This protocol applies to all cases in NSW, but excludes children aged less than 5 years who are tested in Broken Hill, as there are locally developed clinical guidelines and response protocols in place for those children.
Where initial case investigation identifies occupational exposure and wider clusters within workplaces or non-compliance with the work health and safety regulation, Public Health Units (PHUs) should provide case details to SafeWork NSW and/or the Resources Regulator (Section 10).
The treating doctor is responsible for managing patients with elevated blood lead levels.
Identify lead sources of confirmed cases, through home assessment or environmental investigation, and recommend interventions to address or minimise exposures.
A capillary blood lead level of ≥5 µg/dL in the absence of a confirmatory venous blood test.
A venous blood lead level of ≥5 µg/dL.
Individuals can absorb lead by breathing air that contains very fine particles of lead or by swallowing contaminated dust, soil, water or food. Young children, especially under 2 years of age, may be exposed to lead from contaminated soil, paint and dust through crawling, hand-to-mouth behaviours and mouthing objects such as toys that are contaminated with lead. Individuals with pica, an eating disorder where people eat things that are not food such as soil and flaking paint may also have increased risk of ingestion of lead. While skin contact with lead can lead to some absorption, it is not the primary pathway of exposure for the general population. Dermal exposure is most likely for people who work with lead or materials containing lead.
Trace amounts of lead can be found across a range of natural sources so most Australians will have 'background' level of blood lead of less than 5 micrograms per decilitre (µg/dL). It is uncommon for someone to have a blood lead level greater than 10 µg/dL. More information on sources of lead is available in the NHMRC 2016 guidelines Managing Individual Exposure to Lead in Australia.
Most people in Australia live in places where there are very small amounts of lead in food, air and soil. There are some towns in Australia, such as Broken Hill, Port Pirie and Mount Isa where there are active lead mines or smelters close to residential and commercial areas. In Broken Hill, there are specific programs in place to screen children for blood lead, educate children and families about lead risks, remediate public lands and reduce emissions.
Environmental lead may be present due to existing or legacy contamination from industry. In some communities, soil may still contain lead deposited from traffic fumes prior to the removal of lead from petrol. Lead based paint used in houses or buildings built before the 1970s is also a source of environmental lead. Peeling paint may be ingested by children, and lead may be inhaled during renovations if fine particles are produced through paint stripping or sanding.
Exposure to lead has substantially reduced in recent decades due to national initiatives which have restricted the addition of lead to paint and petrol, and the reduction of use of lead in consumer goods (e.g., toys, cosmetics and cans). Although the use of lead in petrol and paints in Australia has been restricted, it may still be found in some fuels (aviation gasoline for piston engines and some racing fuels) and paints and finishes on some products (e.g., cars and boats). Lead is still used in lead-acid batteries and some ceramic glazes.
Certain occupations present a risk of lead exposure. Working in mining, smelting, recycled metals, construction and soldering can cause elevated blood levels. If a worker's blood lead level exceeds thresholds defined in NSW Work Health and Safety Regulation 2025, they must be removed from lead-risk work.
In Australia, regulated public drinking water supplies are monitored and may be treated to remove lead to comply with the Australian Drinking Water Guidelines. Some sources of drinking water such as rainwater tanks and groundwater can become contaminated from the leaching of lead from roofs and pipes or from anthropogenic sources.
In recent years, there have been elevated blood lead level cases in members of some communities related to imported Ayurvedic or other traditional remedies, imported cosmetics, spices and food products. While these emerging sources of exposure make up a minority of cases, it is important that they are considered during case investigation. Other sources of lead include hobbies involving recreational shooting (exposure to lead in ammunition), making leaded lights or leaded windows (lead lighting) and making lead sinkers. Cases of severe lead poisoning associated contaminated illicit opium products were also reported in NSW and Victoria in 2018.
Public health efforts aim to minimise people's exposure and blood levels as much as possible. The health effects of lead can differ between individuals based on their blood lead level, age, duration of exposure (over the short term or a longer period), and the presence of other health conditions. Lead can be harmful to people of all ages, but the risk of health effects is highest for unborn babies, infants and children under the age of 5 years. Children are born with essentially the same blood lead level as their mother. In a lead contaminated environment, their blood lead level can increase as they begin crawling on floors and when hand to mouth behaviour and mouthing of objects begin. Hand to mouth and mouthing behaviours typically increase between 6 to 9 months and peak at around 2 years of age. In a child with normal development and in a static environment, their blood lead is unlikely to rise after 2 years of age.
Blood lead levels greater than or equal to 10 µg/dL may have harmful effects on many organs and bodily functions. Effects such as increased blood pressure, abnormally low haemoglobin, abnormal kidney function, long-term kidney damage, behavioural problems, cognitive impairment and abnormal brain function have been observed at blood lead levels between 10 µg/dL and 60 µg/dL in adults and children. Encephalopathy generally occurs at blood lead levels of 100-120 µg/dL in adults and at 70-100 µg/dL in children. This condition is characterised by irritability, agitation, poor attention span, headache, confusion, uncoordinated walking or movement, drowsiness, convulsions, seizures or coma. In extreme situations, irreversible brain damage or even death can occur at these elevated blood lead levels.
