presentation- pdf - Environmental Health Watch

Program areas
Asthma Triggers
in the Home
• Healthy indoor environments – home &
Healthy Homes Initiative – Mahoning Valley
Stuart Greenberg
childcare; substandard housing; children &
elderly; lead, asthma, pesticides, mold, etc.
January 21, 2010
• Affordable green housing - green
housing for people who need it the most
www.ehw.org
216/961-4646
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A Healthy House is
EHW Healthy House projects
1. Dry
•
Lead + Asthma (1998-99)
•
Roach Allergen Reduction
•
Urban Mold & Moisture (1999-2003)
•
Community Environmental Health
Resource Center (2002-04)
•
City-County Healthy House (2004-09)
•
Case Healthy Homes & Patients
•
Tenants for Healthy Housing
2. Well-ventilated
3. Comfortable
(1999-2002)
4. Clean and uncluttered
5. Free of
–
–
–
–
(2006-011)
(2007-10)
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Lead hazards
Combustion by-products
Pests and pesticides
Other contaminants
http://www.healthyhomestraining.org/Practitioner/Materials.htm
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Asthma –
the increase is breathtaking
• #1 chronic illness of childhood
• Rate doubled over last 20 years
• Deaths of children increased 50%
• In some Cleveland schools, 35% of
students have asthma
• Many theories, no answer for increase
http://www.ehw.org/Asthma/ASTH_BurdenofAsthma.htm
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Environmental Health Watch - www.ehw.org - 1/20/10
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Income disparities –
2004 BRFSS Adult Lifetime Asthma Prevalence
Income Level
http://www.ehw.org/Asthma/ASTH_BurdenofAsthma.htm
U.S.
Ohio
< $15,000
16.2
21.3
$15-24,999
14.2
17.5
$25-49,999
12.9
11.0
> $50,000
12.5
8.3
7
http://www.cdc.gov/asthma/brfss/04/brfssdata.htm
Substandard housing
Substandard housing and asthma
• 40% of risk of
asthma for minority
children attributable
to residential
triggers.
8
• Pest infestation & spray pesticide use
• Long-term roof and plumbing leaks
leading to mold growth
• Heating by gas stoves and unvented
space heaters
• Old carpets – reservoirs for triggers
• Non-cleanable surfaces
B. Lanphear, et al,
Residential Exposures Associated
with Asthma in US Children,
PEDIATRICS, March 2001
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Variety of asthma triggers
Different kinds of asthma
triggers interact
• Psychosocial
stress
• Strong emotions
• Exercise
• Weather changes
• Respiratory
infection
• Medications
• Foods
• Outdoor pollens and
molds
• Outdoor air pollution
• Indoor allergens and
irritants
• Outdoor pollution enhances allergic
airway inflammation
• Psycho-social stress interacts with
environmental triggers (JE Clougherty,Synergistic
Effects of Traffic-Related Air Pollution and Exposure to Violence
on Urban Asthma, Environmental Health Perspectives, August
2007)
• Accumulation of disadvantages health disparity impact intensified
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Environmental Health Watch - www.ehw.org - 1/20/10
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Asthma trigger sources
Inhalant Allergens
House dust mites
Cockroaches
Warm-blooded
pets
• Rodents
• Mold
•
•
•
Respiratory Irritants
• ETS
• Formaldehyde
• VOCs
• Unvented gas
stoves
• Outdoor pollution
2007 NIH Asthma Guidelines <http://www.nhlbi.nih.gov/guidelines/asthma/>
NIH Expert Panel Report 3: Guidelines for the
Diagnosis and Management of Asthma 2007
•
For long-term asthma management,
essential to control relevant inhalant
allergens and irritants
•
Reducing exposure can reduce
inflammation, symptoms, need for
medication
Multifaceted, in-home interventions
effective; single steps generally not
•
•
Determine inhalant sensitivity
http://www.nhlbi.nih.gov/guidelines/asthma/
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CDC Task Force
Effective home-visit programs
For children with asthma the Task Force
recommends:
Program characteristics associated
with positive health outcomes:
• the use of home-based, multi-component,
multi-trigger interventions, with an
environmental focus...
