Multifamily Housing Healthy - Johns Hopkins Bloomberg ... · Multifamily Housing Healthy ......

People Places and Policies: MakingPeople, Places and Policies: Making Multifamily Housing Healthy

Gary Adamkiewicz, PhD MPHHarvard School of Public HealthHarvard School of Public Health

Delaware Healthy Homes Summit3.12.2014

Overcrowding High rates of infectious disease (epidemics) High rates of infectious disease (epidemics) Cholera Tuberculosis Typhoid fever

Poor sanitation Fire hazards Poor lighting No ventilation

(Bellinger DC and Bellinger AM, JCI, 2006)

• Prevalence increasing worldwide• Currently affects 5‐10% of US

• >17 million Americans affected17 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

*(NEJM, 2006)

(NYT, 4/19/2003)UCLA Center for Health Policy Research report"Income Disparities In Asthma Burden and Care In California“ 2010

A b tAsbestosSBS

Radon

Legionnairesdiseasedisease

NO CO L dETSNO2, CO Lead

Moisture/MoldVOCs

/

Formaldehyde Allergens

Pesticides/Ch i l

Allergens

A biChemicals AmbientPollution

fl dflame retardants

h h lphthalates phthalatesphthalates

PCB

energy

PCBsventilation

pesticidesPAH

GenesHealth

Genes

Environment

Environment• Diet• Environmental exposures• Physical activity• Occupation• Neighborhood

h i l disparity linkages• Psychosocial stress• Healthcare • etc.

disparity linkages

Sources Structure Behavior

Indoor Environments

Physical Structure • Size/design of structure• AgeSi f li i

Indoor Sources• Cooking appliances• Tobacco smokeCl i d

Source use patterns• Cooking appliance usage• Cooking practicesS ki b h i


• Size of living space• Single family vs. multifamily• Leakage and/or air exchange • Heating systemsM h i l il i

• Cleaning products• Air fresheners• Personal care products• FurnishingsP i id

• Smoking behavior• Consumer product usage• Personal care product usage

• Mechanical ventilation• Pesticides• Pollutant reservoirs• Water sources

Activity Patterns• Time spent at home• Interaction with sources• Influence on air exchangeOutdoor SourcesOutdoor Sources

• Traffic• Industrial Activity• Residential Activity• Contaminated soilContaminated soil

(Adamkiewicz et al., 2011))

Low SES ↑ High SES ↑• Combustion by-products• Lead• Allergens

Exposures associated w/single family homes• Radong

• Mold• Pesticides• ETS

• VOCs from attached garages

• Formaldehyde• Some VOCs• PBDEs

‘Modern’ chemicals (e.g. SVOCs) ??

MANY CASES OF SOURCE GRADIENTS TOWARD LOW SES

Housing Variable Low

Income

High

IncomeIncome IncomeBuilt before 1980 (%) 71.56 48.63

Area of peeling paint larger than 8 x 11 (%) 3.11 0.99

Any inside water leaks in last 12 months (%) 9.14 7.98

Neighborhood with heavy street noise/traffic (%) 28.19 16.69

Industry/factory within ½ block (%) 6 90 1 74Industry/factory within ½ block (%) 6.90 1.74

Unit uncomfortably cold for 24+ hrs (%) 10.70 6.71

Evidence of rodents in unit (%) 17.77 16.26

Mean floor area of unit (ft2) 1524 2853

Mean occupant density (number per 1000 ft2) 2.78 1.82

Homes with cracks in floor, wall, or ceiling (%) 7.13 3.31, , g ( )

Homes with holes in floor (%) 1.85 0.37

(Adamkiewicz et al 2011, using data from AHS, 1999)(Low income = <$30k/yr; High income = >$100k/yr))

Housing Variable Low

Income

High

Income

Ratio

Income IncomeBuilt before 1980 (%) 71.56 48.63 1.5

Area of peeling paint larger than 8 x 11 (%) 3.11 0.99 3.1

Any inside water leaks in last 12 months (%) 9.14 7.98 1.1

Neighborhood with heavy street noise/traffic (%) 28.19 16.69 1.7

Industry/factory within ½ block (%) 6 90 1 74 4 0Industry/factory within ½ block (%) 6.90 1.74 4.0

