In 2015, pediatrician Mona Hanna-Attisha, M.D., based in Flint, Michigan, put out research that revealed children in her community had been exposed to dangerous levels of lead as a result of contaminated drinking water.
Hanna-Attisha dove into data from the local hospital's Epic electronic health record (EHR) to build her study. Using those data, she exposed Flint's water crisis.
That research got a team of clinicians and data scientists curious: "Was this just a Flint problem or were there other areas within the U.S. that had children with elevated blood levels as well?” said Doug Winesett, M.D., in an interview with Fierce Healthcare.
Two teams of clinicians and data scientists analyzed de-identified health data from Epic Systems on 5.6 million children born between 2014 and 2020 for a study. In addition to identifying the two regions with the most affected children, they also discovered that 16 of the top 20 problem areas were in urban settings, according to the study by Epic Health Research Network (EHRN).
Local providers are likely more keenly attuned to the prevalence of lead in their communities, Winesett, one of the study's authors, told Fierce Healthcare. But the country as a whole may not see the big picture or realize how widespread the problem is. The study aimed to address that.
While there is variation regionally across the country, the Midwest and Northeast have the highest share of children with elevated blood lead levels, the analysis found.
States that had the largest number of affected areas include Ohio, New York and Illinois, according to the study. The data used are not comprehensive, and in areas where the sample is less representative (defined as penetrance), figures may be overinflated, Winesett said.
The 'silent' epidemic
The problem with lead exposure is that symptoms are not really visible, Hanna-Attisha told Fierce Healthcare. It’s what she terms a “silent pediatric epidemic,” and the reason she decided to title her book about the Flint water crisis as “What the Eyes Don’t See.”
Hanna-Attisha was not involved in the new EHRN analysis of blood lead levels in children.
Children under the age of six are at a higher risk because they are still developing, and even low blood lead levels can permanently damage cognitive function. Thus, criteria exist for providers to screen children via blood tests. The guidelines can vary by state. Those at highest risk of exposure, according to the Centers for Disease Control and Prevention (CDC), are children in low-income families, communities of color and those who live in housing built before 1978 (the year residential use of lead paint was banned). For children with these and other risk factors, it’s recommended to be screened at least once at the age of one.
To track workplace lead exposure in adults, the CDC runs a program called ABLES.
“Lead is a chronic form of environmental racism,” Hanna-Attisha said. Lead exposure does not begin and end with Flint, she emphasized. While the U.S. banned residential use of lead paint, for instance, older homes containing it still exist; while the use of lead pipes for water consumption has also been banned, old pipes have not all been torn out.
“We have this legacy of lead that we have yet to deal with,” the pediatrician said. “There are Flints everywhere.”
The power of data
Winesett and his teams examined anonymized health data available through Epic Systems’ Cosmos database, which is part of EHRN and gathers data from participating Epic clients. The database currently harbors what the company terms “observational evidence” on 115 million patients across the country.
Because of the accessibility of the data, the study didn’t take long to complete, unlike traditional research, Winesett explained. “We're able to do it in a much shorter timeline because we have access to that data,” he said.
The CDC’s childhood blood lead surveillance system gathers data from state and local health departments. That kind of bird’s-eye view is “not a lens usually afforded to clinicians,” Hanna-Attisha said. But after hearing about the potential contamination of Flint's drinking water back in 2015, that type of data is what she needed to evaluate the levels of lead in the children in her county. After encountering many roadblocks to get the data at the state level, the pediatrician turned to her own hospital, Hurley Medical Center, which used Epic. As it would turn out, being home to the only children’s hospital in its community, it had a lot of data—countywide, in fact.
With those data, Hanna-Attisha was able to observe health trends over time and identify the Flint water switch as the culprit behind elevated lead levels in blood.
“Epic is one of the unsung heroes of the Flint water crisis,” Hanna-Attisha said, emphasizing that the system proved useful when public health agencies failed.
She added electronic medical records can “complement surveillance systems” as a creative way to identify high-risk areas.
Despite its capabilities, Epic’s data are limited. Any findings are an underestimation of ongoing preventable lead exposure across the country, Hanna-Attisha said. State and federal policies aimed at addressing systemic health inequities are needed.
“We are literally using children as detectors of environmental contamination,” she said. Screening “tells me there’s an environmental problem, but it’s too late for that child.”
To combat lead poisoning, the CDC recommends primary and secondary prevention—removing lead hazards from the environment and follow-up care. In 2016, Michigan state was granted permission from the Centers for Medicare & Medicaid Services (CMS) to expand health coverage and lead abatement services for eligible properties. Hanna-Attisha is a proponent of these types of programs.
While some may argue they’re costly, the pediatrician pointed to a Pew and Robert Wood Johnson Foundation report that found preventing lead poisoning in children born in 2018 alone could save the U.S. $84 billion over the long term (not including the costs to achieve prevention).
There is no treatment for lead poisoning, but there are support mechanisms that can help, like ensuring proper nutrition and healthcare access. Hanna-Attisha, who is currently the director of the Michigan State University-Hurley Children’s Hospital Pediatric Public Health Initiative, also leads a community program called the Flint Registry. It, too, uses Epic to follow residents over time, she said, and direct those affected by lead-contaminated water to resources.
Hanna-Attisha and Winesett see a lot of promise in population-level health data, which can reveal trends and crises that drive action to improve public health.