•
•
•
•
• on the basis of strong evidence of
effectiveness in reducing symptom days,
improving quality of life,…and reducing the
number of school days missed
Crocker, D. Home-Based Environmental Interventions to Reduce Asthma
Morbidity, 2008 CDC/HUD/EPA National Healthy Homes Conference
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Community centered
Clinically connected
Collaborative
Targeted -
– assess trigger sensitivity and exposure
– site-specific interventions
Asthma Health Outcomes Project –
Univ. of Michigan SPH Allies Against Asthma
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www.alliesagainstasthma.net/AHOP
Asthma
management tasks
1. Control home environmental triggers
2. Manage medication regimen
3. Anticipate and respond to
exacerbations
4. Use health care system effectively
5. Communicate with childcare and
school personnel
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Crocker, D. Home-Based Environmental Interventions to Reduce Asthma Morbidity,
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2008 CDC/HUD/EPA National Healthy Homes Conference
Environmental Health Watch - www.ehw.org - 1/20/10
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Crocker, D. Home-Based Environmental Interventions to Reduce Asthma Morbidity, 2008
CDC/HUD/EPA National Healthy Homes Conference
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Home visit-based
trigger control programs
EHW trigger control interventions
Hands-on Assistance
• control equipment & materials
• conduct low-level remediation
• refer for higher-level work
Family Education & Engagement
• information they can use
• tips for practical problem-solving
• focus on making bedroom a safe space
• within family capabilities and challenges
• Home assessment - identify
trigger sources and pathways
• Education on triggers
• Recommendations for mitigation
• Control materials and equipment
– HEPA vacuum cleaner
– mattress/pillow encasements
– pest control materials
• Direct mitigation
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Target trigger control
interventions
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Target trigger control
interventions
• Evidence of sensitivity to allergen
Interventions are
• more effective
• less costly
• less a burden on the family
– medical history (seasonal outdoor)
– testing: skin or blood test (perennial indoor)
• Evidence of exposure to allergens and
irritants
– source and pathway identification checklist
– analysis of settled dust
if they can be targeted in terms of
both sensitivity and exposure.
• Targeted trigger interventions - more
effective, less costly, reduced family
burden
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Exposure to cockroach allergen
associated with
German cockroaches
• ―exacerbation of asthma in sensitive
individuals‖ (―sufficient evidence of a
causal relationship‖)
• ―development of asthma‖ (―limited or
suggestive evidence of an association‖)
Clearing the Air, Committee on the Assessment of Asthma and Indoor
Triggers, Institute of Medicine, 2000
<http://www.nap.edu/catalog.php?record_id=9610>
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Roach sensitization,
exposure and hospitalization
Roaches and asthma
National Cooperative Inner-city
Asthma Study
Rosenstreich et al. Role of Cockroach Allergy and Exposure to Cockroach
Allergen in Causing Morbidity among Inner-City Children with Asthma.
NEJM 1997;336:1356.