Unit uncomfortably cold for 24+ hrs (%) 10.70 6.71 1.6

Evidence of rodents in unit (%) 17.77 16.26 1.1

Mean floor area of unit (ft2) 1524 2853 0.5Mean occupant density (number per 1000 ft2) 2.78 1.82 1.5Homes with cracks in floor, wall, or ceiling (%) 7.13 3.31 2.2Homes with cracks in floor, wall, or ceiling (%) 7.13 3.31 2.2

Homes with holes in floor (%) 1.85 0.37 5.0

(Adamkiewicz et al 2011, using data from AHS, 1999)(Low income = <$30k/yr; High income = >$100k/yr))

Motivated by asthma concerns

Indoor exposures and risk factors Allergens (Peters et al. 2008)C b ti b d t (Z t t l 2005) Combustion by‐products (Zota et al. 2005)

Pesticides (Julien et al. 2007) Ventilation (Zota et al. 2005)e a o ( o a e a 005) Smoking (Kraev et al. 2009)

Disease burden / vulnerability Disease burden / vulnerability

Opportunities for intervention Single landlord Initiatives / policies / construction / re‐hab

4‐yr National Cancer Institute study (PI: G. Sorensen)

OVERALL GOALS OF STUDYOVERALL GOALS OF STUDY To study social and physical determinants of cancer risk‐related behavior among residents of low‐income housing

THIS ANALYSIS To understand the prevalence of key environmental hazards

ithi l i h i i th B twithin low‐income housing in the Boston area To understand the extent of clustering of these hazards To examine associations with self‐reported health among residents of these housing units

Cambridge, Chelsea, Somerville15 bli & 5 i t l d 15 public & 5 privately managed

Family units Approx 40 households per Approx. 40 households per development (n=828 subjects)

Surveys + visual inspectionsy p

Characteristic n (%) Characteristic n (%)

Demographics

Age ‐ n (%)18‐29 30‐3940‐49

153 (19%)218 (26%)169 (21%)

Survey language ‐ n (%)EnglishSpanishCreole

445 (54%)221 (27%)162 (20%)

50‐5960+

( )145 (18%)140 (17%)

Gender ‐ n (%)Male 169 (20%)

( )

Education ‐ n (%)Grade school or below (<8 yrs) Some HS (9‐11.5 yrs) High School (12 yrs)

152 (21%)123 (17%)200 (27%)Male

Female 169 (20%)659 (80%)

Race/ethnicity ‐ n (%)Hispanic 341 (41%)

High School (12 yrs) More than high school (13+ yrs)

200 (27%)261 (35%)

Years living in development ‐ n (%)0‐5 years 382 (48%)

Non‐Hispanic White Non‐Hispanic Black Other

93 (11%)316 (38%)74 (9%)

Income below poverty ‐ n (%)

5‐10 yearsMore than 10 years

184 (23%)226 (29%)

Number of people in apartmentMean (SD) [Range] 3.0 (1.5) [1‐13]Income below poverty n (%)

YesNo

445 (58%)327 (42%)

Mean (SD) [Range] 3.0 (1.5) [1 13]

Characteristic n (%)

Environmental indices [n with problem (%)]Environmental indices [n with problem (%)]CHEMICALFrequent use of pesticides or air fresheners in the homes

MOLDVi ibl ld ld t t t t d b id t i ibl

663 (81%)

358 (43%)Visible mold or mold treatment reported by resident or visiblemold noted during inspection

SECONDHAND SMOKEAny reported smoking within the home

172 (22%)y p g

PESTSFrequent sightings of mice, cockroaches or rats

COMBUSTION BY‐PRODUCTSGas stove without mechanical kitchen exhaust or reported use of

443 (54%)

415 (52%)Gas stove without mechanical kitchen exhaust or reported use of gas stove to heat apartment

INADEQUATE VENTILATIONInadequate kitchen or bathroom mechanical ventilation

368 (48%)

Summed indexMean (SD) [Range] 2.9 (1.3) [0‐6]

40

20

30

ercent

0

10

0

Pe

0

0 1 2 3 4 5 6

Summed Index

These hazards were likely to be clustered46% of homes had four or more hazards46% of homes had four or more hazards

