Post on 09-Jul-2020
National Center for Environmental HealthAgency for Toxic Substances and Disease Registry
Lessons Learned from Flint, MI: Implications for our Community
CAPT Renée Funk, DVM, MPH&TM, MBA, DACVPMAssoc Dir, Emerg Mngt, NCEH/ATSDR
LT Gamola Z. Fortenberry, PhD, MPHEpidemic Intelligence Service Officer, NCEH/ASTER-Health Studies BranchMay 17, 2017
Photo source: abcnews.go.com
RESPONSE TO WATER CONTAMINATIONIN FLINT, MI
Background on Flint Water Contamination – Timeline
April 2014
Aug. 2015
Oct. 2, 2015
Dec. 14,
2015
Jan. 2016
Feb. 1, 2016
March 15,
2016
Change to Flint river water
Dr. Mona Hanna-Attishapublishes study of blood lead levels
Genesee County issues public health emergency;Water source switched back to Detroit water
Flint Mayor Weaver declared a state of emergency
Federal assistance begins, under a Unified Coordination Group (UCG)
CDC EOC activated under a Unified Coordination Group (UCG)
CDC deactivates EOC, continues to provide assistance
May 17-19, 2016
CASPER conducted
U.S. Government Objectives in Flint
▪ Immediate access to safe water (FEMA)
▪ Long term safety of the water supply (EPA)
▪ Immediate needs regarding health (HHS and Unified Command Group)
▪ Community resilience (HHS and Unified Command Group)
Photo source: PBS Newshour website
NCEH/ATSDR ACTIVITIES IN FLINT, MI
Enhancing Blood Lead Surveillance in Flint, MI (Guidance issued February 2016)
▪ Because of the situation in Flint, Michigan, the US Centers for Disease Control and Prevention (CDC) recommends immediate testing for lead levels for all children who were 0-6 years of age between 10/1/2015 and 4/1/2016 who live in the City of Flint, live in a home using City of Flint water, or who attend school, childcare or often spend time with a caregiver in the City of Flint All children who have a blood lead level ≥5 ug/dl should be placed with a case manager. This screening needs to be completed by April 1, 2016.
Morbidity and Mortality Weekly Report (MMWR)
▪ Blood lead levels among children aged <6 years living in the City of Flint, MI, 2013–2016• Released June 17, 2016
• Report added
❖ Proportion of children aged <6 years in Flint, MI with BLLs ≥5 µg/dLwas significantly higher during switch to Flint Water System
• Implication for health practice
❖ Encourage use of NSF certified water filters to remove lead
❖ Use filtered or bottled water for drinking, cooking, and brushing teeth
Photo source: MLive.com
MMWR Methods
▪ Examined distribution of BLLs ≥5µg/dL among children aged <6 years before, during, and after switch in water source
▪ Used cross-sectional analysis conducted during four time intervals
▪ Confirmed BLLs ≥5 µg/dL defined as having one venous blood lead test ≥5 µg/dL or two capillary blood lead tests ≥5 µg/dL drawn within 12 weeks of each other
▪ Analyses limited to children living in area serviced by FWS at time of test
Pre-Water Source Switch
Before switch in water supply
to Flint River
04/25/2013–04/24/2014
Early Water Source Switch
During switch in water supply
to Flint River
04/25/2014–01/02/2015
Late Water Source Switch
When there was boil water
advisory from city officials
01/03/2015–10/15/2015
Post-Water Source Switch
After water supply switched
from Flint River to DWS
10/16/2015–03/16/2016
Table 3. Multivariate adjusted odds ratios* comparing odds of elevated blood lead levels ≥5 µg/dL among children† aged <6 years, by select covariates
OR (95% CI)
Time period
Pre-Water Source Switch 1.0
Early Water Switch 1.46 (1.06–2.01)
Late Water Switch 1.28 (0.92–1.76)
Post-Water Source Switch 0.75 (0.51–1.12)
Age group§
<1 year 1.0
1–2 years 2.25 (1.25–4.06)
3–5 years 1.36 (0.73–2.53)
Season
Winter (Dec–Feb) 1.0
Spring (Mar–May) 1.41 (0.91–2.16)
Summer (Jun–Aug) 2.14 (1.44–3.18)
Fall (Sep–Nov) 2.25 (1.57–3.22)
*Odds of having BLLs ≥5 µg/dL during the pre-water–switch period compared with the early, late and post-water source switch periods. †Flint resident defined as living in a house served by the Flint Water Service (FWS) at the time of test. §At time of test.
