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Document Number: 

46)11-1-168 

Docket Number: 

A-83-22 

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EPA AIR DOCKET 

Draft of manuscript to" be presented 

Conference of Prospective Studies 

September 6-12, 1986. 

%o<x>> 

at the Third International 

of Lead, Edinburgh, Scotland, 

Environmental Lead, Reproduction and Infant Development 

J. Grassiano*, D. Popovac", M. Murphy*, A. Mehmeti'v, J. Kline**, 

C. Ahmcsdi^, P. Shrout**, Z. Zvicer", G. Wasserman**, E. Gashi", 

Z. Stein**, B. Rajovic^, L. Belmont**, B. Colakovic", R. Bozovic", R. Haxhiu", L. Radovic~, R. Vlaskovic^, D. NenezicA, and 

N. Lolacono* 

•Columbia University, College of Physicians & Surgeons, NY, NY 

"Mediciniski Facultet, University of Kosovo, Pristina, Yugoslavia 

^Mediciniski Centar, Titova Mitrovica, Yugoslavia 

**New York State Psychiatric Institute, NY, NY 
til 

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I 

ABSTRACT: 

We are studying the relation of chronic lead <Pb) exposure to 

adverse pregnancy outcome and infant development. This study 

draws upon a unique community surrounding a Pb smelter, refinery 

and battery plant in Titova Mitrovica, Yugoslavia. Control 

subjects are being studied in Pristina, a non-Pb-exposed town 40 

km to the south. 

Recruitment of women at 12-20 weeks gestation will terminate in 

January, 1987, at which time we will have entered approximately 1000 women from each town into the study. Preliminary 

data from 456 women in Mitrovica and 650 women in Pristina 

indicate that, at mid-pregnancy, the blood Pb concentrations 

(BPb's) in Mitrovica range from 2-47 ug/dl, with a mean of 17.4 

ug/dl. The major determinant of elevated BPb is geographic 

proximity to the Pb industry. In Pristina, mid-pregnancy BPb's 

range, from 1-23 ug/dl, with a mean of 5.4 ug/dl. Thus far, 207 

pregnancies have come to term in Mitrovica, and 268 in Pristina. 

There is a strong association between maternal BPb at delivery 

and cord BPb's over a wide range of BPb's. In Mitrovica, the 

mean cord BPb is 19.0 ug/dl, while in Pristina it is 5.4 ug/dl. 

The socioeconomic, ethnic and maternal physical characteristics 

are quite comparable between the two towns, an important asset in 

a study of this type. 

A study of infant development has been initiated in subsets of 

infants born to women in the pregnancy outcome study. In 

Mitrovica, infants with high, mid-range, and low cord BPb's 

are being selected for follow-up; thus far, the mean cord BPb's 

of these groups are 25.2, 17.3, and 11.2 ug/dl, respectively. In 

Pristina, a control group of infants matched to the Mitrovica 

high BPb group on SES has a mean cord BPb of 3.9 ug/dl. Another 

control group in Pristina, matched to the Mitrovica low BPb group 

on SES and cord BPb, has a mean cord BPb of 8.2 ug/dl. 
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IHTR0DUCTX0E3S 

The autonomous province of Kosovo, Yugoslavia, is a mountainous 

farm region in th® process of industrialization because of its 

rich mineral resources. Th® city of Titova Mitrovica9 approximately 40 km north of Pristina, th® capitol of th® province, is 

th® sit® of on® of th® largest lead ( Pb) smeltoro An Europe. 

Approximately 100? 000 people ar® exposed to Pb (amissions from the 

Pb ©melter, of whom 60?000 live in th© highly exposed city area 

which lie© in a valley at the convergence of th© Xbar and Sitnica 

rivers. In 19829 KI® reported an alarming prevalence of elevated 

blood Pb concentrations (BPb's) among children and adults in 

Mitrovica (1). At that tim®, th© mean air Pb concentration, 

measured monthly at fiv© locations in th© town, ranged from 21.3 

to 29„2 u/m3° In 19839 prior to the initiation of this study, a 

new filtration system went on line at th© smelter? since that 

time, the mean air Pb concentration has been reduced to 7.0 

ug/m3, still 10 times th© allowable limit of 0.7 ug/m3 in 

Yugoslavia. Thus, ©levated BPb remains a problem in Mitrovica. 

After reviewing the literature concerning possible effects of Pb 

on human pregnancy outcome (2), we became convinced of th© need 

for specific effects to be explored in relation to precise 

measures of BPb during pregnancy. In particular, previous 

studies had generally failed to adequately control for known risk 

factors such as maternal weight, height9 parity9 previous 

reproductive history9 smoking and social class. The populations 

of Mitrovica and Pristina, with their comparable social structures but wid©ly divergent ranges of BPb°©9 provide an opportunity for such a study. For similar reasons, they also provid® a 

unique opportunity for a prospective study regarding the influence of prenatal and post-natal Pb exposure on infant development. 