Site

Environmental Indicators

HouseholdHousehold

Site

Current chemical usageCurrent chemical usageMold

Current smokingPests

Combustion by‐productsInadequate ventilation

Household

q

Household

Site

Current chemical usage

p < 0.001Important to think about structural/systemic issues

Current chemical usageMold

Current smokingPests

Combustion by‐productsInadequate ventilation

Household

q

Important to think aboutHousehold Important to think about occupant behavior

Site

Environmental Indicators

HouseholdHousehold

Environmental Self‐reported 0

Indicators health

* *Odds Ratio = 2.15 (1.4,3.3)

p<0.001p 0.001

Odds of self‐reporting health as poor to fair,

All associations are adjusted for site age race/ethnicity poverty status survey language education having

p ,with good to excellent as control

All associations are adjusted for site, age, race/ethnicity, poverty status, survey language, education, having a child under 5 in the household, having an adult over 65 in household, tenure in apartment, gender and 'ever smoked’. *p<0.05


p for trend = 0 008p for trend = 0.008


Environmental Tobacco Smoke (ETS)• Secondhand smoke contains more than 4,800 chemicals, of which at least 60 are known to cause cancer

• There is no safe level of secondhand smoke exposure. Period.

• Health effects:

lung infections

ear problems

SIDS

asthma asthma

lung cancer (20‐30% increase)

coronary heart disease (25‐30%coronary heart disease (25 30% increase)

• Some groups may be more susceptible

• Smoke travels between units through i d k i h ll d flair ducts, cracks in the walls and floors, elevator shafts, and electrical lines; and,

• Ventilation systems and engineering• Ventilation systems and engineering fixes do not eliminate secondhand smoke; so,

• Eliminating indoor smoking in multiunit housing is the only way to completely protect people from exposureprotect people from exposure

All buildings have unintended air pathwayspathways

In multifamily, this occurs between units between units and common areasbetween units and common areas between units and outdoors

Common pathways: pipe penetrationsp p p doors/windows

There is no effective way to eliminate all paths for SHS movement

Eli i ti i d ki i lti it h i i th l• Eliminating indoor smoking in multiunit housing is the only way to completely protect occupants from exposure

Recent study: NCI‐funded study of housing developments in Cambridgehousing developments in Cambridge, Somerville and Chelsea

Major findings‐Measurable levels of nicotine in all but one non‐smoking unit‐ In some units, equivalent to almost a cigarette per daycigarette per day‐ Residents who reported smelling cigarettes smoke from other units frequently had higherlevels of nicotine in the air

Non‐smoking units

Recent study: NCI‐funded study of housing developments in Cambridgehousing developments in Cambridge, Somerville and Chelsea

How often doll i tt

These results are consistent with

More thanOnce/week

you smell cigarette smoke from other units?

consistent with SHS moving

between units

Non‐smoking units

Once/week

Once/week

or between common areas

and unitsOnce/week or less

and units

ksmokers

gradient by odor report

nonsmokers

(Kraev et al. 2009)

On Oct 1, 2012, Boston became the largest city in the country to makelargest city in the country to make it’s public housing smoke‐free

NIH RO1 with MGH Non smoking families

Bill McGonagle

Non‐smoking families Boston and Cambridge (control) Surveys, nicotine, salivary cotinine

(in‐home) Common area (nicotine/PM2.5)

Common‐area measurements showmeasurements show differences by resident characteristics and by smoking policy

• Pesticide and other Chemical Exposures• widespread use• widespread use• few studies of residential exposure

• Wide range of potential health effects• EDC endpoints • cancer• respiratory (e.g., asthma)p y ( g , )• fetal development• ADHD• etc• etc.

• Few studies addressing• disparities• determinants of exposure

From Weschler and Nazaroff (2008)

Banned:

DDT (1972)Organochlorines

DDT (1972)

chlordane (1998)

Banned:

diazinon (2001)Organophosphates

Current ingredients:

chlorpyrifos (2000)

Pyrethroidspermethrin

cypermethrin

etc.???