MMWR Conclusions
▪ The use of water from the Flint River without proper corrosion control exposed the residents to excess amounts of lead.
▪ All children aged <6 years living in the City of Flint should have their blood tested for lead, if they have not had a blood lead test since October 2015.
▪ Case management should be provided to all children with BLLs ≥5 µg/dL.
Rash Investigation
▪ Consisted of four parts• Questionnaire (390 interviews conducted)
• Clinical referral to a dermatologist (122 examined)
• Water sampling in houses (170 samples)
• Evaluation of water quality data from water treatment plant
▪ Study found that one possible explanation for the majority of eczema-related rashes is the fluctuations in water quality while residents were using Flint River water
▪ Community participation in roll out
Point-of-Use Water Filter Testing
▪ Worked with EPA to assess the effectiveness of the filters when the water concentrations are above the 150 ppb certification level
▪ Confirmed filters effectively remove lead from water even at very high levels
▪ Determined drinking filtered tap water is safe for everyone, including pregnant women and children
Community concerns
Community Assessment for Public Health Emergency Response (CASPER)
Flint Community Resilience Group▪ Michigan Department of Health
and Human Services (DHHS)▪ Genesee County Health
Department ▪ Genesee Health System ▪ University of Michigan−Flint
CASPER
Flint Community Assessment for Public Health Emergency Response (CASPER) Objectives
To assess city-wide
• Household-level, self-reported behavioral health concerns for those ≥ 21 years and those <21 years
• Individual-level, self-reported behavioral health concerns
• Household access to behavioral health services and perceived barriers
• Resource use for water-related needs and barriers to access
• Communication with affected community
Flint Community Assessment for Public Health Emergency Response (CASPER) Objectives
To assess city-wide
• Household-level, self-reported behavioral health concerns for those ≥ 21 years and those <21 years
• Individual-level, self-reported behavioral health concerns
• Household access to behavioral health services and perceived barriers
• Resource use for water-related needs and barriers to access
• Communication with affected community
CASPER Sampling Design
▪ Sampling frame• City limits of Flint, Michigan
• 24,983 housing units
• 102,000 people
Individual-Level Behavioral Health Questions
▪ Several individual-level behavioral health questions adopted from national Behavioral Risk Factor Surveillance System (BRFSS) • Depressive symptoms questions from the Patient Health Questionnaire-
2 (PHQ-2)
• Anxiety questions from the Generalized Anxiety Disorder-2 (GAD-2)
▪ Participant Selection Criteria• Aged 18 years or older
• Present at time household-level interview conducted
• Upcoming birthday nearest to the date of interview
Data Collection
▪ May 17–19, 2016
▪ Two- person interview teams assigned to two or three clusters and instructed to go to every nth household
▪ Three attempts at each household before replacement
Data Analysis
▪ SAS®9.3 used for data analysis
▪ Data weighted to adjust for non-random sampling and obtain population estimates
▪ Generated frequencies and percentages with 95% confidence intervals
▪ Compared 95% confidence intervals to Michigan BRFSS data• Statistically significant if the confidence intervals did not overlap
▪ Tracking form data were used to calculate completion, cooperation and contact rates
RESULTS
Questionnaire Response Rates
Percent (%) Rate Description
Completion 85.7 180/210 Total completed210
Cooperation 75.0 180/240 Total completedTotal contact made
Contact* 52.4 180/343 Total completedTotal selected
*Excludes vacant housing
Individual-Level Data
Individual Demographics
▪ Average age of respondent was 49 years (range = 18−88 years)
▪ 69% of respondents were female
▪ 80% lived in Flint 12+ years; 6% two years or less
▪ Race• 58% identified as black• 43% identified as white• 5% other or refused
Individual Self-Reported Behavioral Health Concerns: Depression and Anxiety Symptoms Over Last Two Weeks