Yh<s Pir©giraairacy Quatcoja© Steadies Recruitment of approximately 1000 

pregnant women (12=20 weeks gestation) in each town began in May9 

1985 and will terminate in January9 1987. Since the study is 

ongoing, we provid© in this report only descriptiv® data about 

those cases recruited and analyzed to date9 i.®.9 456 women in 

Mitrovica and 650 women in Pristina. We will ultimately examine 

whether exposure to Pb, assessed by SPb and erythrocyte protoporphyrin (EP) at mid-pregnancy and at term, is associated 

with an increased risk of selected adverse pregnancy outcomes? 

late spontaneous abortion and stillbirth, premature delivery, 

intrauterine growth retardation, and congenital malformations. 

The possible interaction between iron deficiency and Pb toxicity 

will be examined utilizing concurrent measurements of serum 

ferritin and hemoglobin concentrations. Factors known to 

influence reproductive outcome, such as social class9 past 

reproductive history and general health status are being assessed 

through questionnaires. Fetal Pb exposure will be determined by 

measurements of BPb and EP in umbilical cord blood, serum 

ferritin and hemoglobin concentrations are also being measured. 

The possible influence of exposure to other heavy metals will be 

i**.*.. u *. *.L,lL.ih^ 
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examined by analysis of various elements in placental tissue 

obtained at delivery. Evaluation of the newborn includes 

gestational age assessment (3) and a carefully structured 

physical examination for congenital malformations. Multivariate 

analyses of this data set should ultimately reveal important 

information concerning the dose-response relationships between Pb 

exposure and pregnancy outcomes. 

Preliminary analyses of data from the mid-pregnancy interviews 

suggest that these two populations are similar with respect to 

parental age and education, maternal height and weight, gravidity, ethnicity and socioeconomic status. They are somewhat 

dissimilar with respect to the higher proportion of women 

reporting smoking, any alcohol drinking and working in Pristina 

(Table 1). Of these latter three characteristics, smoking is 

known to influence birthweight (4); findings for alcohol drinkers 

(5) and maternal occupation in relation to birthweight are 

inconsistent. The relations of these factors and others to 

birthweight and late fetal death in the study pregnancies will be 

examined, and analytic adjustment will be made for their effects 

in assessing the influence of location and BPb on the various 

pregnancy outcomes. 

Table 1. Sociodenographic Characteristics 

and Habits of the Populations 

Maternal 

Maternal 

Paternal 

Paternal 

Maternal 

Maternal 

TitQYB riitrQYica. 

N 

age (yrs ) 

education (yrs) 

age (yrs) 

education (yrs) 

weight (kg) 

height (cm) 

456 

26.3 

9.5 

30.6 

12.1 

66.7 

163.2 

Pristina 

650 

26.9 

9.3 

30.7 

11 .7 

66.8 

166.1 

X 

X 

X 

X 

Albanian 

Serbian 

Other 

No answer 

55.9 

24.8 

17.8 

1 .5 

Total number of pregnancies 3.3 3.3 

Ethnicity: X Albanian 55.9 59.4 

24.9 

14.9 

0.7 

X cigarette smokers 23.0 29.8 

X of women who drink 

any alcohol 5.7 9.5 

X of women with jobs 30.5 45.8 

The mid-pregnancy questionnaires have shown social characteristics to be similar, particularly with regard to socioeconomic 

status (Table 2) . 

V 
Talbl© 2o SoeiLal Cteairact<sri£3tieo @<F teDno P@iptta2.at 2. ©BB© 

P6 

Titova Mitrovica 

H 

Number of adults in home 

Number of children in home 

Number of rooms in home 

Monthly family income 

(millions of old dinars) 

456 

4.5 

2.1 

3.4 

7o0 

The distribution of mid-pregnancy BPb's in th® 

focAfiSJsXm 

6 5 0 

4 , 

2 . 

3< 

7< 

t w o 

.4 

,1 

, 2 

,1 

towns a r e 

illustrated graphically in Figure 

Mitrovica is 17.4 ug/dl while the 

ug/dl. Th© mean EP io Mitrovica 

Pristina is 32.5 ug/dl§ the mean 

1. Thus far„ the mean BPb in 

m©an BPb in Pristina is 5.4 

io 49.8 ug/dl9 while that in 

serum ferritin concentration© 

ar<B identical in th© two towns, 19.8 ng/dl. 

