Lessons Learned from Flint, MI: Implications for our Community

Transcription

1 National Center for Environmental Health Agency for Toxic Substances and Disease Registry Lessons Learned from Flint, MI: Implications for our Community CAPT Renée Funk, DVM, MPH&TM, MBA, DACVPM Assoc Dir, Emerg Mngt, NCEH/ATSDR LT Gamola Z. Fortenberry, PhD, MPH Epidemic Intelligence Service Officer, NCEH/ASTER-Health Studies Branch May 17, 2017 Photo source: abcnews.go.com

2 RESPONSE TO WATER CONTAMINATION IN FLINT, MI

3 Background on Flint Water Contamination Timeline Change to Flint river water Genesee County issues public health emergency; Water source switched back to Detroit water Federal assistance begins, under a Unified Coordination Group (UCG) CDC deactivates EOC, continues to provide assistance April 2014 Aug Oct. 2, 2015 Dec. 14, 2015 Jan Feb. 1, 2016 March 15, 2016 May 17-19, 2016 Dr. Mona Hanna-Attisha publishes study of blood lead levels Flint Mayor Weaver declared a state of emergency CDC EOC activated under a Unified Coordination Group (UCG) CASPER conducted

4 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

5 NCEH/ATSDR ACTIVITIES IN FLINT, MI

6 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.

7 Morbidity and Mortality Weekly Report (MMWR) Blood lead levels among children aged <6 years living in the City of Flint, MI, Released June 17, 2016 Report added Proportion of children aged <6 years in Flint, MI with BLLs 5 µg/dl was 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

8 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 Early Water Source Switch Late Water Source Switch Post-Water Source Switch Before switch in water supply to Flint River During switch in water supply to Flint River When there was boil water advisory from city officials After water supply switched from Flint River to DWS 04/25/ /24/ /25/ /02/ /03/ /15/ /16/ /16/2016

9 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 ( ) Late Water Switch 1.28 ( ) Post-Water Source Switch 0.75 ( ) Age group <1 year years 2.25 ( ) 3 5 years 1.36 ( ) Season Winter (Dec Feb) 1.0 Spring (Mar May) 1.41 ( ) Summer (Jun Aug) 2.14 ( ) Fall (Sep Nov) 2.25 ( ) *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.

10 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 Case management should be provided to all children with BLLs 5 µg/dl.

11 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

12 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

13 Community concerns

14 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

15 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

16 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

17 CASPER Sampling Design Sampling frame City limits of Flint, Michigan 24,983 housing units 102,000 people

18 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

19 Data Collection May 17 19, 2016 Two- person interview teams assigned to two or three clusters and instructed to go to every n th household Three attempts at each household before replacement

20 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

21 RESULTS

22 Questionnaire Response Rates Percent (%) Rate Description Completion /210 Total completed 210 Cooperation /240 Total completed Total contact made Contact* /343 Total completed Total selected *Excludes vacant housing

23 Individual-Level Data

24 Individual Demographics Average age of respondent was 49 years (range = 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

25 Weighted Individual Percentage (%) Individual Self-Reported Behavioral Health Concerns: Depression and Anxiety Symptoms Over Last Two Weeks % 66.6% % 33.4% Yes No Depression Symptoms Anxiety Symptoms

26 Individual Self-Reported Behavioral Health Concerns: Financial Stress in Last 12 Months Frequency Weighted % Worried or stressed about paying rent/mortgage (n=180) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) Never/Rarely Always/Usually/Sometimes * ( ) Worried or stressed about buying nutritious meals (n=180) Never/Rarely Always/Usually/Sometimes * ( ) *Significantly different p<0.05 level

27 Individual Self-Reported Behavioral Health Concerns: Financial Stress in Last 12 Months Frequency Weighted % Worried or stressed about paying rent/mortgage (n=180) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) Never/Rarely Always/Usually/Sometimes * ( ) Worried or stressed about buying nutritious meals (n=180) Never/Rarely Always/Usually/Sometimes * ( ) *Significantly different p<0.05 level

28 Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison Frequency Weighted % Physical illness and injury during the past 30 days (n=176) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) <13 days >14 days * ( ) Poor mental health during the past 30 days (n=174) <13 days >14 days * ( ) Interruption of normal activities during the past 30 days (n=178) <13 days >14 days * ( ) *Significantly different p<0.05 level

29 Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison Frequency Weighted % Physical illness and injury during the past 30 days (n=176) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) <13 days >14 days * ( ) Poor mental health during the past 30 days (n=174) <13 days >14 days * ( ) Interruption of normal activities during the past 30 days (n=178) <13 days >14 days * ( ) *Significantly different p<0.05 level

30 Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison Frequency Weighted % Physical illness and injury during the past 30 days (n=176) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) <13 days >14 days * ( ) Poor mental health during the past 30 days (n=174) <13 days >14 days * ( ) Interruption of normal activities during the past 30 days (n=178) <13 days >14 days * ( ) *Significantly different p<0.05 level

31 Individual Self-Reported Behavioral Health Concerns and 2014 Behavioral Risk Factor Surveillance System (BRFSS) Comparison Frequency Weighted % Physical illness and injury during the past 30 days (n=176) Weighted 95% CI Michigan BRFSS Weighted % (95% CI) <13 days >14 days * ( ) Poor mental health during the past 30 days (n=174) <13 days >14 days * ( ) Interruption of normal activities during the past 30 days (n=178) <13 days >14 days * ( ) *Significantly different p<0.05 level

32 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

33 Discussion Increased behavioral health impacts in crisis-affected communities observed after other human-induced events 1 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 prevalence 1. 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, Prehospital and Disaster Medicine. 2012;27: 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): 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: 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): 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):

34 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

35 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

36 PROTECTING CITIZENS FROM LEAD EXPOSURE

37 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

38 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 Program Director of the CDC $15 m $7.5 m FY17 and FY18

39 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

40 Questions For more information, contact NCEH/ATSDR CDC-INFO ( ) TTY: Follow us on 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.