0.25
1
low
no
0.2
2
hi
no
0.15
3
low
yes
0.1
4
hi
yes
0.05
0
1
25
Spray-based roach control
• Regular pesticide application —
whether pests are present or not
• Broadcast application — spray
baseboards, floors, walls; bomb or fog
whole house
• Pesticides of worrisome toxicity
• Not effective – pests come back
2
Group
3
health concerns
4
Rosenstreich et al. NEJM 1997;336:1356
Household pesticides
• 80-90% homes report use
• Increasing evidence on adverse
health impacts at household
level exposure
• Persistence on surfaces, when
done right; often done wrong
• Broadcast application (spray,
fog, bomb) = greatest
exposure
27
Spray pesticide –
allergic
• Sensitivity + exposure
associated with morbidity
p = 0.001
0.3
exposed
• 37% had positive skin test for
roach allergen
• Roach allergen at high levels in
50% of bedrooms
group
Hospiatlizations in the past year
0.4
0.35
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Children and elderly most at risk –
greater exposure and vulnerability
• Children –
• Acute exposure — allergic
crawling, hand-to-mouth
activity, breathing
rates, developing
nervous system, less
able to detoxify
• Elderly –
time at home, chronic
illnesses, compromised
immune system
reaction, asthma attack, respiratory
irritation, flu-like symptoms, and
skin rash
• Chronic exposure — reproductive
problems, neurological diseases,
cancers, immune disorders
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Safer roach control –
Integrated Pest Management
Spray-based roach control
No pesticide sprays,
bombs or foggers –
•irritant chemicals
•toxic chemicals
•not effective
• Not safe
• Not effective
• Still too common,
especially in low-income housing
Use gel baits, bait
stations and borate
powders
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Integrated Pest Management
IPM elements
• Developed for agriculture
• Adapted for urban/structural
pests
• Recommended by health and
environmental agencies
• State-of-the-art in the industry
• Being able to spell it doesn’t mean
you know how to do it
• Identification & assessment
• Environmental controls - exclusion,
harborage removal, sanitation
• Mechanical capture
• Pesticide use only as needed
• Least toxic, least volatile pesticide
• Precision targeting of pesticide; no
broadcast application
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Assessment
Identification
•
•
•
•
•
•
•
•
•
•
•
•
Type and number
Entry points
Harborages
Food sources
Water sources
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Occupant report
Live/dead roaches
Droppings/stains
Control materials – sprays, traps
Sticky traps
Flush
Dust analysis for Bla g 1 & 2
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Environmental controls
Seal entry points and harborages
Store food securely
Deny roaches:
• food
• water
• hiding places
• entry
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Priority to non-chemical
control methods
• Traps
• Vacuuming
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Pesticide use •
•
•
•
Only as needed
No broadcast application
Least toxic, least volatile
Small amounts, precision targeted,
inaccessible to children and pets
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Environmental Health Watch - www.ehw.org - 1/20/10
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How Roach Baits Work . . .
Roaches smell the bait
Poisoned roaches
go home…and die!
Other roaches
eat the dead
roaches
Roaches eat the bait
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Those roaches are poisoned and die too!
Multiple modes of
bait transfer
• Necrophagy – eat the dead
• Coprophagy – eat feces
• Emetophagy – eat secretions
Extent depends on availability
of primary food sources
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Gel baits, bait stations and
borate powders
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Roach allergen is persistent
• Elimination of infestation
alone not sufficient to
reduce exposure below
clinically relevant level
• Occupant or professional
house cleaning not
effective; allergens
missed or concentrated
into hot spots
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EHW cockroach allergen
reduction HH project
Cockroach allergen reduction through
IPM and specialized cleaning
1. Infestation reduced/eliminated by
precision-targeted IPM
-
hot-air flushing
HEPA vacuuming
baiting
Flush
2. One-time lead dust cleaning
3. Occupant education and on-going
cleaning effort
http://www.ehw.org/Asthma/ASTH_HUDRoach_Sum.htm49
Cleaning intervention
• Based on the HUD protocol for cleanup of
lead dust:
– HEPA vacuuming
– Wet mopping and rinsing
– HEPA vacuuming
Vacuum
Bait
•Roaches flushed with hot air
•Roaches and debris removed by
HEPA-filtered vacuum
•Harborages identified and
baited
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Roach control –
shared responsibility
• Landlord- maintain dwelling unit free from
defects that support roach infestation.
• Results: reduced cockroach allergen to
below exacerbation levels and near
proposed levels of sensitization
• Pest Control Contractor - inspect entire unit
to determine roach harborages, entry points,
and food and water resources; use safe and
effective treatments to get rid of the
roaches; and provide on-going monitoring.
• Tenants - cooperate with pest control
efforts by contractor and landlord; maintain
housekeeping practices that do not support
roach infestation.