0
10
20
30
40
50
60
70
80
Depression Symptoms Anxiety Symptoms
Wei
ghte
d In
div
idu
al P
erce
nta
ge (
%)
Yes
No29.4%
70.6%
33.4%
66.6%
Individual Self-Reported Behavioral Health Concerns: Financial Stress in Last 12 Months
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Worried or stressed about paying rent/mortgage (n=180)
Never/Rarely 87 42.7 33.3–52.0 ---
Always/Usually/Sometimes 90 55.1* 46.6–63.6 34.8 (33.4–36.2)
Worried or stressed about buying nutritious meals (n=180)
Never/Rarely 96 49.9 39.3–60.4 ---
Always/Usually/Sometimes 82 49.5* 38.6–60.3 21.9 (20.7–23.1)
*Significantly different p<0.05 level
Individual Self-Reported Behavioral Health Concerns: Financial Stress in Last 12 Months
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Worried or stressed about paying rent/mortgage (n=180)
Never/Rarely 87 42.7 33.3–52.0 ---
Always/Usually/Sometimes 90 55.1* 46.6–63.6 34.8 (33.4–36.2)
Worried or stressed about buying nutritious meals (n=180)
Never/Rarely 96 49.9 39.3–60.4 ---
Always/Usually/Sometimes 82 49.5* 38.6–60.3 21.9 (20.7–23.1)
*Significantly different p<0.05 level
Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Physical illness and injury during the past 30 days (n=176)
<13 days 112 63.0 52.6–73.4 ---
>14 days 64 37.0* 26.6–47.4 12.6 (11.8-13.6)
Poor mental health during the past 30 days (n=174)
<13 days 110 62.3 55.9–68.7 ---
>14 days 64 37.7* 31.3–44.1 12.9 (11.9-14.0)
Interruption of normal activities during the past 30 days (n=178)
<13 days 127 71.2 63.0–79.3 ---
>14 days 51 28.8* 20.7–37.0 8.7 (8.0-9.6)*Significantly different p<0.05 level
Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Physical illness and injury during the past 30 days (n=176)
<13 days 112 63.0 52.6–73.4 ---
>14 days 64 37.0* 26.6–47.4 12.6 (11.8-13.6)
Poor mental health during the past 30 days (n=174)
<13 days 110 62.3 55.9–68.7 ---
>14 days 64 37.7* 31.3–44.1 12.9 (11.9-14.0)
Interruption of normal activities during the past 30 days (n=178)
<13 days 127 71.2 63.0–79.3 ---
>14 days 51 28.8* 20.7–37.0 8.7 (8.0-9.6)*Significantly different p<0.05 level
Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Physical illness and injury during the past 30 days (n=176)
<13 days 112 63.0 52.6–73.4 ---
>14 days 64 37.0* 26.6–47.4 12.6 (11.8-13.6)
Poor mental health during the past 30 days (n=174)
<13 days 110 62.3 55.9–68.7 ---
>14 days 64 37.7* 31.3–44.1 12.9 (11.9-14.0)
Interruption of normal activities during the past 30 days (n=178)
<13 days 127 71.2 63.0–79.3 ---
>14 days 51 28.8* 20.7–37.0 8.7 (8.0-9.6)*Significantly different p<0.05 level
Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison
Frequency Weighted %Weighted
95% CI
Michigan BRFSS
Weighted % (95% CI)
Physical illness and injury during the past 30 days (n=176)
<13 days 112 63.0 52.6–73.4 ---
>14 days 64 37.0* 26.6–47.4 12.6 (11.8-13.6)
Poor mental health during the past 30 days (n=174)
<13 days 110 62.3 55.9–68.7 ---
>14 days 64 37.7* 31.3–44.1 12.9 (11.9-14.0)
Interruption of normal activities during the past 30 days (n=178)
<13 days 127 71.2 63.0–79.3 ---
>14 days 51 28.8* 20.7–37.0 8.7 (8.0-9.6)*Significantly different p<0.05 level
Summary of Key Findings
▪ 34% of individuals self-reported anxiety symptoms and 29% self-reported depressive symptoms
▪ Prevalence of individuals with negative quality of life indicators higher in Flint compared to state of Michigan BRFSS findings
▪ 51% of households felt that the physical health of at least one member had worsened due to Flint water crisis
Discussion
▪ Increased behavioral health impacts in crisis-affected communities observed after other human-induced events1–5
▪ Increased prevalence of individuals reporting poor physical health, poor mental health, or limited activity days during the last 30 days. • Quality of life indicators almost three times higher compared to
reported prevalence1. Buttke D, Vagi S, Bayleyegn T, Sircar K, Strine T, Morrison M, Allen M, Wolkin A. Mental Health Needs Assessment After the Gulf Coast Oil Spill—Alabama and Mississippi, 2010.
