Correspondence between

case management resources continue for families You are correct, Larry, that the MDHHS data is pulled out of the Data Warehouse by Flint zip. Eden

g xxxEND_PAGE:dhhs03_b0303_1121_1126_2 001123 Reynolds, Lawrence; Laura Carravallah; Marc Edwards; Valacak, Mark; Andy Leavitt; Base Camp Email; Lasher, Geralyn (DHHS); Eisner, Jennifer (DHHS); Dykema, Linda D. (DHHS)

case management resources continue for families Eden, i support frequent updates. Mona and her tearm can continue to de the GIS work and track progress {or lack thereof} in the blood leads. i think that overall, the latest data implies we are on the right track. We can use the upclates to reinforce the importance of using the Hiters and bottled water that are being provided... Kast Regards,

case management resources continue for families Hi Dr. Reynolds, | just got done with an email with Mona--- This is a general public report that is high level--not a technical report, and was not meant to represent a technical report. This is general information--of course our surveillance program is tracking by zip, Medicaid, locality, etc. We can discuss further what type of reporting may be useful to a technical audience---as long as not identifiable (some zips have to be suppressed) | don't see why this can't be done (probably not every two weeks like this public one would be) Warm Regards, Eden Michig. 201 Towns: lreys2@email. com> Sent: Thursday, December 3, 2015 3:25 PM

case management resources continue for families This is a good start but maybe lacking context . Would GIS software identify clusters ? |! am disappointed to see, at this moment , thatDr. Edward's study and Dr. Mona's study which have more granular reporting are given no credence. Is there a reason ? wonsenae == Forwarded message ----------

xxxEND_PAGE:dhhs03_b0125_0333_0336_1 000334 Looping | our toxicologist, as we ha e discussed this. Note that anyone should be using filtered or bottled water now, so that the issue of which house and which risk should already be addressed. Also- we do not have any data supporting adults with blood lead levels that high ( Off top of my head) and none have been in the 40's or higher since Long before April 2014. Regardless, Linda and | had talked about breastfeeding moms... She can help. Eden Sent from my iPhone

Here is the flyer fromm the interagency website, attached.

Good rnorning, Mote that MOHHS/GCHD is about ta send out (by emails and hopefully you all can disseminate at will to your colleagues?) a provider letter with provider resources, which will also all be on the webpage we are using. Parent letters with resources for them will be going out in hard copy through schools and daycares---all of this will be occurring in the next couple of days. Note that there is already 4 flyer on the Michigan. gou/Hintweter webpage for pregnant moms and breastleeding--note that, like all others including children, treatment only occurs for fevels over 45, but removing lead frorn any envirorumental sources fs important at all times. We have already gotten information regarding pregnancy ari lead levels from CDC: (Mary Jean Brown): “Pragnant women who work with lead should be tested (occupational, hobby, shooting ranges, renovation exposures). Worrled women who want to be tested should rat be refuse but if their only exposure is the water the only Intervantion is tie stop drinking the water from the river and itis my understanding that that has bean accornplished. There is na medical treatment for oregriant wornen {chelation therapy} in the first trimester because of teratogenic concerns. At blood lead levelg >=45 in later trirnesters, chelation: may be corsidered to protect the fetus but should only be done in consultation with sarneone familiar with chelation in earhy childhood and high risk pregnancies. A general alert to area OB/Gyn's ard maternity clinics that patients should not drink water frarn the river, would be advisable.” xxxEND_PAGE:dhhs03_b0161_0693_0696_3 000696 Eden Eden V. Wells, MD, MPH, FACPM Chief Medical Executive Michigan Bepartment of Health and Human Services 204 Townsend St, 5"" Floor CVB Lansing, ME48913 Sent: Friday, October 30, 2015 10:51 AM

Dear Eden, Our county medical society is in the process of drafting a “fact sheet” specifically for our physician members to try and help them help their patients. We are endeavoring to keep the content consistent with the other messaging going out, but to use as many channels as we can, and to make this very easy for physicians to digest (i.e. brief and pertinent to their patients). | am attaching our draft to this email, as well as some of the articles that we have found. One of the questions that came up is what to tell lead-exposed mothers who are pregnant or breastfeeding. We have pulled a number of articles that talk about lower maternal BLLs, but these are usually in the context of lower lead levels in drinking water. We are not sure if these recommendations still hold in our situation: the water is variable, the mothers are not routinely tested (should they be?), and lead is released

Laura, It looks great, there is a small section of the prirnarily Hint Township zip code that is in the city of Flint and gets Flint water, That zin cade is 48532. Mark Valacak, MPH, Health Officer Genesee County Health Department, 630 S. Saginaw St. Suite 4 Flint, Mi 48502-1540 Phone 810-257-3588 Fax 810 257-3147 E-mail x a us Please consider the environment before printing this e-mail. "There are two lasting bequesis we can hope to give our children: one is roots; the other is wir Hodding Carter *NOTICE: This e-mail, including attachments, is intended for the exclusive use of the addressee and may contain proprictary, confidential or privileged information. If you are not the intended recipient, any disclosure, use, distribution, copying, or taking of any action in reliance of the contents of this e-mail is strictly prohibited. If you have received this e-mail in error, please notify me via e-mail and permanently delete the original and dest all copies. Thank you. for a copy of the Health Department’s Notice of Information Practices, contact the Health Department or visit the Health Department’s website at Sent: Thursday, October 22, 2015 10:34 AM

