Asthma and the Indoor Environment: Lessons learned from ... · Asthma and the Indoor Environment:...
Transcript of Asthma and the Indoor Environment: Lessons learned from ... · Asthma and the Indoor Environment:...
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Asthma and the Indoor Environment: Lessons learned from Boston’s
Healthy Public Housing Initiative
Boston-NY Healthy Public Housing SummitFebruary 15-16, 2007
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• Prevalence increasing worldwide• Currently affects 5-10% of US
• >17 million Americans affected• Incidence, severity increasing• Highest in industrialized countries• Leading chronic illness among children
• Prevalence among children rose from 3.6% (1980) to 5.8% (2005)*
• In the US, costs exceed $14 billion/yr
THE ASTHMA PROBLEM
*(NEJM, 2006)
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• Asthma rates highest among urban poor
(NYT, 4/19/2003)
THE ASTHMA PROBLEM
(Boston Globe, 3/27/2006)
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Hypotheses–Environmental exposures–Housing conditions–Obesity–Access to health care–Genetic variants–Intrinsic factors (e.g., premature birth)–Social/psychological factors (e.g., stress, exposure to violence)
Age- and gender-adjusted asthma hospitalization rates in Boston, 1992 (Gottlieb et al., 1995)
THE ASTHMA PROBLEM - DISPARITIES
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• Boston Public Housing FactsLargest apartment owner in Boston15,000 units in 68 developments25,000 residents (10,000 children)Average Income: 17% of Boston-area median• < $10,000 for a family of four
Boston Public Housing
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• Public/GovernmentBoston Housing AuthorityBoston Public Health Commission
• UniversitiesBoston University School of Public HealthHarvard University School of Public HealthTufts University School of Medicine
• CommunityCommittee for Boston Public Housing, Inc.Franklin Hill Tenant Task Force, Inc. West Broadway Tenant Task Force, Inc. Public Health Initiative, South Boston Community Health Center
• PrivatePeregrine Energy GroupUrban Habitat Initiatives
Healthy Public Housing Initiative Collaborators
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It takes a village
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Healthy Public Housing Initiative Activities
FocusGroups and Survey
Resident Education and Employment
ManagementSystems Analysis
& Policy
Interventions &Health Outcomes
Source: HPHI Policy Advisory Council Meeting, December 2003.
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Initial Environmental Assessment Survey
• Surveys - 238 TOTAL132 in West Broadway106 in Franklin Hill
• Visual Inspections done as part of survey• Environmental Sampling - 80 Total
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• Project goalsImprove home environments to improve health & increase quality of life for residents of public housing in BostonBuild capacity within city agencies, community organizations, & resident groups to sustain effortImpact national policy on housing design and health care financing for asthmaEmpower residents through training, employment and shared decision-making.
Healthy Public Housing Initiative
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• 60 families with asthmatic children from Boston Housing Authority developments enrolled in intervention study:
West BroadwayWashington BeechFranklin Hill
• Health data• Environmental Measurements• Interventions
Clinical – Asthma case management: training, access to peak flow meters, monthly diaries and maintaining an appropriate medication regimen.Environmental – IPM, new mattresses, pillow covers, air purifier, plastic ware, minor home improvements, industrial cleaning.
ManagementSystems
FocusGroups
Survey
Analysis&
Policy
Interventions &Health Outcomes
HPHI intervention
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Concept behind intervention
• Residential exposure to indoor allergens contributes to severity of asthma symptoms, greater impact for low SES populations
• Focus groups, past studies emphasized significance of cockroaches and other pests
• Conventional pesticide use to eradicate roaches can contribute to health impacts IPM needed
• Concerns also exist about other environmental exposures, adequacy of health care, social stressors, etc.
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• Resident education • Industrial Cleaning• Mattress Replacement• Integrated Pest Management (IPM)
An effective method of pest control based on modifying the physical environment and reducing the use of chemicals. Techniques include:
• eliminate sources of food and water• block entry• reduce habitation sites• monitor infestation sites
• Environmental MeasurementsTemperature/HumidityAllergen levelsRoach countsPesticide levelsAir exchange ratesNitrogen dioxide
HPHI Activities
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• Design – Longitudinal intervention
• Asthma management• Base rates for symptoms, QoL survey• Monthly follow-up visits• Pre- and Post-intervention environmental assessments
HPHI Health Assessment
3 months 9-15 months
∆
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Outline - Results
• Quality of Life – Health Outcomes• Allergen levels• Air exchange/Nitrogen dioxide• Pesticide levels
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HEALTH OUTCOMES / QUALITY OF LIFE
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Study Population
27%22%40%27%Pets25%28%29%21%Below Average Housekeeping73%33%83%97%Holes in Walls23%7%33%30%Visible Mold 44%44%20%50%High Occupant Density 2%5%0%0%Caucasian
29%21%29%35%African-American75%75%71%65%Hispanic
Race/Ethnicity*4919723# of Units
TotalWest Broadway
Washington Beech
Franklin Hill
Characteristics
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Health Outcomes
• Did our interventions improve asthma-related quality of life (QOL) for children in our study?