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Web resources
• EHW Pests and Asthma
<www.ehw.org/Asthma/ASTH_home1.htm#Pests>
• National Center for Healthy Housing
<www.healthyhomestraining.org/IPM/>
• Alliance for Healthy Homes
<www.afhh.org/hhe/hhe_health_hazards.htm>
• Building a Framework for Healthy Housing
<www.hud.gov/offices/lead/NHHC/index.cfm>
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http://www.ehw.org/Asthma/ASTH_home1.htm#Pests
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Cockroach IPM Case Studies
Rodent allergens
National Center for Healthy Housing
<http://www.healthyhomestraining.org/ip
m/Studies.htm/>
•
•
•
•
•
• Mouse and rat allergens in dander,
urine, feces and saliva
• Small particles remain airborne for
extended periods
• National Cooperative Inner-city
Asthma Study –
Comparison of Cost and Effectiveness
Bait Aversion – Cincy Cockroach
EHW Roach Allergen Reduction
Boston Public Housing
Farm Worker Pesticide Exposure
- sensitivity: rat = 21%; mouse =18%
- detected: rat = 33%; mouse = 95%
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Mouse control
•
•
•
•
•
Seal entry points.
Remove food, water,
clutter.
Don’t use poison
pellets.
Use snap traps.
Only use poison
(blocks) in locked
bait station.
Risky methods
• Uncontrolled rodenticides
–
–
poison pellets
poison blocks
• Illegal poisons
– naphthalene moth balls
– ―Tres Pasitos‖
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Mold control
• Dry wet items
thoroughly ASAP
• Discard porous items
soaked for more than
a couple of days
• EPA books:
Mold removal
•
•
•
•
– 800/438-4318
– www.epa.gov/iaq/molds
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Clean mold from hard surfaces scrub with stiff brush, hot water &
detergent; dry thoroughly
Use PPE – gloves, respirator,
goggles, etc.
Biocides not necessary
Generally area > 3’x3’ requires
professional
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How Water Enters a Building
Mold control
• Speciation and
quantification generally
not needed
Building
envelope leaks
(liquid)
– unless young infant in home
• Key to mold control is
moisture control
-Cooking,
-Bathing,
-Watering
plants,
-Breathing,
-Washing,
-Combustion
appliances
(water vapor)
-Plumbing leaks
(liquid)
-Surface water
(liquid)
-Groundwater
(liquid)
-Air from soil
(water vapor)
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Moisture reduction
General strategy:
• Seal building enclosure
• Divert rainwater from foundation
•
•
•
•
•
–
Moisture, Mold & Asthma-
School of Medicine, RB&C, County Board of Health
• Prospective, randomized controlled trial,
moderately severe asthmatic children (n = 62)
• Homes with indoor mold
gutters & grading
• Both groups: action plan, education, and
individualized problem solving
Point source ventilation
Repair plumbing leaks
Repair faulty combustion appliances
Cover bare soil in crawl spaces
Eliminate cold condensing surfaces
• Remediation group: mold removal and
household repairs to reduce moisture
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Moisture, Mold & Asthma-
School of Medicine, UH, County Board of Health
Carolyn M. Kercsmar et al, Reduction in Asthma Morbidity in Children
as a Result of Home Remediation Aimed at Moisture Sources,
Environmental Health Perspectives, August 2006
Moisture interventions
<http://ehw.org/Asthma/ASTH_home1.htm#Moisture>
• Both groups improved in asthma
symptomatic days during the preremediation portion of the study
• Remediation group - significant decrease in
symptom days (p = 0.004) after repairs;
control group did not significantly change.
• Remediation group - lower rate of
exacerbations (1 of 29 vs. 11 of 33,
p = 0. 003).
http://www.ehponline.org/members/2006/8742/8742.pdf
http://ehw.org/Asthma/ASTH_home1.htm#Moisture
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House dust mites
• Feed on skin flakes shed by people
and pets.
• Thrive in warm, humid
environments.
• Particles do not remain airborne
more than a few minutes after
disturbance.
