How Routine Lead Tests in North Carolina Uncovered Contaminated Applesauce Pouches

Lead is toxic even at low levels, and in young children it can cause harm that affects their whole lives. In summer 2023, routine testing in North Carolina flagged four children with elevated blood lead levels. What investigators found led to a nationwide recall and the discovery of about 500 cases of childhood lead exposure across the country. Melanie D. Napier, Edward H. Norman and colleagues at the North Carolina Department of Health and Human Services reported the investigation.

How North Carolina tests

North Carolina encourages lead testing for all children at ages 1 and 2, and requires it for children on Medicaid. Every blood lead result for a child under 6 is reported to the state's Childhood Lead Poisoning Prevention Program. A child with two consecutive results of 5 micrograms per deciliter (μg/dL) or higher within 12 months qualifies for a home investigation by a county environmental health specialist. Suspect foods or products are tested by the State Laboratory of Public Health, and results above the state's reporting limit — 1.0 part per million for most spices and foods — go to the Food and Drug Administration.

Three households

From June to August 2023, routine tests found four children in three unrelated households in western North Carolina with elevated levels. None had symptoms.

Across the homes, product samples held 1.9–3.0 ppm of lead. The families were told to throw the products away, and follow-up tests showed the children's lead levels falling — added evidence the source had been found.

The response

State officials worked with FDA, county health departments and the state agriculture department's laboratory, which confirmed the findings. Testing after the recall kept finding high lead in WanaBana products from homes and stores, 1.9–5.8 ppm. County staff made 217 store visits from December 8 to 19 and pulled recalled products from five stores; food banks, child care centers and school food services were alerted.

CDC then searched nationwide for children with blood lead above its reference value of 3.5 μg/dL linked to the pouches. By January 2024, about 500 cases had been identified nationally, 22 of them in North Carolina.

Why testing everyone matters

CDC recommends focusing lead testing on children with social risk factors — such as belonging to a racial or ethnic minority group, living in a low-income household or having known environmental exposure — and on those in housing built before 1978, alongside Medicaid's testing requirements. But fewer than half (45%) of North Carolina's 22 cases were on Medicaid, and for half of the children — including all four in this report — no typical lead source was found. North Carolina's practice of testing all young children may have caught cases that would otherwise have been missed, and found a new source sooner.

Lead paint, water, dust and soil are the best-known hazards, but lead has also turned up in candies, spices, ceremonial powders and alternative medicines. As old houses with lead paint are renovated or torn down, those environmental sources are becoming less common, making it more important to watch for others, such as spices adulterated with lead chromate.

The investigation and response. Credit: CDC, MMWR.

Sources

Based on Napier MD, Huneycutt A, Moore C, et al., "Childhood Lead Exposure Linked to Apple Cinnamon Fruit Puree Pouches — North Carolina, June 2023–January 2024," MMWR, Centers for Disease Control and Prevention; in the public domain.