• QOL measures (Juniper, ccores range 1-7 ): SymptomsActivity LimitationEmotional FunctionTotal
• Did symptom indicators improve?
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QOL scores improved overall
mean improvement during HPHI
1
2
3
4
5
6
7
-10 -5 0 5 10 15
Months
Tota
l Jun
iper
Sco
re
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Improvement is attributable to Interventions
Im p ro ve m e n t Be fo re & Afte r In te rve n tio n s (4 m o n th s)
1234567
-6 -1 4 9
M o n th s
Tota
l Jun
iper
Sco
re
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Symptoms
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Symptoms
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ALLERGENS
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Objectives – Allergen Study
• ObjectivesTo determine if cockroach allergen levels can be reduced in public housing.To determine if reductions in allergen levels can be maintained
• RationaleTo see if the type of interventions worked.To determine whether interventions should be part of BHA’soperation.To determine conditions that have to be dealt with for interventions to be successful.
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Measurements
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IPM: Cleaning
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Bedroom Cockroach Allergen Levels
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Bla g 2 Bed Conc (U/g)
Cumu
lative
Perce
nt (%
)
Pre-InterventionPost 1 monthPost 3 monthsAsthma trigger level
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Allergen Levels – Intervention Effect
72%
62%58%
31%
7%12%
8% 9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Pre-Intervention
Immediatelyafter
3 months after
6 months after
Perc
ent
Kitchen
Bed
Percent Kitchen/Bed Cockroach Allergen Levels Above Effect Thresholds
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Estimated Kitchen Cockroach Allergen Levels
0
10
20
30
40
50
60
70
0 2 4 6 8 10
Months after Intervention
Cock
roac
h Al
lerg
en C
once
ntra
tions
(U/g
)
Bla g 1 Kitchen
Bla g 2 Kitchen
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Allergen Levels by Sources of Food, Shelter and Access
(p-value=0.02)
By “Clutter” level By “Holes in Walls”
(p-value=0.08)
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Conclusions – Allergen Study
• Interventions can reduce cockroach allergen levels.• May need to do building-wide.• May need to do on an on-going basis to maintain results.• Need to address sources of food and hiding spaces.• Need to address pest entry ways.
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Conclusions – Allergen study
• Determinants of pest-related allergens include:Lack of housing renovationsHoles in the wallsHousekeeping practicesSeason
• IPM and cleaning worked• Integrated measures must be implemented on a
regular basis and building-wide to maintain results.• Behavior modification and improvements to physical
conditions are key to intervention success
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AIR EXCHANGE / NO2
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Study of Air exchange and NO2
• Indoor NO2 levels are a function of:Gas StovePilot lightVentilation rateStove exhaust/range hoodUsage patternOutdoor levelsSize of homeHumiditySmoking
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Air Exchange Summary Statistics by Season
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Nitrogen Dioxide Concentrations by Season
40% above EPA standard in winter
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• Higher Indoor NO2 levels in our cohort• Significantly higher in heating season• Heating Season~ 40% above EPA Standard• Peak levels can be an order of magnitude higher than 2 wk avg
• AERs similar to national distribution• Air Exchange Rates significantly lower in heating season• 34% of apts. do not meet ASHRAE std. in heating season
• Indoor NO2 is a strong function of:• Air Exchange Rates• Outdoor NO2 levels
• Supplemental Heating with Gas Stove• Reported by 27% of Cohort (36% in West Broadway)• Trend between gas stove heating and increased indoor NO2
Ventilation/NO2 Study - Conclusions
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PESTICIDES
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Pesticides: Study Objectives
Determine prevalence and concentration of pesticides in public housing
Explore methods to classify pesticide exposures• Wipes vs. Dust (low burden on families)
• Management Files vs. Management files & Home Visit (low-cost screening tools)
Evaluate the effectiveness of Integrated Pest Management interventions (changes in pesticide concentrations)
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Household Pesticides
• OrganophosphatesBlack Jack Roach & Ant KillerRaid Ant BaitRaid Ant Controller
• PyrethroidsBlack Jack Roach & Ant KillerRaid Ant & Roach KillerHot Shot Roach & Ant KillerTempo 20 WP InsecticideChinese Chalk
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Target Analytes Oral LD50 in Rat (mg/kg)
Organophosphates• Chlorpyrifos* (135-163)• Diazinon* (300-400)
Pyrethroids• Cyfluthrin* (590)• Cypermethrin (250)• Deltamethrin* (135)• Esfenvalerate (458)• Permethrin (383)• Bifenthrin (70)• Cyhalothrin (114)• Allethrin (1100)• Resmethrin (>2500)• Sumithrin (>3500)• Tetramethrin (>5000)
Source - EXTOXNET. A Pesticide Information Project of Cooperative Extension Offices of Cornell University, Michigan, Oregon State and University of California at Davis.
