Blood Lead Levels Among Children Aged <6 Years - Flint, Michigan, 2013-2016.

During April 25, 2014-October 15, 2015, approximately 99,000 residents of Flint, Michigan, were affected by changes in drinking water quality after their water source was switched from the Detroit Water Authority (DWA), sourced from Lake Huron, to the Flint Water System (FWS), sourced from the Flint River.* Because corrosion control was not used at the FWS water treatment plant, the levels of lead in Flint tap water increased over time. Adverse health effects are associated with lead exposure (1). On January 2, 2015, a water advisory was issued because of detection of high levels of trihalomethanes, byproducts of disinfectants.(†)(,)(§) Studies conducted by local and national investigators detected an increase in the prevalence of blood lead levels (BLLs) ≥5 µg/dL (the CDC reference level) among children aged <5 years living in Flint (2) and an increase in water lead levels after the water source switch (3). On October 16, 2015, the Flint water source was switched back to DWA, and residents were instructed to use filtered tap water for cooking and drinking. During that time, pregnant and breastfeeding women and children aged <6 years were advised to consume bottled water.(¶) To assess the impact on BLLs of consuming contaminated drinking water, CDC examined the distribution of BLLs ≥5 µg/dL among children aged <6 years before, during, and after the switch in water source. This analysis enabled determination of whether the odds of having BLLs ≥5 µg/dL before the switch differed from the odds during the switch to FWS (before and after the January 2, 2015, water advisory was issued), and after the switch back to DWA. Overall, among 9,422 blood lead tests in children aged <6 years, 284 (3.0%) BLLs were ≥5 µg/dL during April 25, 2013-March 16, 2016. The adjusted probability of having BLLs ≥5 µg/dL was 46% higher during the period after the switch from DWA to FWS (and before the January 2, 2015, water advisory) than during the period before the water switch to FWS. Although unrelated to lead in the water, the water advisory likely reduced tap water consumption and increased consumption of bottled water. Characterizing exposure to lead contaminated drinking water among children aged <6 years living in Flint can help guide appropriate interventions.

School-based pediatric asthma surveillance in Massachusetts from 2005 to 2009.

BACKGROUND: Asthma is the most common chronic disease among children today, yet surveillance is limited to national and state estimates which can vary over time, by location and by population types. This article describes a comprehensive statewide school-based asthma surveillance program and examine 5 years of surveillance data. METHODS: After pilot testing, a 1-page survey was mailed to school nurses in all public, private, and charter schools in Massachusetts. Variables measured included the number of students with a diagnosis of asthma by sex, grade (K-8), race/ethnicity by school and by community of residence. RESULTS: The participation rate increased each year, and by the 5th year it was nearly 100%. The reported asthma prevalence was 10.6% (averaged for the 5-year period) and noted to be higher among males each year. CONCLUSIONS: This work provides evidence that a school-based pediatric asthma surveillance system can be developed and successfully implemented. The feasibility of using school health records, as an accessible data source to readily identify asthma cases can provide reliable aggregate community-based pediatric asthma prevalence information.

Consumers' estimation of calorie content at fast food restaurants: cross sectional observational study.

OBJECTIVE: To investigate estimation of calorie (energy) content of meals from fast food restaurants in adults, adolescents, and school age children. DESIGN: Cross sectional study of repeated visits to fast food restaurant chains. SETTING: 89 fast food restaurants in four cities in New England, United States: McDonald's, Burger King, Subway, Wendy's, KFC, Dunkin' Donuts. PARTICIPANTS: 1877 adults and 330 school age children visiting restaurants at dinnertime (evening meal) in 2010 and 2011; 1178 adolescents visiting restaurants after school or at lunchtime in 2010 and 2011. MAIN OUTCOME MEASURE: Estimated calorie content of purchased meals. RESULTS: Among adults, adolescents, and school age children, the mean actual calorie content of meals was 836 calories (SD 465), 756 calories (SD 455), and 733 calories (SD 359), respectively. A calorie is equivalent to 4.18 kJ. Compared with the actual figures, participants underestimated calorie content by means of 175 calories (95% confidence interval 145 to 205), 259 calories (227 to 291), and 175 calories (108 to 242), respectively. In multivariable linear regression models, underestimation of calorie content increased substantially as the actual meal calorie content increased. Adults and adolescents eating at Subway estimated 20% and 25% lower calorie content than McDonald's diners (relative change 0.80, 95% confidence interval 0.66 to 0.96; 0.75, 0.57 to 0.99). CONCLUSIONS: People eating at fast food restaurants underestimate the calorie content of meals, especially large meals. Education of consumers through calorie menu labeling and other outreach efforts might reduce the large degree of underestimation.

"Operation Helping Hands": Massachusetts health and medical response to Hurricane Katrina.

