLs were significantly higher at Samples 2 and 3 compared to Sample 1 (paired t-test, p<.OOOI); however, the mean change
in BLLs from Samples 1 to 3 was only 1.Oug/dL (range,
-9.6 to 10.7).Fifteen of 316 (4.7%) and nine of216 (4.2%)
persons at Sample 2 and 3, respectively,had BLL elevations greater than 5 ug/dL.
Men had higher mean changes in BLLs at Samples
2 and 3 compared to women (t-test, p=.017 and ,029)
(see Table 1).
BLLs among Volunteers in Albania, Bulgaria, and
Hungary increased significantly at Samples 2 and 3 compared to Sample 1 (paired t-tests, p<.OOI).Volunteers in
Romania had the greatest mean increase in BLL at Sample 2 with 3.88 ug/dL, but with only eight paired samples, this change was not statistically significant. Study
participants in the Czech Republic and Poland had significantly elevated BLLs at Samples 2 or 3, but not both.
Volunteers in Slovakia actually experienced a mean
decrease in BLLs.
There was no statisticallysignificant difference in the
length of stay among the countries studied.
There also were no significant differences in the
degree of BLL change by age, marital status, race, or j o b
category.
Results
Four hundred and twenty-fivevolunteers participated
in the study by providing at least one in-country blood
sample for analysis.An additional 368Volunteers provided
a baseline blood sample in the United States (Sample l),
but declined to provide any in-country samples (reasons
for not participating were not available); these persons
were excluded from further analyses.
The median age of study participants was 26.6 years
(range, 21-84), 255 (60.0%) were female, 371 (93.9%)
were white, and 369 (88.1%) were single. Most participants were classroom teachers (73.O%), 18.1% were small
business advisors, and 8.9% were involved in environmental-related jobs (mostly park development advisors).
More than 95% of participants had a college or higher
degree.The median number of months spent in-country at the time of mid-service (Sample 2) and end-ofservice (Sample 3) collections were 15.0 (range, 10.0-17.6)
and 22.3 (range, 20.7-27.3) months, respectively.
Geometric mean BLLs for the three sample periods and change in BLLs between sample intervals are presented in Table 1. Overall, 74% experienced an increase
Discussion
Blood lead surveillance data showed that adult Peace
Corps Volunteers experienced a small increase (1.O
ug/dL) in BLLs during their stay in Eastern Europe.An
increase of this magnitude would have no meaningful
impact on the health of an adult.These data suggest that
large increases in BLLs occur too infrequently to justify
blood lead monitoring of allVolunteers.
It is unclear whyvolunteers in Albania,Bulgaria, and
Romania had the highest mean increases in BLLs.These
comparisons, however, should be viewed with caution
given the relatively small sample sizes. It is also unclear
why nien experienced a significantly higher increase in
BLLs compared to women.There was no evidence that
persons who did not provide in-country blood samples
for lead analysis were at greater or lower risk for lead exposure compared to those who did provide such samples.
During in-country training, Volunteers are given
general information about various preventive health
measures, including specific guidelines for minimizing
exposures to environmental hazards, such as washing
and peeling fresh fruits and vegetables before eating.
However, it is unknown how consistently or strictlyvolunteers follow these recommendations.
The sources of lead exposure for Volunteers are
unclear, but may include water, food, and air sources.
134
J o u r n a l o f T r a v e l M e d i c i n e , V o l u m e 4, N u m b e r 3
Table 1 Blood Lead Levels (BLLs) among Peace Corps Volunteers in Eastern Europe by Characteristics of Volunteer
Mean Change in B L L [95% conjdence intervals]
Ip value*)
Geometric Mean B L L (ug/dL)
Number in
Group
Sample 1
(U.S. baseline,
n = 342)
Sample 2
(Mid-sewice,
n = 399)
Sample 3
(End ofsewice,
n = 260)
248
60
32
24
44
2.03
2.58
3.12
3.68
4.09
2.99
3.68
3.68
4.18
4.19
Female
170
255
2.61
2.26
Race
White
Nonwhite
371
24
2.38
2.74
Characteristic
Age
20-29
30-39
40-49
50-59
> 60
Gender
Male
Country of Service
Albania
22
Bulgaria
32
Czech Republic 25
Hungary
95
Poland
148
Romania
8
Slovakia
Marital status
Single
Married
Job Sector
Education
Environment
Small Business
Development
Total
A f Sample 21
(n = 3 16 pairs)
At Sample 3 t
(n = 216pairs)
3.36
3.89
3.12
4.99
4.43
1.08 [.73, 1.431
1.12 [.52,1.72]
.78 1.23, 1.321
.36 [-1.14, 1.861
.55[-.49,1.60]
(p=.60)$
1.17 [.82, 1.531
1.08 [-. 12,2.28]
.47 [-.24, 1.181
1.06 [-.94,3.05]
.34 [-.99,1.67]
(p=.53)5
4.01
3.00
4.18
3.22
1.36 [.94, 1.781
.72 [.39,1.04]
(p=.017)
1.41 [.92,1.90]
.74 [.37,1.11]
(p=.029)
3.31
3.86
3.52
3.69
.92 [.64,1.20]
