Research | Children’s Health Outbreak of Fatal Childhood Lead Poisoning Related to Artisanal Gold Mining in Northwestern Nigeria, 2010 Carrie A. Dooyema,1,2 Antonio Neri,1 Yi-Chun Lo,2 James Durant,3 Paul I. Dargan,4 Todd Swarthout,5 Oladayo Biya,6 Saheed O. Gidado,6 Suleiman Haladu,6 Nasir Sani-Gwarzo,7 Patrick M. Nguku,6 Henry Akpan,8 Sa’ad Idris,9 Abdullahi M. Bashir,9 and Mary Jean Brown1 1Healthy Homes and Lead Poisoning Prevention Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; 2Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; 3Agency for Toxic Substances and Disease Registry, Atlanta, Georgia, USA; 4Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, United Kingdom; 5Médecins Sans Frontières, Amsterdam, the Netherlands; 6Nigerian Field Epidemiology and Laboratory Training Program, Abuja, Nigeria; 7Centers for Disease Control and Prevention, Abuja, Nigeria; 8Nigerian Federal Ministry of Health, Abuja, Nigeria; 9Zamfara State Ministry of Health, Gusau, Nigeria Background : In May 2010, a team of national and international organizations was assembled to investigate children’s deaths due to lead poisoning in villages in northwestern Nigeria. o Bjectivs : Our goal was to determine the cause of the childhood lead poisoning outbreak, inves- tigate risk factors for child mortality, and identify children < 5 years of age in need of emergency chelation therapy for lead poisoning. Methods : We administered a cross-sectional, door-to-door questionnaire in two affected vil- lages, collected blood from children 2–59 months of age, and obtained soil samples from family compounds. Descriptive and bivariate analyses were performed with survey, blood lead, and envi- ronmental data. Multivariate logistic regression techniques were used to determine risk factors for childhood mortality. r esult : We surveyed 119 family compounds. Of 463 children < 5 years of age, 118 (25%) had died in the previous year. We tested 59% (204/345) of children < 5 years of age, and all were lead poisoned (≥ 10 µg/dL); 97% (198/204) of children had blood lead levels (BLLs) ≥ 45 µg/dL, the threshold for initiating chelation therapy. Gold ore was processed inside two-thirds of the family compounds surveyed. In multivariate modeling, significant risk factors for death in the previous year from suspected lead poisoning included the age of the child, the mother’s work at ore-pro- cessing activities, community well as primary water source, and the soil lead concentration in the compound. c onclusi : hTe high levels of environmental contamination, percentage of children < 5 years of age with elevated BLLs (97%, > 45 µg/dL), and incidence of convulsions among children before death (82%) suggest that most of the recent childhood deaths in the two surveyed villages were caused by acute lead poisoning from gold ore–processing activities. Control measures included envi- ronmental remediation, chelation therapy, public health education, and control of mining activities. k ey words : artisanal gold mining, childhood, environmental health, lead poisoning, nervous system. Environ Health Perspect 120:601–607 (2012). http://dx.doi.org/10.1289/ehp.1103965 [Online 20 December 2011] Childhood lead exposure results in lower intel- ligence and behavior problems and negatively affects multiple body systems (Bellinger 2004; Canfield et al. 2003; Lanphear et al. 2005; Mendelsohn et al. 1998; Tellez-Rojo et al. 2006). Young children are particularly sus- ceptible to lead exposure because of behav- ioral factors, such as frequent hand-to-mouth activities, and biological factors including greater gastrointestinal absorption and devel- oping neurological systems (Bellinger 2004; Henretig 2006; Lidsky and Schneider 2003). Encephalopathy typically occurs with blood lead levels (BLLs) ≥ 100 µg/dL but can occur with BLLs as low as 70 µg/dL [Centers for Disease Control and Prevention (CDC) 2002; Henretig 2006]. Symptoms of acute lead encephalopathy include vomiting, changes in behavior, ataxia, convulsions, and coma (CDC 2002; Henretig 2006). Currently, childhood lead poisoning resulting in encephalopathy and death in developed countries is rarely reported, and the last documented child fatality from lead poisoning in the United States was in 2006 (Berg et al. 2006). However, hundreds of U.S. pediatric deaths from acute lead enceph- alopathy were recorded in the first half of the 20th century. For example, 202 deaths from childhood lead poisoning were recorded in U.S. cities from 1931 and 1940, with 25% occurring in Baltimore, Maryland (McDonald and Kaplan 1942). Most lead poisoning in this period occurred in urban settings from deteriorating lead house paint and lead-painted cribs. Lead-poisoned children in this era fre- quently had high BLLs. One study evaluating lead poisoning in 293 children from 1931 to 1970 found the mean BLL for children with mild, severe, and fatal acute lead encephal- opathy to be 328 µg/dL, 336 µg/dL, and 327 µg/dL, respectively (National Research Council 1972). Sources of global lead poisoning include lead mining and smelting, battery recycling, leaded gasoline, paint, traditional medicines, toys, and discarded electronic devices (Meyer Environmental Health Perspectives • volume 120 | number 4 | April 2012 et al. 2008). Lead poisoning is of specific concern for children in developing countries (Falk 2003). The World Health Organization (WHO) estimates that lead poisoning causes 0.6% of the global burden of disease and contributes to approximately 600,000 cases of intellectual disability in children annu- ally (WHO 2010). During the past 20 years, moderate to high elevations of BLLs have been documented globally in clusters of chil- dren living in mining and smelting communi- ties or areas where lead batteries are reclaimed (Brown et al. 2010; Garcia Vargas et al. 2001; Kaul et al. 1999; Lalor et al. 2006). However, only one report found in recent literature documents fatalities from childhood lead poi- soning; in 2008 in Senegal, informal battery recycling was determined to be the likely cause of death of 18 children (Haefliger et al. 2009). Description of the outbreak. During meningitis surveillance activities conducted February–April 2010, Médecins Sans Frontières (MSF) and local Nigerian public health officials observed higher than expected numbers of childhood illnesses and deaths in four villages in rural northwestern Nigeria. Most of the illnesses and deaths occurred in children < 5 years of age. Symptoms included vomiting, abdominal pain, headache, and Address correspondence to C.A. Dooyema, 4770 Buford Highway, MS K-26, Chamblee, GA 30341 USA. Telephone: (770) 488-5039. Fax: (770) 488- 5369. E-mail: igb7@cdc.gov We acknowledge the Nigerian Federal Ministry of Health, Zamfara Ministry of Health, Gabriele Poggensee, Centers for Disease Control and Prevention (CDC) Nigeria, and I. Von Lindern, C. Bartrem, M. von Braun, and S. Tirima of TerraGraphics Environmental Engineering Inc. At CDC Atlanta, we acknowledge the Center for Global Health, Global Disease Detection Program, L. Davis, and the Division of Laboratory Sciences at the National Center for Environmental Health. Financial support was provided by the CDC Global Disease Detection Program, CDC Nigeria, and the Nigerian Field Epidemiology and Laboratory Training Program. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC or the Agency for Toxic Substances and Disease Registry. The authors declare they have no actual or potential competing financial interests. Received 19 May 2011; accepted 20 December 2011. 601