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Background

In 2012, traditional Burmese medicines in NSW were found to be contaminated with arsenic (As).(1) Similar products in the United States,Ìýand alsoÌý'Thanakha (or 'Thankha')',Ìýhave been identified as a source of lead exposure in Karen* refugee children.(2)

These products were sold under various names includingÌý'Daw Kyin orÌýWonotsay','Daw Tway'Ìýand 'Saya Pyaung Gyi'ÌýÌýbrand powderÌý(see below)

• Daw Tway and Daw Kyin are used to aid strength and digestion and to treat constipation in babies and young children
• Saya Pyaung Gyi powder is used as a topical antiseptic powder in babies
• Thanakha is used as a cosmetic, to lighten skin, and is sometimes used for sun exposure. It can have a greenish or white appearance (like face paint)
• These products are available as powders, pellets and creams, and may be applied to the skin or tongue, or taken orally
• They are manufactured in SE Asia and have been found in Burmese grocery stores in Sydney and Victoria. In NSW these products were found to have very high concentrations of total As, although no information was available on whether this was the inorganic (toxic) or organic form. It was unclear whether the same products in Melbourne contain As.
• NSW Health and NSW Food Authority requested withdrawal of these products from sale and issued aÌýhealth warning
• Traditional Ayurvedic medicines were previously identified as a source of lead poisoning in Victoria, and also led to aÌýat the time.

ÌýDAW KYIN	ÌýSAYA PYAUNG GYI brandÌý	ÌýDAW TWAY
ÌýÌý	ÌýÌýÌýÌýÌýÌý	Ìý
Found in NSW and Victoria, identified as containing As in NSW	Found in NSW and Victoria, identified as containing As in NSW	ÌýSource of lead toxicity in US

Assessment

• A history of exposure should be sought in all patients from Burma/surrounding areasÌý(e.g. Karen, Burmese, Karenni and Chin refugee groups)
• If patients have a history of exposure/ingestion of Burmese traditional powders:
  • Assess for symptoms of toxicity, which may be non specific:
    • Arsenic: diarrhoea, abdominal pain, nausea, vomiting, skin changes, hair loss, nail changes, generalised weaknessÌýfurther information
    • Lead: abdominal pain, nausea, vomiting, constipation, fatigue, lethargy, irritability, headache, behavioural changes, tremor, arthralgia,Ìýfurther information
  • Acutely unwell children should be referred to the local emergency departmentÌýfor assessment and management
  • Consider investigations for arsenic and lead exposure
    • Full blood count (FBC)
      • Acute arsenic poisoning - haemolytic anaemia
      • Chronic arsenic exposureÌý - basophilic stippling, rouleaux, and pancytopenia
      • Lead toxicity - microcytic anaemia, basophilic stippling, sideroblasts
    • Spot urinary arsenic concentrationÌýfurther informationÌýÌýÌý
      • Detects arsenic exposure within 48-72 hours
      • Seafood consumption within 48 hours of urine testing can lead to false positive results
    • Whole blood lead concentrationsÌýfurther information
  • Provide advice to avoid use of Burmese traditional powders/medicines

ManagementÌý

The principals of management of patients with heavy metal toxicity include:

• Removing the sourceÌýof heavy metal
• Urgent specialist management of children with symptoms of toxicity
  • Some children may require chelation therapy (further information onÌýAsÌýandÌýPb)
• Ask family to bring the product so it can be tested
• Cases of toxicity should beÌýÌý(laboratories will report elevated blood lead levels)

For further adviceÌýplease contact:

• The Poison Information Centre Australia - 13 11 26
• Immigrant Health Fellow, RCH Ph 93455522 pager 7142
• Clinical Pharmacology Fellow, RCH Ph 93455522 pager 4995

References

• References