the home & human health mid-atlantic center for children’s health & the environment -...

The Home & Human Health

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE06-08

Jerome A. Paulson, MD, FAAPProfessor of Pediatrics & Public Health

George Washington UniversityMedical Director for National & Global Affairs

Director, Mid-Atlantic Center for Children’s Health & the Environment

Child Health Advocacy InstituteChildren’s National Medical Center

Dr Paulson has NO conflicts of interest to

declare. • This material was developed by the Mid-Atlantic

Center for Children’s health & the Environment and funded under the cooperative agreement award number 1U61TS000118-03 from the Agency for Toxic Substances and Disease Registry (ATSDR).

• Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

VISION

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

VISION

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

MACCHE – MACCHE – A Resource for the A Resource for the

RegionRegion• One of 10 Pediatric Environmental

Health Specialty Units (PEHSUs) in the US

• Serve DE. PA, MA, VA, WV, and DC• Source of Education• Source of Information

PEHSU Regions

The Mid-Atlantic Center for Children’s Health & the Environment

What Kinds of Problems does

MACCHE Deal With?• Lead poisoning• Pesticide exposures• Sick building

problems• Water pollution• Air pollution• Job related exposures

in adolescents• Volatile Organic

Compounds

• Exposure to hazardous waste sites

• Environmentally related asthma

• Agricultural pollutants

• Solvents• Carbon monoxide• Arsenic• Mercury

The Mid-Atlantic Center for Children’s Health & the Environment

MACCHE – MACCHE – Contact InformationContact Information

•www.childrensnational.org/MACCHE

• macche@childrensnational.org

• 202-471-4829

• 866-622-2341

Objectives

• Upon completion of this activity, the participant should be able to:Recognize the impact of the home

environment on the health of children.

Integrate the information into workplace wellness programs for employees.

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Visions of Housing & Health

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Fields of Study Related to Housing & Health

Geology

Neurology & development

Pulmonary disease

Immunology

Allergy

Infectious Diseases

Renovation

Architecture

Building Sciences

ManufacturingBuilding materials

Furniture Plumbing

Agriculture

Mining

Forestry

Housing & Health

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

New Building - Existing Building

• NewSiting issuesBuilding materialsRemoval of wasteDesign issues

– Lighting– Ventilation

• ExistingCleaningMaintenanceRenovation

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Housing & Human Health

• Radon• Lead• Mold• Allergens• Physical factors - injuries

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Radon

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

How Radon Enters a House

http://geopanorama.rncan.gc.ca/whitehorse/radon_e.php?p=1

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Radon as Health Hazard

• Radon chemically inert and electrically uncharged

• Radioactive• Decay produces radon progeny• Inhaled into the lungs attached to dust• Emit alpha radiation• Disrupts DNA of these lung cells• Exposure to alpha radiation may lead to

development of cancerMid-Atlantic Center for Children’s Health & the Environment - MACCHE

Radon as Health Hazard

• Radon clearly associated with lung cancer in miners

• Exposed to much higher concentration of radon than in homes

• Many smokers, most males and exposed to dust and other hazards

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Radon as Health Hazard

• Committee of National Academy of Sciences estimates 15,400 or 21,800 cases of lung cancer per year in the United States can be attributed to radon among ever-smokers and never-smokers together.

• Most of the radon-related lung-cancers occur among ever-smokershttp://books.nap.edu/openbook.php?record_id=5499&page=R1

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Radon & Homes

• Issue varies in different parts of country

• How to build to limit radon incursion?

• How to monitor home over time as basement floors and walls change?

• Cost-effective amelioration methodologies?

• Request a free radon test kit Barbara.A.Davis@wv.gov 304-356-4322

http://www.epa.gov/radon/zonemap.html#more%20about%20the%20map

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

> 4 pCi/L

2-4 pCi/L

< 2 pCi/L

Lead

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

What Did They Know &

When Did They Know It?