In 2015, the NHMRC's review of the health effects of lead found an association between reductions in intelligence quotient (IQ) and academic achievement in children at blood lead levels less than 10 µg/dL. There is weaker evidence that blood lead levels less than 5 µg/dL are associated with reductions in IQ or academic achievement. However, the NHMRC review notes that the relative contribution of lead to the above health effects is difficult to determine. The effects of blood lead level less than 10 µg/dL on IQ, academic achievement and behavioural problems are likely to be small, with stronger influences being exerted by other factors such as socioeconomic status, education, parenting style, diet or exposure to other substances.
Primary prevention involves the removal of source lead or remediation if the source can be identified. It includes activities such as ensuring old lead paint that is damaged, disturbed, flaking or deteriorating is safely removed.
Long term primary prevention strategies often require a cross-agency approach, including identifying and sealing off contaminated land and sites, and banning products containing lead. Educating the public on how to minimise contact with lead, such as by providing information on the risks of using products containing lead such as lead flashings used in roofing and alternatives to these products as well as safe practices for hobbies involving lead use (e.g. recreational shooting, fishing, lead lighting and antique restoration) is important.
NSW Health works with communities, other Government agencies and industry on strategies to prevent and manage lead and communicates risk minimisation information to the public.
Secondary prevention involves population-based health screening to identify those with elevated blood lead levels so that interventions can be undertaken to reduce further exposure and blood lead levels.
Once blood lead levels have been detected, secondary prevention includes personal strategies to reduce exposure, repeat testing and follow up of cases.
Tertiary prevention is achieved through treatment of high blood lead levels (greater than or equal to 45 µg/dL in children under 18 and in pregnant women, and greater than or equal to 70 µg/dL in adults) using chelation therapy if clinically indicated. It also includes repeat testing and follow up of cases.
Within 5 working days following notification, enter probable and confirmed cases into the NSW Notifiable Conditions Information Management System (NCIMS).
Creation of an exposure event in NCIMS and linking of cases with same exposure source should be done within 10 working days following notification, noting there may be circumstances where it may take longer to ascertain if an exposure is occupational or not. Information about whether the case has occupational exposures may be ascertained through the laboratory notification sent into NCIMS (e.g., if the ordering doctor is an occupational physician, if the blood test has been conducted in an occupational setting or if there are contact details on the form such as a phone number and/or address associated with a workplace) or through the case interview. PHUs should refer occupationally acquired cases to SafeWork NSW and/or the Resources Regulator for intervention where there are concerns about workplace clusters or non-compliance with work health and safety legislation (Section 10).
Venous blood lead testing is the standard, accepted and most accurate method for testing individuals and communities for recent exposure to lead. Venous blood is preferred because it is less prone to contamination from lead on the skin.
Point of care testing of capillary blood via finger prick can be used for screening purposes. This is the method generally used as part of the Broken Hill childhood blood lead screening program because it is considered less invasive for children, quicker and more convenient, promoting increased participation rates.
Cases who have a positive capillary blood test result should be considered a probable case and should be confirmed using venous blood testing.
Table 1 provides a risk assessment matrix based on blood lead level and age/gender of the case to determine the level of risk and guide the PHU response (outlined in Table 2) to elevated blood lead levels in non-occupational settings.
This outlines the PHU response to elevated blood lead in cases with non-occupational exposures.
Section 10 outlines the approach and referral pathways for managing occupational exposures where PHUs identify workplace clusters or non-compliance with work health and safety legislation.
Response
Timeframe
Public health units should contact the cases resulting from occupational exposures and provide them with their test results and NSW Health factsheet on lead to raise awareness of lead poisoning and how to reduce their exposure to lead.
The managing doctor is responsible for the clinical management or referrals of patients.
PHUs should provide advice to the managing doctor by letter (see Appendices 3 and 4) and or by phone as per above.
Identifying and removing or avoiding the source of lead exposure is crucial in all cases.
The following resources are available to support people who are considering pregnancy or are pregnant:
The purpose of an environmental investigation is to identify exposure sources of lead, identify persons exposed to those sources and guide specific interventions.
Environmental investigations are particularly important in settings where vulnerable people may be exposed, for example childcare facilities and social housing. Targeted environmental sampling is more efficient than scattered approaches. However, environmental sampling is expensive and may be misleading. Therefore, identifying and characterising those potential sources that can be ruled out should be the first step.
For all high or extreme risk cases where sources of environmental exposure or risk factors cannot be determined through a case interview (Appendix 1), the PHU should undertake an initial site environmental investigation to identify lead source(s), with lead sampling conducted where appropriate (Appendix 2).