Th® first births to otudy participants occurrod in October, 

1985. To dat®, BPb data have been compiled from 207 maternal/infant pairs in Mitrovica and 268 pair® in Pristina. In Mitrovica, 

thus far, the mean maternal BPb at term is 21.4 ug/dl9 while th© 

mean umbilical cord BPb is 19.0 ug/dl. Sn Pristina, th© mean 

maternal BPb at term io 6.7 ug/dl9 while th© mean, umbilical cord 

BPb is 5.4 ug/dl. Th© distributions of maternal BPb's at term 

arm illustrated in Figure 29 while th© distributions of umbilical 

eord BPb'o are illustrated in Figure 3. 

While numerous oth©r studies hav© described an association 

between maternal and fetal BPb's (reviewed in 6) 9 none hav© 

involved a population with ouch a wide range of BPb's. The 

placenta appears to b® a vtsiry weak barrier to Pb over a wid® 

range ©f BPb'®9 as evidenced by th© strong association between 

maternal and umbilical cord BPb'o in Mitrovica shown in Figure 4 

(r « 0.86§ P < .0018 olop© = 0.87>§ once additional data are 

accumulated, we will determine whether th© association involves 

non-linear ao well as linear components. Th© average maternal 

mid-pregnancy BPb's, maternal BPb'o at delivory9 and umbilical 

cord BPb's for our cases that have eem© to term ar© presented in 

Table 3. 

Tatol© 3§ Avairag® °o I 

Titova Mitrovica 

N * 207 

ffoir Cass© C<aa© feo Teams 

N • 26 8 

Maternal Mid-Pregnancy 17, 

Maternal Delivery 21, 

Umbilical Cord 19, 

6 5.4 

6.7 

5.4 

Thus, because of the wid© range of BPb's, the apparent lack of 

confounding by spcial class, and th© large number of women 

involved, this prospective study promises to answer many issues 

surrounding the possible influence of Pb exposure on pregnancy 

*i. JM.*J*i A ••MMMIBW i*i*..iMmt.Jkk-iUikaiiLi.* . fa " — - ----- H>a.^,JiM.i,^m 
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outcome. It is still too early, however, for 

definitive data concerning pregnancy outcome. 

us to present any 

The Infant Developaent Study: 

environmental Pb exposure on phy 

linguistic development during 

subsets of infants born to women 

outcome study. The infants will 

months of age. At each visit, 

ference will be measured; a pedi 

and blood will be collected 

hemoglobin and serum ferritin 

assessments will be carried out: 

In order to assess the effects of 

sical, behavioral and cognitiveearly life, we are following 

who participate in the pregnancy 

be examined at 6, 12, 18 and 24 

weight, height, and head circumatric history will be performed 

for the measurement of BPb, EP, 

In addition, the following 

6 month visit: Bayley Scales of Infant Development (7) 

Bates Infant Characteristics Questionnaire (8) 

12 month visit: Bayley Scales of Infant Development 

Bates Infant Characteristics Questionnaire 

18 month visit: 

24 month visit: 

Bayley Scales of Infant Development 

Memory for Locations Task (9) 

Bayley Scales of Infant Development 

Bates Infant Characteristics Questionnaire 

Memory for Locations Task 

Receptive Language Assessment (10) 

a. Selection of Subjects: In Mitrovica, 384 infants will be 

selected on the basis of cord BPb's. We will select the following cases: 

Group a) the 144 infants with the highest cord BPb's; 

cord BPb's of 20 ug/dl or more are eligible 

for entry into this group. 

Group b) the 120 infants with the lowest cord BPb's; 

cord BPb's of < 15 ug/dl are eligible. 

Group c) a random sample of 120 infants from the 

remaining births, with BPb's of > 15 ug/dl 

and < 20 ug/dl. 

In Pristina, 264 infants will be selected for comparative 

purposes: 

Group d) 144 infants will be matched to the "high" 

cord BPb group (Group a) for SES. The hypothesized effects of Pb 

on mental development in the first years of life are likely to be 

seen in this comparison. It is likely that only minimal adjustment for SES will be required in the statistical analysis. 

Group e) 120 infants will be matched to the "low" cord 

BPb group (Group b) for SES and cord BPb. By virtue of their 
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town of residence, it is likely that the BPb's of infants in 

children in group b will rise during the first two years of 

life, while those of group e will not. Thus, this control group 

will enable us to attempt to distinguish prenatal from post-natal 

Pb effects. 

We have established that there is a strong association between 

parental education and other indicators of SES such as family 

income, rooms/home, number of residents/home, etc. We have 

therefore used maternal and paternal education as the SES 

selection factors. In order to minimize loss to follow-up, 

infants living more than 10 km from the hospital have been 

excluded in each town. Other exclusion criteria include twins, 

major central nervous system defects, chromosomal abnormalities 

or other conditions (e.g., microcephaly, hydrocephaly) likely to 

profoundly affect growth or mental development. 

Thus far, 243 have been selected for follow-up from births which 

occurred during the interval of October, 1965 through March, 

1986. Of those, 150 have been evaluated at 6 months of age. The 

mean cord BPb's of groups a-e are illustrated in Table 4. 

