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Elevated Blood Lead Levels in Children Associated with the Flint Drinking Water Crisis: a Spatial Analysis of Risk and Public Health Response

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Elevated Blood Lead Levels in Children Associated with the Flint Drinking Water Crisis: a Spatial Analysis of Risk and Public Health Response AJPH RESEARCH Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response Mona Hanna-Attisha, MD, MPH, Jenny LaChance, MS, Richard Casey Sadler, PhD, and Allison Champney Schnepp, MD Objectives. We analyzed differences in pediatric elevated blood lead level incidence percentage of lead pipes and lead plumbing, before and after Flint, Michigan, introduced a more corrosive water source into an aging with estimates of lead service lines ranging 7 water system without adequate corrosion control. from 10% to 80%. Researchers from Virginia Methods. We reviewed blood lead levels for children younger than 5 years before Tech University reported increases in water 5 (2013) and after (2015) water source change in Greater Flint, Michigan. We assessed the lead levels (WLLs), but changes in blood lead levels (BLLs) were unknown. percentage of elevated blood lead levels in both time periods, and identified geo- Lead is a potent neurotoxin, and child- graphical locations through spatial analysis. hood lead poisoning has an impact on Results. Incidence of elevated blood lead levels increased from 2.4% to 4.9% (P < .05) many developmental and biological pro- after water source change, and neighborhoods with the highest water lead levels ex- cesses, most notably intelligence, behavior, fi perienced a 6.6% increase. No signi cant change was seen outside the city. Geospatial and overall life achievement.8 With estimated – analysis identified disadvantaged neighborhoods as having the greatest elevated blood societal costs in the billions,9 11 lead poi- lead level increases and informed response prioritization during the now-declared public soning has a disproportionate impact on health emergency. low-income and minority children.12 When Conclusions. The percentage of children with elevated blood lead levels increased one considers the irreversible, life-altering, after water source change, particularly in socioeconomically disadvantaged neighbor- costly, and disparate impact of lead exposure, hoods. Water is a growing source of childhood lead exposure because of aging infra- primary prevention is necessary to 13 structure. (Am J Public Health. 2016;106:283–290. doi:10.2105/AJPH.2015.303003) eliminate exposure. Historically, the industrial revolution’s See also Rosner, p. 200. introduction of lead into a host of products has contributed to a long-running and largely silent pediatric epidemic.14 With n April 2014, the postindustrial city of Water from the Detroit Water and lead now removed from gasoline and paint, IFlint, Michigan, under state-appointed Sewage Department had very low corrosivity the incidence of childhood lead poisoning emergency management, changed its water for lead as indicated by low chloride, low has decreased.15 However, lead contamina- supply from Detroit-supplied Lake Huron chloride-to-sulfate mass ratio, and presence tion of drinking water may be increasing water to the Flint River as a temporary 3,4 of an orthophosphate corrosion inhibitor. because of lead-containing water in- measure, awaiting a new pipeline to Lake By contrast, Flint River water had high frastructures, changes in water sources, and Huron in 2016. Intended to save money, the chloride, high chloride-to-sulfate mass ratio, changes in water treatment including disin- change in source water severed a half- 5 – and no corrosion inhibitor. Switching fectant.16 18 A soluble metal, lead leaches into century relationship with the Detroit Water from Detroit’s Lake Huron to Flint River drinking water via lead-based plumbing or and Sewage Department. Shortly after the water created a perfect storm for lead leach- lead particles that detach from degrading switch to Flint River water, residents voiced 6 ing into drinking water. The aging Flint plumbing components. (“Plumbing” is concerns regarding water color, taste, and water distribution system contains a high derived from the Latin word for lead, odor, and various health complaints in- cluding skin rashes.1 Bacteria, including Escherichia coli, were detected in the distri- ABOUT THE AUTHORS bution system, resulting in Safe Drinking Mona Hanna-Attisha and Allison Champney Schnepp are with Hurley Children’s Hospital/Michigan State University Water Act violations.2 Additional disinfec- College of Human Medicine, Department of Pediatrics and Human Development, Flint, MI. Jenny LaChance is with Hurley Medical Center Research, Flint. Richard Casey Sadler is with Michigan State University College of Human Medicine, tion to control bacteria spurred formation of Division of Public Health, Flint. disinfection byproducts including total tri- Correspondence should be sent to Mona Hanna-Attisha, MD, MPH, FAAP, Hurley Medical Center, Pediatrics 3W, One halomethanes, resulting in Safe Drinking Hurley Plaza, Flint, MI 48503 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. Water Act violations for trihalomethane This article was accepted November 21, 2015. 