Further sampling and testing of potential lead sources are then the responsibility of the owner or occupier of the premises or property. The owner or the occupier may be advised to engage a qualified independent assessor or an occupational hygienist to identify or confirm the source. Tenants should be encouraged to report any potential lead hazards to landlords. The PHU may advocate with premises or property owner/s for lead hazards to be assessed and/or addressed.
Where imported cosmetics, remedies, spices, or other products are found to be sources of lead, the PHU should work with Health Protection NSW to engage with the relevant agencies (e.g., NSW Food Authority, Department of Customer Service, Therapeutic Goods Administration, Australian Competition and Consumer Commission) to take appropriate regulatory action to ensure unsafe imported products are not available for sale in Australia. Risks with these products may need to be communicated to affected communities and health professionals working with these communities.
Steps in an environmental investigation include:
Note: The PHU should advise the case that the information provided does not replace specialised professional expert investigation or advice by an occupational hygienist and it is the responsibility of the owner to undertake their own investigations.
The following links from the US Department of Housing and Urban Development provide some guidance for onsite investigations:
Elevated blood lead levels in adults may be sentinel events that indicate potential exposure for children in the household of the affected adult. This may be due to a hobby the adult is engaged in or through bringing lead contaminated work clothes into the home environment.
Secondary exposure to a lead source can occur if a case wears or brings occupational attire contaminated with lead into the home environment. Therefore, people who live in the same household as the case are considered at risk.
Blood lead testing of family or household members should be recommended by the PHU to the treating practitioner if any of the following risk factors are noted:
According to the NSW Work Health and Safety Regulation 2025, workplaces are required to notify occupational exposures resulting in high blood lead levels directly to Work Health and Safety regulators, and these notifications are to be managed by workplaces. Clause 407 of the NSW Work Health and Safety Regulation 2025 also specifies the recommended intervals at which workers who carry out lead risk work should be re-tested based on previous lead test results, gender and reproductive age.
Since 1 July 2021, this legislation has required businesses that conduct 'lead risk work' to remove workers from 'lead risk work' and notify the regulators if:
The worker can return to 'lead risk work' when they have had follow up health monitoring and their blood lead levels drop below:
Under the NSW Work Health and Safety Regulation 2025 all employers are required to notify SafeWork NSW when it has been determined that work at a site is lead risk work, or when the information provided in a lead risk work notification change. Mine operators also must notify the Resources Regulator when a worker is removed from lead risk work.
If the PHU identifies a cluster of cases with occupational exposures through the NCIMS laboratory notification (e.g., if the test has been ordered by an occupational physician, if the blood test has been conducted in an occupational setting or if there are contact details on the form linked to a workplace) or through case interviews, the PHU may contact SafeWork NSW (and the Resources Regulator for lead risk work related to mines) to ensure that the risk is managed and the workers receive clinical management. Another instance where PHUs may contact the regulators includes when PHUs identify workplace non-compliance with the Work Health and Safety legislation.
Under the Public Health Act 2010 and Health Records and Information Privacy Act 2002, notifiable conditions data can only be shared for public health purposes and for purposes directly related to the reason the information was collected. In most circumstances it should not be necessary to share individuals' data with regulators, and if requested by the regulator, individual data should only be shared with the permission of the individual. PHUs must ensure that secure file transfer is used for referrals to regulators when sharing identifying information about individuals with regulators.
PHUs should contact Environmental Health Branch at hssg-ehbsurveillance@health.nsw.gov.au for contact details at SafeWork NSW and the Resources Regulator.
1. Angelon-Gaetz, K.A.; Klaus, Christen; Chaudhry, Ezan A; Bean, Deidre K. Lead in Spices, Herbal Remedies, and Ceremonial Powders Sampled from Home Investigations for Children with Elevated Blood Lead Levels — North Carolina, 2011–2018. MMWR, 2018. 67(46): p. 1290–1294.
2. Hore, Paromita; Alex-Oni, Kolapo; Sedlar, Slavenka; Nagin, Deborah. A spoonful of Lead a 10 year look at spices. Journal of Public Health Management and Practice. January/February 2019. 25 Suppl 1. p S63-S70.
3. Managing Individual Exposure to Lead in Australia - A Guide for Health Practitioners. National Health and Medical Research Council. April 2016. https://www.nhmrc.gov.au/about-us/publications/managing-individual-exposure-lead-australia.
4. Recommended Actions Based on Blood Lead Level. Centers for Disease Control and Prevention. Recommended Actions Based on Blood Lead Level | Childhood Lead Poisoning Prevention | CDC.
5. Schwarcz, Leilani; Crystal, L Begay; Chilton, Lance A; Shirley, J Brian; Seifert, Steven. Childhood Lead Exposure Associated with the Use of Kajal, an Eye Cosmetic from Afghanistan — Albuquerque, New Mexico, 2013. CDC Morbidity and Mortality Weekly Report, 2013. 62(46): p. 917-919.
6. The Environmental Case Management of Lead-exposed Persons: Guidelines for Public Health Units. New Zealand Ministry of Health. March 2021.