• Recruitment in 2 communities• Roxbury, MARoxbury, MA• Gadsden County, FL

• Conducted approximately 200 home visitsS• Survey

• Visual inspection• Sampled house dust

• Lab analysis (dust samples)• Pesticides (49 analytes)• Other chemicalsOther chemicals

Median concentrations in house dust (ng/g)

Compound Class Public Housing (n=10)

Other Housing (n=90)

p value

Diazinon Organophosphate 27 10 0.04Piperonyl butoxide Synergist 1720 180 0.04Piperonyl butoxide Synergist 1720 180 0.04cis‐Permethrin Pyrethroid 2590 308 0.01trans‐Permethrin Pyrethroid 5090 731 0.01Cypermethrin Pyrethroid 3250 90 <0.001

Elevated levels in public housing households.Possible dri ersPossible drivers:‐ infestion‐ legacy‐ pest control practices

BANNED ON MARKET

DDT chlorpyrifos permethrin

1972 2001

INTEGRATED PEST MANAGEMENT

Focuses on what pests need for survival◦ FoodW t◦ Water

◦ Shelter◦ Access◦ Access

Minimizes use of ‘high exposure’ formulations◦ Foggers aerosols ‘street’ pesticidesFoggers, aerosols, street pesticides

Uses ‘low exposure’ formulations◦ Baits, gels, trapsBaits, gels, traps

Encouraged by HUD

CBH Study Principal Investigator: Alex Lu

IPMIIS (Integrated Pest Management Intervention I t it St d ) Committee for Boston Public Housing

Boston Housing Authority

Focused on exposure to children

Intensity Study) PI: Snehal Shah (BPHC) Boston Public Health Commission Committee for Boston Public Housing Boston Housing Authority Focused on exposure to children

at site transitioning to IPM

Funding: NIEHS 1R21ES017948‐01

Boston Housing Authority

Focused on understanding how IPM intensity is related to quality of life, mental health, exposuresFunding: NIEHS 1R21ES017948 01 , p

Funding: U.S. Department of Housing and Urban Development.

Housing represents a significant i f l b llportion of energy usage globally

We need a better understanding of the tradeoffs between health and energy as we evaluate housing‐based interventionsg

Need models which can evaluate interventions viant

levels

ge / costs

evaluate interventions via relevant metrics: health

ontaminan

nergy usag

energy cost

Ventilation

Co En

energy data ‐ http://www.buildingscience.com/

existing weatherizeweatherize

renovaterenovate‘green’

new

buildbuild‘green’

The BRIGHT Study

Boston Residential Investigation onBoston Residential Investigation on Green and Healthy Transitions

Results – all households

Old Colony

h h

Cathedral

Washington Beech

Results – all households

Old Colony

Conventional Green

How do these transitions affect: Comfort? Satisfaction? Environmental exposures? Health? Energy usage?

Goal: 400+ surveys + sampling study surveys

2012 – 200+ 2013 – 200+Summer ‐100 Winter‐100 Summer ‐100 Winter ‐100

Conventional Conventional

Green Green

Conventional

Green

Ski h / bl

Burning/itching eyes

Sore or dry throat

Wheezing

Sneezing attacks

Inner ear infection

Skin rashes/problems GreenConventional

Nosebleeds

Breathing problems

Blurred vision

Wheezing

Nausea

Coughing

Tired more than usual

Nosebleeds

0 10 20 30 40 50 60 70

Dizziness

Headaches

Nausea

0 10 20 30 40 50 60 70

Percent reporting symptom in past 30 days

Ski h / bl

Burning/itching eyes

Sore or dry throat

Wheezing

Sneezing attacks

Inner ear infection

Skin rashes/problems GreenConventional

Nosebleeds

Breathing problems

Blurred vision

Wheezing

Nausea

Coughing

Tired more than usual

Nosebleeds*p<0.05

0 10 20 30 40 50 60 70

Dizziness

Headaches

Nausea

0 10 20 30 40 50 60 70

Percent reporting symptom in past 30 days

30

35

Conventional

25

30Green

*p<0.05

15

20

p

10

0

5

0 1 2 3 4 5 6 60 1 2 3 4 5 6 >6

Number of Symptoms in Past Month

1000

PM2.51000

NO21000

Formaldehyde

100

PM2.5 (U

G/M

3) 100NO2 (U

G/M

3)100

e (U

G/M

3)

1

10P

Y1

10

Y1

10

Form

alde

hyde

Y2012 2013Year 2012 2013Year 2012 2013Year

C t l G P t ChControl Green Percent Changen GM (GSD) n GM (GSD)