• Bed and couch focus for control:
Dust mite control
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Hands-on Assistance
• Encase pillows and mattress in allergenimpermeable coverings
• Reduce excess humidity
Educate • Wash bedding weekly in hot water (>130ºF
scalding hazard), bleach, hot dryer
• Remove carpet in bedroom
• Minimize stuffed toys – wash weekly or
freeze and vacuum
• Minimize humidifier use
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Pets with fur and feathers
Environmental tobacco smoke
– heavy allergen loading
– long duration exposure
– at breathing zone.
• Allergens airborne for days; transported
widely on clothes
• Cat allergen detectable in 100% of homes
tested, even with no pet history
•
•
•
•
•
•
•
•
•
Remove pet
Keep pet outdoors
Keep out of bedroom
HEPA air cleaner in small closed room
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Products with strong odors
• pesticides
• cleaning
products
• paints
•
•
•
•
art supplies
perfume
air fresheners
cosmetics
Minimize use.
Use when person with asthma not present.
Use aggressive ventilation.
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•
Combustion products remain airborne
for days
Particles cling to clothing, furniture,
walls, car interiors, hair
Quit
Smoke outside
Don’t smoke in a car
Separate smoking rooms don’t wor.
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Combustion gases & particles
• Have annual furnace inspection
• Do not use fuel-burning unvented space
heater or fire places
• Do not use stove for heating
• Do not burn candles or incense
• Use kitchen exhaust fan
• Do not idle car in garage
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General interventions
for multiple triggers
•
•
•
•
Specialized cleaning
Dust can contain:
• Mold
• Dust mites
• Roach parts/
droppings
• Mouse urine/feces
• Pollen
• Animal dander
• Lead
• Pesticides
• Smoke particles
Moisture reduction
Pest control
Specialized cleaning
Make bedroom a
safe space
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Special cleaning methods
•
•
•
•
Vacuum very slowly; ―dirt finder‖ helps
Use low-emission HEPA-filtered vacuum
Remove shoes; use washable door mat.
Remove carpets (safely)
•
Use wet cleaning methods
Allergen
Source
Cat & Dog
–change rinse water, mop heads, cleaning rags
frequently
•
Target sources & pathways
Make floors smooth and cleanable
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Source reduction and
cleanup of pathways
Particle Size
(micrograms)
1-5
Exposure
Pathway
Air, dust
Rodent
1-15
Cockroach
5-35
Air, surfaces,
fabrics, dust
Dust, fabrics
House dust
mite
5-35
Dust
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Air cleaners
• HEPA air cleaner in small closed
room can reduce airborne cat
dander, mold spores and particulate
matter in ETS.
• Roach and dust mite particles
settle quickly after disturbance
– dust reservoirs focus of control.
• Pet allergens carried on particles
that can stay airborne for hours
and days
• No substitute for source
reduction – still have settled dust
reservoirs.
– air cleaners can help.
• Ozone and ionic cleaner produce
ozone, a lung irritant.
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Too Much To Do?
Make bedroom a safe space
•
•
•
•
•
Start Here
Make the bedroom a safe space for a
person with asthma
•
Use allergen-proof bedding covers.
Keep floors bare; use washable rugs.
No upholstered furniture or drapes.
Wash bedding biweekly in hot water.
Keep toys, books, clothes in drawers
or covered boxes.
Keep doors closed.
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Make bedroom a safe space
•
•
•
•
•
•
Remove shoes at the door.
No smoking, pets or plants.
Use window air conditioner, not a
humidifier or vaporizer.
Use HEPA room air cleaner.
Clean/decontaminate the room
weekly.
No household products with strong
odors.
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Web sites
• Environmental Management of Pediatric Asthma:
Guidelines for Health Care Providers, National
Environmental Education & Training Foundation,
2005,
<http://www.neetf.org/health/asthma/asthmaguide
lines.htm>C
– Environmental History Form, Environmental
Intervention Guidelines, Sample Patient Flyers,
EPA Asthma Home Environment Checklist
• Asthma and Indoor Environments, USEPA
<http://www.epa.gov/asthma/>
• Environmental Health Watch, <www.ehw.org>
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Thanks for your attention.
www.ehw.org
216/961-4646
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