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Great- thanks!

We are expanding the distribution of the physician info through some additional channels. Sent from my iPhone Begin forwarded message:

Toni l LaRocco MS, RN Director of Nursing Services Genesee County Health Department 810.237 4544 flarocco@achd us 28 Bags bat sae 2g AE tans ahal we Base ees Bre 2, oe " gle, ff Exeere é& nee 4 stn bape & mead MLS Ronegatee, GhaEs ke oedee, confewon Ue ebine lo & feast, & house stl & f . foe ra é ie bone, « stranger inte a fled Goatitude makes cease of van past, doings peace fox lodag, and é £8 2 me: 2? Ltalee 8 eneor per forcreis Mledidy oats ad for the exc if you are : # afin error, sflzane notty me vig amall and permanently delete the cradle an x! deduce al copies. Thank you. visit the Health Department's wepsiie a f informant: a ies. contact the Health Cepartment or nit anene GONE US,

Good morning, Please see the attached message that has been cleared for dissemination to Flint providers. Genesee County will blast fax and use their professional networks (GCMS, etc.) to disseminate to all providers. | have CC'd Dr. Mona Hanna-Attisha and Dr. Reynolds here, and they can distribute through their networks as well. Our Medicaid program will be working with the local health plans about lead screening recommendations based upon this message. This will also go out as a low-alert from our Health Alert Netowrk to appropriate Flint sites/providers, so | have CC'd Craig Henry. If there are any questions, please do not hesitate to contact me. Warm Regards, Eden xxxEND_PAGE:dhhs02_b1249_4708_4711_1 004709 Eden V. Wells, MD, MPH, FACPM Chief Medical Executive Michigan Department of Health and Human Services 201 Townsend Street, 5th Floor CVB Lansing, MI 48913 Phone: 517-335-8011 wellse3@michigan.gov

Thank you. Dr. Wells—please have your folks add this language to the HAN.

Hi all — still awaiting final clearance from our communications office —| will send you notice of what is going out and when and all of that once we know! Have a nice evening, eden Sent from my iPhone

Eden & Sue, i don’t know how much infarmation your staff has shared with you about the legionella situation here. MBHHS staff has been informed that we have received a FOIA frorn an attorney reprasenting one of the positive cases who died, Lam sending some info which was already shared with your staff as some background material FYI 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 mvalacak@gchd us ses aase consider the environment before printing this e-mail. “Ther 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, copying, or taking of any action in reliance of the contents of this e-mail is strictly prohibited, Hf you have received this e-mail im error, please notify me via e-mail and permanently delete the original and destroy all copies. Thank you. For a copy of the Health Deparhnent’s Notice of Information Practices, contact the Health Department or visit the Health Department’s website at hited /wenw. ech. us/

Hi, Pwanted to give you 2 aurnriary of the lead screering and case management activilies. i will not be on the call ihis aferrioon. Getting things set for Thursday. Overall, things went very well last week wilh @ much smaiier turnoul than hoped. Bul nol necessarily surpriging. Tori L LaRocco MS, RN Director of Nursing Services Genesee County Health Deparirnent 810.237 4544 flarocco@achd.us és S the fellhe £8 af £E basus what we have kee anougl, aad move, £8 axes oxen’ ibe 7 . EGA ‘ Bi i Pe ¢ ronpasin te be Séaey ia FE 2nx tava weak ile x frost, a: sone. E8 a howe, & &beaeger ie 2 4 e Ez HOR for domes, = cory) 9g, of faking of any ¢ foal in airar, ploase notty irs via ema and p seni Ge late ine engined and destroy gi Copies. “rise He you, For a copy Deparim Health Depenment’s Notice of Information Practices, contact the Healin Deparment or visi ihe Hea Swaleie at hitouAwww.cohd us! xxxEND_PAGE:dhhs03_b0571_1977_1978_2

in adults when we see high levels it is generally an cecupational exposure and inhalation of lead furnes in industrial exposure settings like battery manufacturing, lead smelting, and stained fead glass. A courle of factors are irnportant to remernber when we are talking about lead exposure in achuilts versus children. Absorptians rates from gastrointestinal exposure are lower in adults versus children. So where a toddler might absorb about 50%, absorption rates decline in adults to 3-10%. About 90% of lead will end up in the bone where it mimics calcium, iicauses fess harm there than if it went to soft tosues ke the Hver or Rdneys. The problem is that under cireurnstances that cause calcium mabilzation, lead stured in the bane may remohilize and circulate in the blood, elevating blood lead levels. The mobilization af stored lead with pregnancy, menopause, and aging is a cause for concern, Sa to help mitigate that there should be an emphasis an good nutrition and a calcium rich diet. Pragnant and breastfeeding woman should be sure to take their vitamins te minimize calchirn rnobilization from the bones. Reinforcing these messages would help minimize exposure. 1 xxxEND_PAGE:dhhs03_b0161_0693_0696_1 000694 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 Please consider 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, 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 destroy all copies. Thank you. For a copy of the Health Department’ visit the Health Departinent’s website at iittn/Aweay. geh Notice of Information Practices, contact the Health Department or pus!