• Knowledge of lead hazards goes back to ancient times

• 1904. Publication of paper linking exposure to lead-based paint exposure & childhood lead poisoning. J. Lockhart Gibson, Australiannoted dangers of painted walls and verandas

• 1905. Gibson “[T]he use of lead paint within the reach of children should be prohibited by law.“

• US restriction on indoor lead paint 1978

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Scope of the Problem

• Not an issue with new housing• An issue with pre-1978 housing• Have the potential to eradicate childhood

lead poisoning“…an estimated 25% of the nation's housing

(equivalent to 24 million housing units) had significant lead-based paint hazards in the form of deteriorated paint, dust lead, or bare soil lead.” (Jacobs, et al. 2002. Environ Health Perspect 110:A599-A606) (http://www.ehponline.org/members/2002/110pA599-A606jacobs/jacobs-full.html

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Younger Children at Greater Risk

• 1-2 year olds

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Impact of Lead on the Body

• Function ofAge of child

– GI absorption

Amount ingestedLength of time of exposurePeak BLL vs. cumulative

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Impact of Lead on the Body

• Blood lead levels in children < 10 μg/dLLearning disabilitiesHyperactivityAggression and other behavior

problemsDecreased IQDecreased linear growth

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Impact of Lead on the Body

• Blood lead levels in children20 μg/dL – decreased nerve conduction

velocity40 μg/dL – decreased hemoglobin

synthesis80 μg/dL – encephalopathy: seizures,

coma> 100 μg/dL – death

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Normal IQ Distribution

160140120100806040

70 130I.Q.

6.0 million "gifted"

6.0 million “persons withintellectual disability"

mean 100

Effects of a 5 Point Decrease in Mean IQ

160140120100806040

mean 95

70 130

2.4 million "gifted"9.4 million “persons with

intellectual disability"

57% INCREASE IN

“Persons with Intellectual disabilities”

I.Q.

Lead & Homes

• Primary Prevention the Only Appropriate SolutionScreening of children (secondary

prevention) may have been appropriate in the past

Making housing lead-safe is appropriate now and in the future

Immoral & unethical to use children to identify substandard housing

What legal mechanisms do we need to screen homes and make dangerous homes lead-safe?Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Damp Indoor Spaces and Health

Institute of MedicineNational Academy of

Scienceshttp://books.nap.edu/catalog.php?record_id=11011

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

What happens in damp buildings?

• May get increased growth of mold – fungus – mildew Different terms meaning the same thing All indoor space has some mold Mold and products of mold

• May get increased bacterial growth Bacteria and products of bacteria All indoor space has some bacteria

• May get increased dust mites All indoor space, except the most dry or very cold, have

some dust mites

• May get release of degradation products from break down of building materials

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

MOLD

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Environmental Mold Exposure

WallWall

DoorDoor

http://www.cdc.gov/nceh/publications/books/housing/Graphics/chapter_05/Figure5.01.jpg

Ceiling Ceiling heavily heavily contaminated contaminated with moldwith mold

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Indoor factors supporting mold

growth• Nutrition - building materials • Moisture - leaking roofs or pipes,

condensation on or water intrusion through, walls or basements

• Inadequate and/or poorly maintained ventilation systems that May not provide enough air for dilution and/or

dehumidificationMay contain sources of mold and/or disperse

mold spores into the occupants’ breathing zone

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

MOLD & DISEASE

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Four ways that fungi can cause disease in

humans (and animals)

• May be building relatedAllergic or hypersensitivity reactionsIrritant reactionsToxic reactions

• Not likely to be building relatedInfections

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Allergic reactions most common

• About 10% of the population has allergic antibodies to fungal antigens, and 5% have clinical illnessAllergic rhinitis (“hay fever”) or asthma

