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Try out PMC Labs and tell us what you think. Learn More. Hanna-Attisha originated the study, developed methods, interpreted analysis, and contributed to the writing of the article. LaChance and R. Casey Sadler assisted with the development of the methods, analyzedinterpreted the findings, and contributed to the writing of the article.

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Champney Schnepp assisted with the interpretation of the findings and contributed to the writing of the article. We analyzed differences in pediatric elevated blood lead level incidence before and after Flint, Michigan, introduced a more corrosive water source into an aging water system without adequate corrosion control. We reviewed blood lead levels for children younger than 5 years before and after water source change in Greater Flint, Michigan.

We assessed the percentage of elevated blood lead levels in both time periods, and identified geographical locations through spatial analysis. Incidence of elevated blood lead levels increased from 2. No ificant change was seen outside the city. Geospatial analysis identified disadvantaged neighborhoods as having the greatest elevated blood lead level increases and informed response prioritization during the now-declared public health emergency.

Flint water crisis: everything you need to know

The percentage of children with elevated blood lead levels increased after water source change, particularly in socioeconomically disadvantaged neighborhoods. Water is a growing source of childhood lead exposure because of aging infrastructure. In Aprilthe postindustrial city of Flint, Michigan, under state-appointed emergency management, changed its water supply from Detroit-supplied Lake Huron water to the Flint River as a temporary measure, awaiting a new pipeline to Lake Huron in Intended to save money, the change in source water severed a half-century relationship with the Detroit Water and Sewage Department.

Shortly after the switch to Flint River water, residents voiced concerns regarding water color, taste, and odor, and various health complaints including skin rashes.

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Water from the Detroit Water and Sewage Department had very low corrosivity for lead as indicated by low chloride, low chloride-to-sulfate mass ratio, and presence of an orthophosphate corrosion inhibitor. Lead is a potent neurotoxin, and childhood lead poisoning has an impact on many developmental and biological processes, most notably intelligence, behavior, and overall life achievement.

Lead solubility and particulate release is highly variable and depends on many factors including water softness, temperature, and acidity. Lead in drinking water is different from lead from other sources, as it disproportionately affects developmentally vulnerable children and pregnant mothers. As recommended by the CDC and supported by the American Academy of Pediatrics, blood lead screening is routine for high-risk populations and for children insured by Medicaid at age 1 and 2 years. State and national blood lead—screening programs, however, do not adequately capture the risk of lead in water because infants are at greatest risk.

Armed with reports Flint elevated WLLs and recognizing the lifelong consequences of lead exposure, our research team sought to analyze blood lead data before pre and after post the water source switch with a live information system GIS to determine lead exposure risk and prioritize responses. This research has immediate public policy, public health, environmental, and socioeconomic implications.

The pre time period before the water source change was January 1,to September 15,and the post time period after the water source change was January 1,to September 15, After institutional review board approval and Health Insurance Portability and ability Act waiver, we drew data from the Epic electronic medical record system including BLL, medical recorddate of birth, date of blood draw, full dating, sex, and race.

For each child, only the highest BLL was maintained in the data set. We coded timing pre or post of the BLL on the basis of the date of blood draw. We calculated age at time of blood draw. We geocoded the data set with a dual-range address locator, and manually confirmed accuracy of geocoded addresses. We conducted a series of spatial s to as participant records to Greater Flint municipalities and Flint wards including those with high WLLenabling the calculation of the and percentage of children with EBLLs in each geographic region for both time periods.

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We identified Flint wards with high WLLs with water lead sampling maps. We derived overall neighborhood-level socioeconomic disadvantage from census block group variables dating to measure material and social deprivation. We calculated these scores from an unweighted z score sum of rates of lone parenthood, poverty, low educational attainment, and unemployment adapted from Pampalon et al. Positive values denote higher disadvantage, and negative values denote lower disadvantage. Table 1 highlights the overall socioeconomic disadvantage score live by time period and area.

No statistically ificant differences were found in any pre—post value within any of the 4 geographical areas. We created spatial references for EBLL risk and a predictive surface for BLL by using GIS, providing the ability to see otherwise invisible spatial—temporal patterns in environmental exposure. methods for evaluating spatial variation in lead levels have ranged from multivariable analyses at the individual level 41 to interpolation methods such as inverse distance weighting 42 and Kriging.

Both inverse distance weighting and Kriging derive such surfaces by calculating values at unmeasured locations based on weighting nearby measured values more strongly than distant values. As well, Kriging can be run with relatively few input points: adequate ranges fall between 30 and total points, although Kriging Flint been conducted with just 7.

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Our city of Flint sample included children in the pre period and children in the post period, which amounts to a density of approximately 22 points per square mile. Kriging has become an increasingly common method for measuring variations in soil lead, and is given more in-depth treatment elsewhere. In addition, we examined differences in overall socioeconomic disadvantage scores from the pre to post time periods by using the independent t test.

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We used post hoc least ificant difference analysis following statistically ificant 1-way ANOVAs. We uncovered a statistically ificant increase in the proportion of Flint children with EBLL from the pre period to the proportion of Flint children in the post period. In the pre period, 2. Figure 1 shows the EBLL percentage change per area.

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The darkest shades of red represent the highest risk for EBLL based on existing observations. Outside Flint, the entire county falls entirely within the lowest half Flint the range in shades of blue ; the only locations where predicted BLL is greater than 1. Within Figure 2each ward is also labeled according to the percentage of water samples that exceeded 15 ppb.

Figure A quantifies this rate of change with a green to red scale: large live are shown in increasingly darker shades of red, whereas large decreases are shown in increasingly darker shades of green. In wards 5 and 6 which experienced a predicted 0. In ward 5, the EBLL percentage increased from 4. The Flint of intersection between wards 3, 4, and 5 in the east side of the city also appeared high in the Kriging analysis of Figure 2and with a different unit of aggregation this neighborhood would also exhibit a ificant increase in EBLL percentage.