Prehospital and Disaster Medicine. 2012;27:401-8.
2. Palinkas LA, Petterson JS, Russell J, Downs MA. Community patterns of psychiatric disorders after the Exxon Valdez oil spill. Am J Psychiatry. 1993;150(10):1517-1523.
3. Carrasco JM, Pe´rez-Go´mez B, Garcı´a-Mendiza´bal MJ, et al. Health-related quality of life and mental health in the medium-term aftermath of the Prestige oil spill in Galiza (Spain): a
cross-sectional study. BMC Public Health. 2007;7:245.
4. Chung S, Kim E. Physical and mental health of disaster victims: a comparative study on typhoon and oil spill disasters. J Prev Med Public Health. 2010;43(5):387-395
5. Sabucedo JM, Arce C, Senra C, Seoane G, Va´zquez I. Sabucedo JM, Arce C, Senra C, Seoane G, Va´zquez I. Symptomatic profile and health-related quality of life of persons affected by the
Prestige catastrophe. Disasters.2010;34(3):809-820.
Limitations
▪ Surveys may not be representative • Self-report
• Single point in time
• Only individuals available during sampling times
▪ Increased worry or stress experienced cannot be attributed entirely to Flint water crisis • Individual household circumstances
• Economic recession
Public Health Impact
▪ Behavioral health services increased to provide prevention screening and early intervention for children and youth
▪ $4.8 million grant from Substance Abuse and Mental Health Services Administration (SAMHSA) to provide services –including behavioral health and violence prevention programs
▪ $500,000 grant from SAMHSA to • Hire outreach workers from the Flint community
• Expand current behavioral health services
• Educate Flint citizens about available services and support
PROTECTING CITIZENS FROM LEAD EXPOSURE
Flint, MI reminds us of…
▪ Importance of surveillance systems to help identify potential health risks
▪ Value of strong cooperative agreement programs to build capacity at state and local level to support lead poisoning prevention efforts
▪ How precious clean water is and how we must maintain constant vigilance to ensure access to clean water, especially for our most vulnerable citizens
Water Resources Development Act
▪ Response to Flint water crisis
▪ Mandatory Funding
▪ Provided TA to Michigan delegation
▪ Differences in House and Senate bills
Purpose Transfer of Funds Total Amount Amount Per Year Funding Period
Lead Exposure Registry Secretary of HHS $17.5 m $3.5 m FY16 to FY20
Advisory Committee Secretary of HHS $2.5 m $500,000 FY16 to FY20
Lead Poisoning Prevention
ProgramDirector of the CDC $15 m $7.5 m FY17 and FY18
Lead in Water – A National Issue
▪ Focus on safe water from all sources
▪ Ensure that water is sampled as potential source of lead in cities with aging infrastructure
▪ Implement more robust and sensitive surveillance system
▪ Revise existing Lead and Copper Rule to include notification of public health agencies
For more information, contact NCEH/ATSDR1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.atsdr.cdc.gov www.cdc.govFollow us on Twitter @CDCEnvironment
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry.
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