Table 4: Mean Cord BPb's <ug/dl) of Selected Infants 

Titova Mitrovica Pfigtinfl 

Group a: 25.2 

Group b: 11.2 

Group d: 3.9 

(Matched to group a on SES) 

Group e: 8.2 

(Matched to group b on SES and BPb) 

Group c: 17.3 

Other characteristics of groups a-e are shown in Table 5. 

Table 5: Other Characteristics of Selected Infants 

Group a Group b GrPUP C GrQUP d GrgUP 6 

BPb (ug/dl) 25.2 11 .2 17.3 3.9 8.2 

Maternal 

Education (yrs) 

Paternal 

Education (yrs) 

Family Income 

9.6 

11.1 

5.7 

8.3 

12.2 

5.0 

9.2 

12.0 

5.6 

9.5 

11 .3 

6.3 

9.3 

11 .3 

5.9 

(10 dinars/month) 

Birthweight 

(grams) 

3337 3295 3310 3232 3310 
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In summary, we are studying the influence of Pb exposure on 

pregnancy outcome and infant development in two populations with 

an exceptionally wide range of BPb's. The socioeconomic characteristics of the two towns appear to be quite similar. Thus, in 

this study, Pb exposure is not linked to a particular social 

class or ethnic group, an important limitation of many other 

previous and ongoing studies. Because this study is still in the 

process of data collection, the presentation of data concerning 

outcomes of interest must await the next conference. 

References: 

1. Popovac, D, Graziano, J, Seaman, C, Kaul, B, Colakovic, B, 

Popovac, R, Osmani, I, Haxhiu, M, Begraca, M, Bozovic, Z, Mikic, 

M: Elevated blood lead in a population near a lead smelter in 

Kosovo, Yugoslavia. Arch Environ Health 37: 19-23, 1982. 

2. Graziano, JH, Popovac, D, Murphy, MJ, Colakovic, B, Stein, Z, 

Mehmeti, A, Kline, J, Ahmedi, G, Rajovic, B, Gashi, E, Haxhiu, R, 

Radovic, L, Hoxha, I, Zvicer, Z, Popovac, R, Bozovic, R, Shrout, 

P, Lolacono, N: Environmental lead and pregnancy outcome. 

Proc Fifth Int Conf Heavy Metals in the Environ (Athens) 1: 

414-416, 1985. 

3. Ballard, JL, Novak, KK, Driver, M: A simplified score for 

assessment of fetal maturation of newly born infants. J Pediatr 

95: 769-774, 1979. 

4. Abel, EL: Smoking during pregnancy: A review of effects on 

growth and development of offspring. Human Biol 52: 593-625, 

1980. 

5. Stein, Z, Kline, J: Smoking, alcohol and reproduction. Amer 

J Public Health 73: 1154-1156, 1983. 

6. Bell, JU, Thomas, JA: Effects of lead on mammalian reproduction. In, Lead Toxicity. RL Singhal and JA Thomas (eds), 

pp. 169-186, Urban 4 Schwartzenberg, Baltimore, 1980. 

7. Bayley, N: Manual for the Bavlev Scales of Infant DevelopElfill£. New York: Psychological Corporation, 1969. 

6. Bates, JE, Freeland, CA, Lounsbury, ML: Measurement of 

infant difficultness. Child Develop 50: 794-803, 1979. 

9. Kagan, J: The Second Year: The Emergence of Self-AwareHfififi. Cambridge, MA: Harvard University Press, 1981. 

10. Hedrick, DL, Prather, EM, Tobin, AR: The Sequenced Inventory of Communicative Development. 2nd edition. Seattle: 

Seattle University Press, 1984. 

Figures: Figures 1-4 will be distributed at the meeting. 
iwFrequency Distribution of Blood Lead Concentrations 

at Mid-Pregnancy 

Pristina, N = 650 

ES Titova Mitrovica, N 

B Overlap 

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 
i r .:• •'_'* : 

o 

tz 

<D 

fi 

<D 

DL 

Frequency Distribution of Maternal Blood Lead Concentrations 

50r- at Delivery 

Pristina, N = 268 

Titova Mitrovica, N = 209 

Overlap 

SIsL-jra. T—i— r 

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 56 

t aa\ 
.-r •'i-ir-*' ' " '!• ••vinin-n «• 

CO 

.2 

c 

CD 

O 

Q5 

CL 

Frequency Distribution of Umbilical Cord 

Blood Lead Concentrations 

B Pristina, N = 268 

0 Titova Mitrovica, N = 207 

B Overlap 

0 2 4 6 

I ••••• rH—i—i—i—i—| -

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 

Blood Lead (pg/dl) i-*<?o£C \ 
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CDRD BPB <UG/DL) 

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