INTRODUCTION: As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted more than 200,000 evacuees. HYPOTHESIS/PROBLEM: In this case study, "Operation Helping Hands" (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history. METHODS: The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight of operations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned. RESULTS: Activities and services were provided in the following areas: (1) administration and management; (2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and outcomes of similar operations. CONCLUSIONS: This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.

Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making.

Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states.

Developing integrated multistate environmental public health surveillance.

Environmental exposures cause substantial morbidity and mortality in the United States. A major goal of Centers for Disease Control and Prevention Environmental Public Health Tracking program is the development of a national network of health and environmental data with analytic tools for rapid evaluation of specific national or regional environmental health concerns. A six-state collaborative project in the northeast United States was established to assess the feasibility of such a system, assessing the possible association between ambient air quality and adverse birth outcomes. For this regional surveillance project, issues were discussed surrounding the design of a mutually acceptable protocol, obtaining human subjects' protection approvals, obtaining and organizing both the exposure and outcome data, analyzing the data both locally and regionally, and planning subsequent interventions to address identified public health concerns.

Effect of glutathione S-transferase polymorphisms and proximity to hazardous waste sites on time to systemic lupus erythematosus diagnosis: results from the Roxbury lupus project.

OBJECTIVE: The high prevalence of systemic lupus erythematosus (SLE) among African American women may be due to environmental exposures, genetic factors, or a combination of factors. Our goal was to assess association of residential proximity to hazardous waste sites and genetic variation in 3 glutathione Stransferase (GST) genes (GSTM1, GSTT1, and GSTP1) with age at diagnosis of SLE. METHODS: Residential histories were obtained by interviewing 93 SLE patients from 3 predominantly African American neighborhoods in Boston. Residential addresses and locations of 416 hazardous waste sites in the study area were geocoded using ArcView software. Time-varying Cox models were used to study the effect of residential proximity to hazardous sites, GST genotype, and interaction between genotype and exposure in determining age at diagnosis. RESULTS: The prevalence of SLE among African American women in these neighborhoods was 3.56 SLE cases per 1,000. Homozygosity for GSTM1-null and GSTP1 Ile105Val in combination was associated with earlier SLE diagnosis (P = 0.03), but there was no association with proximity to 416 hazardous sites. Available data on specific site contaminants suggested that, at a subset of 67 sites, there was higher potential risk for exposure to volatile organic compounds (P < 0.05 with Bonferroni correction). GST genotypes had a significant interaction with proximity (P = 0.03) in analyses limited to these sites. CONCLUSION: There was no independent association between residential proximity to hazardous waste sites and the risk of earlier SLE diagnosis in this urban population. However, analysis of a limited number of sites indicated that the risk of earlier SLE associated with proximity to hazardous sites might be modulated by GST polymorphisms.

Tracking pediatric asthma: the Massachusetts experience using school health records.

The Massachusetts Department of Public Health, in collaboration with the U.S. Centers for Disease Control and Prevention Environmental Public Health Tracking Program, initiated a 3-year statewide project for the routine surveillance of asthma in children using school health records as the primary data source. School district nurse leaders received electronic data reporting forms requesting the number of children with asthma by grade and gender for schools serving grades kindergarten (K) through 8. Verification efforts from an earlier community-level study comparing a select number of school health records with primary care provider records demonstrated a high level of agreement (i.e., > 95%). First-year surveillance targeted approximately one-half (n = 958 schools) of all Massachusetts's K-8 schools. About 78% of targeted school districts participated, and 70% of the targeted schools submitted complete asthma data. School nurse-reported asthma prevalence was as high as 30.8% for schools, with a mean of 9.2%. School-based asthma surveillance has been demonstrated to be a reliable and cost-effective method of tracking disease through use of an existing and enhanced reporting structure.

A case-control study of childhood leukemia in Woburn, Massachusetts: the relationship between leukemia incidence and exposure to public drinking water.

A 1981 Massachusetts Department of Public Health study confirmed a childhood leukemia cluster in Woburn, Massachusetts. Our follow-up investigation attempts to identify factors potentially responsible for the cluster. Woburn has a 130-year industrial history that resulted in significant local deposition of tannery and chemical manufacturing waste. In 1979, two of the city's eight municipal drinking water wells were closed when tests identified contamination with solvents including trichloroethylene. By 1986, 21 childhood leukemia cases had been observed (5.52 expected during the seventeen year period) and the case-control investigation discussed herein was begun. Nineteen cases and 37 matched controls comprised the study population. A water distribution model provided contaminated public water exposure estimates for subject residences. Results identified a non-significant association between potential for exposure to contaminated water during maternal pregnancy and leukemia diagnosis, (odds ratio = 8.33, 95% CI 0.73-94.67). However, a significant dose-response relationship (P < 0.05) was identified for this exposure period. In contrast, the child's potential for exposure from birth to diagnosis showed no association with leukemia risk. Wide confidence intervals suggest cautious interpretation of association magnitudes. Since 1986, expected incidence has been observed in Woburn including 8 consecutive years with no new childhood leukemia diagnoses.