• Outdoor molds more abundant and important in airway allergic disease

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Allergic Symptoms

• NasalClear nasal

dischargeNasal congestionSneezingPost-nasal drip with

sore throatCoughingHoarsenessNasal obstruction

• PulmonaryAsthma attacks in

sensitized individuals

New onset of asthma

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Molds & Volatile Organic Compounds

• Molds growth can → volatile organic compounds (VOCs) - alcohols, esters, aldehydes, and aromatic compounds

• VOC production varies with growth conditions

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

In higher concentrations, VOCs

can be highly irritating• Eye irritation and conjunctivitis• Skin rashes• Runny nose• Laryngitis and hoarseness• Cough• Chest tightness• Headache and fatigue

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Mycotoxins

• Produced by some, not all molds• Toxigenic species do not always

produce mycotoxin-depends on various conditions

• Mycotoxins - large moleculesNot significantly volatile; i.e., don’t “off

gas”Don’t migrate through walls or floors

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Exposure to Mycotoxins

• For inhalation must get fungal fragments or spores into air

• May cause skin irritation if contact fungi

• Can be toxic when ingested

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Mold & Homes

• Issue varies in different parts of country

• How to build appropriately to control moisture?

• How to monitor home over time as the building envelope changes?

• How to repair home once moisture incursion has occurred?

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Indoor Allergens

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Indoor air pollutants & asthma

• AllergensDust mites (cause/exacerbate)Animal allergens – cats, dogs, rats or mice

(exacerbate)Molds (cause/exacerbate)

• OthersEnvironmental tobacco smoke (exacerbate)Chemicals in the air: wood smoke, paint,

perfume, cosmetics, pesticides, cleaning agents

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Asthma & Housing

• Estimated that 40% of doctor diagnosed asthma in children due to residential exposure

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Cockroaches

• Need warmth• Need water• Need source of

foodKitchenWhere food is

consumed– Kitchen– TV viewing area

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Asthma Morbidity Associated with

Cockroach Antigen• -/- no allergy/low

exposure• -/+ no allergy/high

exposure• +/- allergy/low

exposure• +/+ allergy/high

exposure 0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

-/- -/+ +/- +/+

ER visits/yrHsptl/yr

Rosenstreich, et al. NEJM. 336(19):1356-63, 1997 May 8

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

House dust mites

• Need warmth• Need high

humidity• Need source of

food – dead skin from humans

• Live in mattresses, upholstered furniture and carpet http://creatures.ifas.ufl.edu/urban/house_dust_mite_fig1.jpg

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Asthma Morbidity Associated with House Dust Mite Sensitivity

0

10

20

30

40

50

60

0-2 mm 3-4 mm 5-6 mm >/= 7 mm

Freq wheezeRecent medsReg morbidityUrgent visit

Peat et al. Aust NZ J Med 1994;24:270-6

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Indoor Allergens & Homes

• Maintenance• Humidity control – not too much, not

too little

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Housing Structure & Injuries

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Housing Structure & Injuries

• Issues are a function of age of residentsKidsElderly

• Issues are a function of the clinical status of the residentsVision impairedMobility impaired

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Housing Structure & Injuries

• New ConstructionWhat is standard

vs. what is “extra”?How protective are

the local codes?

• Existing HousingWhat can be

retrofit?How protective are

the local codes?

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Magnitude of Problem

• 13.5 million nonfatal injuries occur in and around the home4 million ER visits and 2800 deaths per

year from home injuries in children

• 2900 people die in house fires,

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

Housing Structure & Injuries

• Recognized Effective InterventionsInstallation of working smoke alarmsIsolation 4-sided pool fencingPre-set safe temperature hot water

heatersAir condition during heat waves Window guards

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

SUMMARY

• Housing influences health• Somewhat different issues for new vs.

existing housing• Housing professionals & health care

professionals have many areas where they can work together to improve individual and public health

• Need a holistic approach when dealing with housing issues in older homes

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE

QUESTIONS?

Mid-Atlantic Center for Children’s Health & the Environment - MACCHE