2 levels. doi: 10.2105/AJPH.2015.303003 February 2016, Vol 106, No. 2 AJPH Hanna-Attisha et al. Peer Reviewed Research 283 AJPH RESEARCH “plumbum.”) Lead was restricted in plumb- a geographic information system (GIS) to system. Children living outside the city where ing material in 1986, but older homes and determine lead exposure risk and prioritize the water source was unchanged served as neighborhoods may still contain lead responses. This research has immediate public a comparison group (n = 2202; pre = 1210; service lines, lead connections, lead solder, or policy, public health, environmental, and post = 992). other lead-based plumbing materials. Lead socioeconomic implications. After institutional review board approval solubility and particulate release is highly This research includes Flint, Michigan, and and Health Insurance Portability and variable and depends on many factors in- surrounding municipalities in Genesee Accountability Act waiver, we drew data cluding water softness, temperature, and County (Greater Flint). Greater Flint is a from the Epic electronic medical record – acidity.19 21 The US Environmental Pro- postindustrial region of nearly 500 000 people system including BLL, medical record tection Agency (EPA) regulates lead in struggling from years of disinvestment by number, date of birth, date of blood draw, public water supplies under the Safe Drinking the automobile industry and associated full address, sex, and race. For each child, Water Act Lead and Copper Rule, which manufacturing activities: the region has lost only the highest BLL was maintained in the requires action when lead levels reach 15 parts 77% of its manufacturing employment and data set. We coded timing (pre or post) of per billion (ppb). 41% of employment overall since 1980.28 the BLL on the basis of the date of blood draw. Lead in drinking water is different from National and local data sources demonstrate We calculated age at time of blood draw. lead from other sources, as it disproportion- dismal indicators for children, especially We geocoded the data set with a dual- – ately affects developmentally vulnerable within Flint city limits.29 32 Greater Flint range address locator, and manually con- children and pregnant mothers. Children can ranks toward the bottom of the state in rates of firmed accuracy of geocoded addresses. We absorb 40% to 50% of an oral dose of childhood poverty (42% in Flint vs 16.2% in conducted a series of spatial joins to assign water-soluble lead compared with 3% to 10% Michigan and 14.8% in the United States), participant records to Greater Flint munici- for adults.22 In a dose–response relationship unemployment, violent crime, illicit drug palities and Flint wards (including those for children aged 1 to 5 years, for every 1-ppb use, domestic violence, preterm births, infant with high WLL), enabling the calculation increase in water lead, blood lead increases mortality, and overall health outcomes (81st of the number and percentage of children 35%.23 The greatest risk of lead in water may out of 82 Michigan counties). with EBLLs in each geographic region for be to infants on reconstituted formula. Greater Flint’s struggles have been am- both time periods. The reference value for Among infants drinking formula made from plified by a history of racial discrimination, EBLL was 5 mg/dL or greater. We identified tap water at 10 ppb, about 25% would ex- whereby exclusionary housing practices were Flint wards with high WLLs with water perience a BLL above the Centers for Disease common.33,34 Such attitudes toward in- lead sampling maps.38 Wards 5, 6, and 7 Control and Prevention (CDC) elevated tegration later precipitated White flight and had the highest WLLs; in each ward, more blood lead level (EBLL) of 5 micrograms per emboldened home-rule governance,35,36 than 25% of samples had a WLL higher than deciliter (mg/dL).24 Tap water may account causing a massive decline in tax revenue for 15 ppb. We theorized that children living in for more than 85% of total lead exposure the city. The declining industrial and resi- this combination of wards would have the among infants consuming reconstituted dential tax bases strained the city’s ability to highest incidence of EBLLs (referred to as formula.25 A known abortifacient, lead has provide basic services and reversed the public “high WLL Flint”; the remainder of Flint also been implicated in increased fetal health fortunes of the city and suburbs.37 was referred to as “lower WLL
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