Citywide, 4 wards 1, 4, 7, and 9 experienced decreases in predicted BLL, 3 wards 2, 5, and 6 experienced large increases, and 2 wards 3 and 8 remained largely the same Figure A. Overall, statistically ificant differences exist between the areas examined outside Flint, high WLL Flint, and dating WLL Flint in all demographic characteristics except sex. The live percentage of African American children is Our findings reveal a striking increase dating the percentage of Flint children with EBLL when we considered identical seasons before and after the water source switch, with no statistically ificant increase in EBLL outside Flint.

The spatial and statistical analyses highlight the greatest EBLL increase within certain wards of Flint, which correspond to the areas of elevated WLLs. A review of alternative sources of lead exposure reveals no other potential environmental confounders during the same time period. As well, no known new lead-producing factories nor changes in indoor lead remediation programs were implemented during the study period. Although Flint has a ificant automobile history, the historical location of potentially lead-using manufacturing e.

Because there was no known alternative source for increased lead exposure during this time period, the geospatial WLLthe innate corrosive properties of Flint River water, and, most importantly, the lack of corrosion control, our findings strongly implicate the water source change as the probable cause for the dramatic increase in EBLL percentage.

As in many urban areas with high levels of socioeconomic disadvantage and minority populations, 46 we found a preexisting disparity in lead poisoning. Flint children already suffer from risk factors that innately increase their lead exposure: poor nutrition, concentrated poverty, and older housing stock. With limited protective measures, such as low rates of breastfeeding, 47,48 and scarce resources for water alternatives, lead in water further exacerbates preexisting risk factors.

Increased lead-poisoning rates have profound implications for the life course potential of an entire cohort of Flint children already rattled with toxic stress contributors e. The Kriging analysis showed the highest predicted BLLs within the city along a wide swath north and west of downtown.

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Flint area has seen ificant demographic change, an increase in poverty, and an increase in vacant properties, especially over the past 25 years Richard Sadler, written communication, October 5, Higher BLLs were also predicted northeast of downtown and in other older neighborhoods where poverty and vacancy rates have been high for many decades.

ificantly, the biggest changes in predicted BLL since were also found in these impoverished neighborhoods; more stable neighborhoods in the far north and south of the city may have experienced improved predicted BLLs because of prevention efforts taken by the more-often middle-class residents in response to the water source change. Of considerable interest is that the areas shown as having the best public health indices by Board and Dunsmore in Figure 2 of dating article 37 are virtually identical to the areas with the worst lead levels today. We undertook our current spatial analytic approach to overcome limitations of zip code boundaries and to develop a more thorough understanding of specific areas in Flint where EBLL risk is more severe post office addresses often do live align with municipal boundaries in Michigan, and one third of Flint mailing addresses are not in the city of Flint.

This spatial analysis is valuable for understanding subneighborhood patterns in EBLL risk because aggregation by zip code or ward minimizes the richness of spatial variation and creates artificial barriers that may obscure hot spots as in the confluence of wards 3, 4, and 5.

Elevated blood lead levels in children associated with the flint drinking water crisis: a spatial analysis of risk and public health response

Such use of spatial analysis for estimating lead exposure risk has been used to target blood lead—screening programs. In our case, in addition to identifying areas of risk, spatial analysis helps guide municipal and nongovernmental relief efforts aimed at identifying vulnerable populations in specific neighborhoods for priority distribution of resources e.

Our research contains a few limitations. First, we may have underestimated water-based lead exposure.

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Our sample included all children younger than 5 years with blood lead screening, although the greatest risk from lead in water is in utero and during infancy when lead screening is not done. If lead screening were recommended at a younger age e. Second, lead screening is not completed for all children.

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It is mandated by Medicaid and CDC-recommended for other high-risk groups; such data may be skewed toward higher-risk children and thus overestimate EBLL, especially in non—high-risk areas. Third, the underserved population of Flint has ificant housing instability: lead levels may reflect environmental exposure, and exposure often cannot be adequately estimated on the basis of current residence alone.

Fourth, although large, our sample does not reflect all lead screening from Flint. Annual data released from this program further support our findings, revealing an annual decrease in EBLL percentage from May to April to until the same period in to 4. Scott, e-mail correspondence, September 25, Following the water switch in Aprilthe 4-year declining trend as seen nationally reversed with an annual EBLL of 3.

Our institution-processed laboratory blood lead tests, however, had an even greater proportion of children with EBLLs versus state data in the post period.

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Future research directions include conducting more detailed geospatial analyses of lead service-line locations with locations of elevated BLLs and WLLs; repeating identical spatial and statistical analyses in the same time period in reflecting changes associated with the health advisory and return to Lake Huron source water; analyzing feeding type breastfed or reconstituted formula for children with EBLLs; analyzing cord blood lead of Flint newborns compared with non-Flint newborns; and conducting water lead testing from homes of children with EBLLs.

A once celebrated cost-cutting move for an economically distressed city, the water source change has now wrought untold economic, population health, and geopolitical burdens. The legal safeguards and regulating bodies deed dating protect vulnerable populations from preventable lead exposure failed. In response to the Flint drinking water crisis, the EPA recently released a memo reiterating and clarifying the need for states to conduct corrosion control reviews before implementing changes. Through vigilant public health efforts, lead exposure live fallen dramatically over the past 30 years.

As our aging water infrastructures continue to decay, and as communities across the nation struggle with finances and water supply sources, the situation in Flint, Michigan, may be a Flint for future safe drinking-water challenges. Ironically, even when one is surrounded by the Great Lakes, safe drinking water is not a guarantee.