1.27 [.36,2.18]
(p=.55)
.93 [.61,1.25]
1.11 [.36,1.86]
2.80 [1.75,3.85]
2.42 [1.48,3.36]
.68 [.08, 1.271
1.12 [.72,1.52]
.26 [-.13, ,651
3.88 [2.02,5.73]
-.92 [-2.20, ,361
(p<,0001)s
3.78 [2.64,4.93]
3.45 [2.13,4.78]
.57 [-.05, 1.181
.86 [.46,1.25]
.64 [.21,1.07]
NA
-.25 [-2.22, 1.721
(p<.OOOl)S
1.03 [.74,1.32]
.61 [-.03, 1.241
(p= .29)
1.04 [.72,1.36]
.89 [-.03, 1.821
(p=.74)
5.29
5.99
2.72
3.86
3.29
12
2.10
2.23
2.32
2.49
2.46
1.25
3.43
4.84
4.97
2.93
3.74
2.77
5.07
2.86
3.47
369
50
2.38
2.45
3.33
3.38
3.54
3.81
303
37
75
2.27
2.55
2.83
3.10
3.57
4.44
3.48
3.89
4.04
425
2.40
3.35
3.59
NA
.87 [.56, 1.181
.83 [-.20, 1.861
1.65 [1.12,2.18]
(~~0.09)s
.97 [.71,1.23]
(p=.81)
1.08 [.74,1.41]
.70 [-.52,1.91]
1.03 [.27,1.79]
(p=0.75)§
1.01 [.71, 1.311
*&testunless otherwise indicated;tBLL at Samples 2 or 3, respectively, minus BLL at Sample 1;*Age at time of Sample 1;
$Analysisof variance.
During the study period, almost all Volunteers were
assigned to urban rather than rural areas. Exposure to lead
in drinking water is possible. During the study period,
approximately 25% of Volunteers in these countries
requested and were given water distillation units; however, only a small proportion of these units were actually used. Exposure to lead in food can occur when
food is grown in contaminated soils or is in prolonged
contact with lead-containing storage containers such as
ceramic ware.' However, the most likely primary sources
of lead exposure in urban areas in Eastern Europe are
emissions from motor vehicles and industrial sources.
Although unleaded gasoline is now commonly available
in Eastern European cities frequented by tourists, leaded
gasoline was the norm during the study period.Airborne
levels of lead are related to the density of motor vehicles and the lead content of gasoline.8Since medical care
is provided forVolunteers by Peace Corps' own medical
units, exposure to lead from dietary supplements, medications, and folk remedies are unlikely.
BecauseVolunteers live and work in situations that
are similar to those of native residents, they are probably
at greater risk of exposure to environmental contaminants
than are temporary residents who work for private companies and embassies. In particular,Volunteers are probably more dependent on local sources of food and water
Eng e t a l . , Lead Levels a m o n g Temporary R e s i d e n t s
than are other temporary residents. It is important to note,
however, that Peace CorpsVolunteers cannot be assumed
to be representative of the populations in their assigned
countries with respect to lead exposure. In addition,
because of the tendency for young children to ingest leadcontaminated soil and dust due to normal mouthing
behaviors: their risk for lead exposure cannot be inferred
from the experience of adults.
In a sense, our data reflect recent reductions in population lead exposures in the United States as much as
they suggest somewhat greater exposure potential in
Eastern Europe. The geometric mean baseline BLL
among Volunteers is slightly less than the geometric
mean of 3.0 ug/dL for US. adults estimated during the
National Health and Nutrition Examination Survey 111
(NHANES), phase 1 survey, from 1988 through 1991.’
In the late 1970s when leaded gasoline and lead-soldered
cans were still widely used in the United States, the
geometric mean BLL for adults was 13.1 ug/dL, substantially higher than the levels amongVolunteers at the
end of their stays in Eastern Europe.
Monitoring of BLLs does not seem to be indicated
for most adult short-term residents. Possible exceptions
may include temporary residents who are pregnant, who
live in close proximity to a point source of lead (e.g., a
lead smelter), or who are occupationally exposed to
lead. Lead monitoring should also be considered for
young children less than 6 years of age. Given the small
BLL increases among women (< 1 ug/dL) in this study,
monitoring of BLLs among women travelers of childbearing age does not seem to be indicated.
Based on our data, the risk of significant lead exposure to healthy adults temporarily residing in Eastern
Europe for a few years seems to be very low. However,
all travelers to countries where lead and other environmental contamination are common should be counseled regarding methods for minimizing exposures during
their residency overseas.
135
Acknowledgments
The authors thank the Peace Corps Medical Oficers in the countries participating in this study, especially
Gillian Weingartner, Chrissie Stacy, Karen Anderson,
Michelle Price, and Cirre Emblem, for assisting with data
collection and study management. In addition, we thank
Terence Lee of the Ofice of Medical Services, Peace
Corps, for assisting with data management.
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