Environmental MeasuresPM2.5 (µg/m3) 42 15.1 (2.3) 18 8.9 (1.8) ‐ 41.1 %NO2 (µg/m3) 43 63.2 (1.8) 18 21.4 (1.2) ‐ 66.1 %Formaldehyde (µg/m3) 41 9.4 (2.1) 18 12.1 (1.8) + 29.7 %y (µg/ ) 4 9 4 ( ) ( ) 9 7Nicotine (µg/m3) 42 0.11 (5.4) 18 0.02 (5.1) ‐ 81.8 %

Health MeasuresHealth MeasuresSymptomSummation 43 3.8 (2.5) 18 1.9 (2.1) ‐ 50.0 %

80

100

omes

20

40

60

omes vs. Con

trol H

‐40

‐20

0

eren

ce in Green Ho

‐100

‐80

‐60

Perce

nt Diffe

‐100PM2.5* NO2* Formaldehyde Nicotine * Median CO2 AER†

Figure 1. Percent difference in concentration (PM2.5, NO2, Formaldehyde, Nicotine, CO2) and changes/hour (AER) in green homes compared to control homescontrol homes.

Values calculated using multivariate longitudinal linear mixed effects models, adjusted for year and mean ambient temperature. Error bars indicate 95% confidence interval.† AER only collected in second year of study. Multivariate model not adjusted for year.


Indoor Environments

Physical Structure • Size/design of structure• AgeSi f li i

Indoor Sources• Cooking appliances• Tobacco smokeCl i d

Source use patterns• Cooking appliance usage• Cooking practicesS ki b h i


• Size of living space• Single family vs. multifamily• Leakage and/or air exchange • Heating systemsM h i l il i

• Cleaning products• Air fresheners• Personal care products• FurnishingsP i id

• Smoking behavior• Consumer product usage• Personal care product usage

• Mechanical ventilation• Pesticides• Pollutant reservoirs• Water sources

Activity Patterns• Time spent at home• Interaction with sources• Influence on air exchangeOutdoor SourcesOutdoor Sources

• Traffic• Industrial Activity• Residential Activity• Contaminated soilContaminated soil



Indoor Environments


smoking

pesticidespesticidespesticides

PBDEs PBDEs

combustion by-prodcombustion by-prodcombustion by-prod combustion by prodcombustion by prodcombustion by prod

Programs, policies, systems Keys to success:• Address root causes• Understand systems• Every encounter is an• Every encounter is an opportunity• people

H h ld f ili

p p• homes

• Need new partnershipsHouseholds, families

Remember – the home is a system

•Weatherization can improve IAQ•Weatherization can improve IAQ, but can also lead to problems

• Renovations can change gdynamics

• Air sealing can lead to increased humidity, increased environmental exposures, backdrafting, andexposures, backdrafting, and changes in airflow patterns which decrease IAQ

• BPHC’s analysis of BRFSS data showed decline indata showed decline in current asthma symptoms from 2006‐2010 for BHA residents

• No decline seen for other housing typesg yp

• Differences remained after adjustments for age, gender ethnicity smokinggender, ethnicity, smoking habits, health insurance, and whether foreign‐‐born

1/1/2013

Jack Spengler Jon Levy

Boston Housing Authority Committee for BostonJon Levy

Glorian Sorensen Committee for Boston Public Housing

Jose Vallarino Meryl Colton Marty Alvarez‐ReevesMarty Alvarez Reeves Joan Arnold

Patricia Fabian Tina Wan Patricia Fabian Sophia Qiu Raphael Arku Piers MacNaughton

Tina Wang Oscar Zarate Kathleen Attfield Robin Dodson Piers MacNaughton Robin Dodson

BRIGHT Study Principal Investigator: G. Adamkiewicz

M l C lt Meryl Colton Marty Alvarez‐Reeves Jose Vallarino John Kane (BHA)

HIC Study Principal Investigator: Glorian Sorensen

M Al R

Mae Bennett‐Fripp (CBPH)

Funding: U.S. Department of Housing and Urban Development (MALHH0229 10) Marty Alvarez‐Reeves

Reggie Tucker‐Seeley Brittany Bricen Lorraine Wallace

Urban Development (MALHH0229‐10).

FreshAir Study Principal Investigator Doug Levy

Ruth Lederman Funding: National Cancer Institute (R01

CA111310‐01A1).

Principal Investigator: Doug Levy Raphael Arku Piers MacNaughton Jose Vallarino

Funding: NHLBI (RO1HL112212‐01A1).

h kthanks

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