This is great- thank you!!! Sent from my iPhone

Water.pdf; ATTOO001.htm Dear Eden, Mark and Kay, lam attaching a draft letter from the medical society that will likely go out today and also my commentary relating to the conversations I have had with the liver services at Henry Ford and UM Ann Arbor. I think the letter is good. I would suggest adding a paragraph - see below. I was able to talk to a Dr. Segovia with Henry Ford hepatology (recommended by Dr. Kim Brown, Director of their Liver Transplant service), and also the nurse of Dr. Askari at UM, the Director of the Wilson Disease clinic there. Dr. Segovia did not have any specific suggestions - they just tell their patients to get their water tested and act accordingly. She was interested in what we find. Dr. Askari's nurse said they tell their patients to use either DISTILLED water (not bottled - for instance they said Dasani actually has rather high levels of copper) OR get a reverse osmosis system. I found some of these systems online and they ranged in price with some around $150 or so. I don't know which ones are good. Dr. Segovia said they may have 1-2 patients with Wilson Disease at the most. Dr. Askari's nurse thought there may be 10 or less in the clinic at UM (they ask them back for annual checks when stable). She said all of their patients get the above advice. I would propose that we add a paragraph that says: "The UM Wilson Disease clinic director, Dr. Askari, recommends that all Wilson Disease patients use either specifically distilled water (not all bottled water is distilled), or a reverse osmosis system. We are hoping to get a reasonably accurate number of patients who may be affected so that we can get the information to them (through you, or through an outside referral clinic) and also see if it is possible to get funding for those who may have difficulty obtaining the necessary water or system, particularly during the next year when the water is still considered more corrosive than average. It is also important to note that copper pipes tend to be more common in newer homes, so the distribution of high concentrations of copper in water may be xxxEND_PAGE:dhhs02_b1073_3743_3745_1 003744 different than that for lead." Iam also going to send this information to Eden Wells at MDHHS at her request. When I spoke to Dr. Marc Edwards on the phone, he did send a list of all the other metals for which he tested and none were over the action limit. As may have been mentioned earlier, he also said that there were no samples which had copper over the action limit, but that is not the appropriate limit for patients with copper storage disease. This problem is clearly much less widespread than the lead problem, but after being surprised once, I don't want for us to leave anything else out this time around. Laura Begin forwarded message: Date: October 22, 2015 at 10:24:21 AMEDT

Great thought about the ophthalmology! Keep me in touch---we are going to advise OB-Gyns about the importance of counseling their pregnant patients as well. Materials forthcoming. Eden

Good afternoon, Dr. Carravallah, We will keep looking, but our chief toxicologist affirmed my concern about filters for copper being able to reduce low enough for Wilson's and unfortunately they do not appear to be able to reduce lead. Eden Haynan Services xxxEND_PAGE:dhhs03_b0015_0026_0030_1 000027 Phone: 517-33 3 [email protected]

Wellsk 3a michigan gav> WH thasa filters {listed below) also remove laad? if so, can just recornmend those filters to the patients (arn working with Pete to estirnate how many there may be) and that may be our solution, They would need to meet the recommiendatians of the Wilson’s Disease Society that Eden sent. Pete said he can send out emali on Monday. fio you have recornmendations as ta how to proceed Mark?

Laskad Jim Hanry of my anviranmental health staff to research the copper filtar raduction issue and talk to the people at NSF. His findings are below, | had a friend who used to work at NSF but is long retired. remernbered from a conversation that often manufactures get products certified for particular chemicals and there is a cost increase with each particular additional certification. So they limit the testing based upon what makes ecanarnic sense for them. inthis exarnple, ft dees not meen that the filters we are distributing do nat red copner but ore likely that they did not pay for that cartification test to be run. Hf that test was not run they cannot clair to he “certified by NSF". Oddiy Brita dines acivertise that their filter reduces copper but it is rot listed on the sheet in the box a certified by NSF for thet. xxxEND_PAGE:dhhs03_b0015_0026_0030_3 000029 NSF did sunply the filters list certified for copper reduction, which is included below for your information. Mark Valacak, MPH, Health Officer Genesee County Health Department, 630 S. Saginaw St. Suite 4 Flint, MI 48502-1540 Phone 810-257-3588 Fax 610 257-3147 E-mail mvalacak@gchd. us der the environment before printing this e-mail. "There are two lasting bequests we can hope to give our children: one is roots; the other is wings.” Hodding Carter *NOTICE: This e-mail, including attachments, is intended for the exclusive use of the addressee and may contain proprietary, confidential or privileged information. If you are not the intended recipient, any disclosure, use, distribution, c dopying, or taking of any ac} tion in n reliance of the contents of this e-mail is strictly prohibited. If you have received this e-mail in error, pl me via e-mail and permanently delete the original and destroy all copies. Thank you. For of the Heaifli Department’s Notice of Information Practices, confact the Health Department or visit the Health rom: oe . Sent: Friday, October 18; 2015 10:23 AM