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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