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45<LOD<LOD<LOD16 (7)Deltamethrin*
40.4<LOD<LOD26 (11)Cyhalothrin
172.50.7<LOD67 (28)Esfenvalerate
56716.41.1<LOD71 (30)Cyfluthrin*
33116.23.7<LOD90 (38)Cypermethrin
5562.60.4<LOD98 (41)Diazinon*
22733.06.80.21100 (42)Permethrin
201.30.30.03100 (42)Chlorpyrifos*
Max75th pctMedianMin%>LOD (n)Analyte
Prevalence (%) and Pesticide Concentrations (µg/m2) in Kitchen Floor Wipes (N=42)
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Kitchen Floor Wipes (N=42)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
0 1 2 3 4 5 6 7 8 9 10 11 12
Number of Pesticides Detected
% o
f Hou
seho
lds
Prevalence of Pesticides Detected
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Cumulative Frequency Distributions (N=42)
Kitchen Wipes
0
10
20
30
40
50
60
70
80
90
100
0.001 0.01 0.1 1 10 100 1000
Cum
ulat
ive
Perc
entil
e
DiazinonChlorpyrifosPermethrinCypermethrinCyfluthrin
µg/m2
Chlorpyrifos
Diazinon
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Prevalence of Pesticides Detected
Vacuum Dust (N=35)
0%
5%
10%
15%
20%
25%
30%
35%
40%
0 1 2 3 4 5 6 7 8 9 10 11 12
Number of Pesticides Detected
% o
f Hou
seho
lds
Kitchen Floor Wipes (N=42)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
0 1 2 3 4 5 6 7 8 9 10 11 12
Number of Pesticides Detected
% o
f Ho
us
eho
lds
Kitchen Floor Wipes Vacuum Dust
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Predictors for identifying households at or above the 75th percentile in pesticide concentrations
Consultant’s assessment of roach problem (mild)
Residents’ self report: Severe roach problem (Y)
Work order requests at baseline (N)
Ethnicity (Hispanic)
Cypermethrin
Ethnicity (Hispanic)
In current apt. > 5 yrs
Residents’ self report: Severe roach problem (Y)
In current apt. > 5 yrs
Ethnicity (Hispanic)
CyfluthrinManagement Files & Home VisitManagement FilesPesticides
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M ses
sion)
log t
ransfo
rmed a
bsolu
te v
alu
e o
f (p
ost-
pre
IP
M k
itchen w
ipe
concentr
ati
ons)
(ng/s
q f
t)
Lower QuartileMinimumMedianMaximumUpper Quartile
Difference in pesticide concentrations for pyrethroidsstratified by number of IPM training sessions
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Summary of Study Findings
PrevalenceEvery home had at least 3 pesticides, some homes as many as 8
Chlorpyrifos found in every home 2 years following withdrawal from sales
Restricted pesticides, e.g., Tempo were found in many homes.
Methods to classify exposuresPositive correlations among target pesticides in dust matrices
Using combination of files and home visit : Sensitivity improved and ability to identify target households improved.
Predictors identified for current use pesticides (pyrethroids) are consistent with assumption that activity patterns may contribute to ‘high end exposure’ households
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IPM Efficacy (reduction on pesticide loadings)
• Resident education was positively associated with reduction in cyfluthrin concentrations (active ingredient for Tempo - a restricted use pesticide)
• Found a negative association with permethrin, which may be suggestive of pesticide substitution
• Homes with poor housekeeping were higher at baseline and got better reductions
Summary of Study Findings
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Pyrethroids (cypermetrin, permethrin)
N=43 homes
(households inpublic housing )
0.11-5.390.013-7.71<LOD-5.17Vinyl floor &
furnishings, e.g., sofa,
rugs
Urban -Boston,
MA
Current Study (2005)
N=7
( Commercial & residences)
1.0-4.521.65-9.941.3-1.84Wood floors, window sills &
furnishings,
e.g., sofa, rugs
Agricultural –Cape Cod,
MA
Rudel et al. 2001
(pilot study)
(min-max)(min-max)(min-max)
Range (µg/g)Range (µg/g)Range (µg/g)
Cis permethrinTrans permethrinCypermethrinSurface sampledsiteStudy
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Classification and Regression Tree (CART)
Classified subgroups (nodes)
Source data-
(a) File review
Floor Wipe data dichotomized at 75th pct.
Predictors
Application of CART
Source data –
(b) File review and home visits
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Overall results/recommendations
• Many environmental risks in our cohort• Interventions can reduce allergen levels• Pesticide residues are widespread• Residents are using restricted-use pesticides• Indoor NO2 levels are high in heating season• Indoor NO2 levels are a strong function of air exchange• Interventions can be designed to control exposures:
e.g. Increased ventilation for pollutantsIPM for allergen and pesticide reduction
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Acknowledgements
• The HPHI team • Funders:
HUD, Boston Foundation, Jesse B. Cox Charitable Trust, W.K. Kellogg Foundation
• For more information:www.hsph.harvard.edu/hphi
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Our Crew
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Our students
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Our supporters
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Our colleagues
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Our colleagues
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Our colleagues
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