in achilts when we see high levels Nis generally an occupational exposure and inhalation of lead fumes in industrial exmasure settings like battery manufacturing, lead srnelting, arid stained lead glass. A couple of factors are irnportant to remernber when we are talking about lead exposure in achilts versus children. Absorptions rates frorn gastrointestinal exposure are lower in adults versus childre where a toddler might absorb about 50%, absarption rates deciine in adults to 3-102. About 90% of lead will and up in the bone where it mimics caicium. tt causes lass harm thers then if it went to soft tissues lke the liver or kidneys. The problem is that under circunistarices that cause calcium mobilization, lead stored in the bone rnay rernobilize and circulate in the blood, elevating blond lead levels. The mobilization of stored lead with pregnancy, menopause, and aging is a cause for concern. So to help mitigate that there should he an emphasis on good nutrition and a caicilurn rich diet. Pregnant and breastfeeding woman should be sure to take their vitarmins to minimize calcium mobilization from the bones. Reinforcing these messages would help minirnize exposure. Mark Valacak, MPH, Health Officer Genesee County Health Department, 630 S. Saginaw St. Suite 4 Flint, Ml 48502-1540 xxxEND_PAGE:dhhs02_b1141_3996_3999_1 003997 Phone 810-257-3588 Fax 810 257-3147 E-mail mvalacak@gchd.us Please consider the environment before printing this e-rnall. “There are two lasting bequests we can hope to give our children: one is roots: the other is wings.” Hoddig Carter "NOTICE: This e~ m including attac! hrenits, s intended for the Si e use of the addressee and may contain proprietary, contfidentis vient, any disclosure, use, distribution, copying, or taking of any action in reliance of the Sactents sak thi wed this e-mail inerror, please notify mie via e-mail and permanently delete the « ‘ginal and destroy all copies. Thank y For a copy of the Heaifli Department’s Notice of Information Practices, confact the Health Department or visit the Health Department’s website at bitp /Avww gchdas/

Hi folks, Here are the final materials from NDHHS on joint letterheads. The press release needs a comment from you all. Please send your final draft of press release to Angela and |. Based on when letters are printed and ready to be sent and ready to send out- this will be ready- will discuss timing for now. Eden Sent from my iPhone Begin forwarded message:

Hi folks, Here are the final materials from NDHHS on joint letterheads. The press release needs a comment from you all. Please send your final draft of press release to Angela and |. Based on when letters are printed and ready to be sent and ready to send out- this will be ready- will discuss timing for now. Eden Sent from my iPhone Begin forwarded message:

Just FYI, as we had some things we wanted to fix---I know Hllda is out but so she gets final version.

Please let me know ASSp as we aligned the language of FAQ and press release and parents letter Sent from my iPhone Begin forwarded message:

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

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

HI there, Mark, Talked with Linda Dykema with MDHHS Tox and George Krisztian at DEQ. The water sampling protocol for schools is virtually complete, but needs piloted. LARA is ready to go and will be in the field by Friday. Plan is to pilot protocols with one school, so Lara will go in on Friday to Freeman School to begin identification of pipes. Then, Lara and DEQ staff will work on Saturday (10/24) to pull the samples---this way they can make sure the protocol makes sense. George is very aware of the limited resources of the LHD to do this much sampling. There will be 12 other schools that will need to be done, and so he asked that, if the LHD wants financial support to assist in the pulling of water samples, to send him a formal request to him at DEQ, (can be by email but request should be formal/letterhead, etc.) . He is CC'd on this email. George can then move that request up the chain through DEQ. Provide details in the formal request as to staffing and overtime, etc, as best you can. Jim may have some more details based on the conversations George and he have had. That is the news as of 5:01 PM. Anything | can do- let me know- you all are on the front line and extremely busy, | know! Eden xxxEND_PAGE:deq04_b534_4938_4940_2 Eden V. Wells, MD, MPH, FACPM Chief Medical Executive Michigan Department of Health and Human Services 201 Townsend Street, 5th Floor CVB Lansing, MI 48913 Phone: 517-335-8011 wellse3 @michigan.gov xxxEND_PAGE:deq04_b534_4938_4940_3

treceivad a fax that was inimy box this rnorning that | have atteched. | aiso just got an email from an NPR affiliated reporter asking me about concerns expressed from to 2 CMU scientists. xxxEND_PAGE:deq15_b519_1960_1965_1 Mark Valacak, MPH, Health Officer Genesee County Health Department, 630 5, Saginaw St. Suite 4 Flint, Mi 48502-1540 Phone 810-257-3588 Fax 810 257-3147 E-mail mvalacak@gchd.us Please consider the environment before printing this e-raail. "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 fhe exclusive use of the addressee and may contain proprietary, confidential or privileged information. If you are not the iniended 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 destroy ali copies. Thank you. For a copy of the Health Department’s Notice of Iuformation Practices, contact the Health Department or visit fhe Health Department’s websife at i haan cchd usd

Hi Mark, do any of you know when this is, and anything about htis press brief noted below? | got wind of it just in the last hour or so. NPR already calling our PIO- we have not heard what this brief is about---we do have Marc Edwards studies that do not show any increase inOPs in his testing... do not have DEQ results (but asked for them) and am looping in our CD group to help formulate any messaging in response-- Any thoughts your way? E Sent: Friday, October 16, 2015 11:47 AM

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