Asthma &

the Built Environment

Rick Kreutzer, Chief Division of Occupational & Environmental

Health&

Janet Tobacman,Housing Specialist California Breathing

Presentation Agenda• Overview of California Breathing• Models to Address Asthma

Clinical Model vs Socio-Ecological Model• Strategic Plan for Asthma in CA

– Current Research– Goal 4:Indoor Settings– Goal 5:Outdoor Settings– SPAC in Action

• Asthma & the Built EnvironmentExisting communities & Planned Developments

CB Program ComponentsSurveillance

Disparitie

s

Schools/ Childcare

Partnerships (CAP)

Work-related Asthma

Housing

Technical support; Data resources; Inform activities

Targeted trainings & workshops; Develop tools & resources

Grants & Training program focused on vulnerable communities

Statewide partnerships of 250+ organizations

Grants & Training program addressing built environment

Surveillance of asthma in workplace

Asthma in California

Children with asthma

1.7 M.

Population 38.3 M.

Adults with asthma 3.7 M.

• Asthma varies by– Income/poverty– Race/ethnicity– Age– Sex– Region

Asthma requires the marriage of medicine and public health

• MEDICINE• Healthy patient• Clinical guidelines

(expert experience)• Controlled clinical

trials • Quality improvement• Provider training• Access

• PUBLIC HEALTH• Healthy population• Strategic plans

(stakeholder input)• Observational data/

surveillance• Evaluation• Social marketing and

media advocacy• Liaison to medicine

Challenges of the Medical and the Population Health Models

• Medical model expends resources for individual patients in hope of changing their outcomes

• Extending medical interventions to large numbers of patients is very expensive

• No impacts on overall population data

• Doesn’t necessarily change underlying social inequalities

• Population health is promoted through measures that will influence behaviors or change conditions. Impacts will be small across large numbers of people, even those without asthma

• Impacts on individual are often small, but population data may be shifted

• May target underlying social inequalities further upstream

Strategic Plan for Asthma in California

• Builds upon progress made over the last five years

• Designed for State and County agencies, non-governmental organizations, health organizations, communities, and concerned stakeholders

• Intended to guide development of work plans for implementation

• Provides framework for evaluating performance in addressing asthma

• Highlights need for collaboration and shared information and resources

Strategic Plan for Asthma in CA• Five goals & 40 objectives

– Goal 1: Implementation, Monitoring, Evaluation of SPAC– Goal 2: Surveillance & Research– Goal 3: Healthcare– Goal 4: Indoor Environments

• Schools• Childcare• Housing• Workplace

– Goal 5: Outdoor Environments• Five cross-cutting priorities: reducing asthma disparities, fostering

asthma awareness and education, focusing on asthma throughout the lifespan, changing systems and policies within organizations, & creating the most health protective asthma policies.

Patient-centric v. Place-centric

• The basis for different actions in the Plan

• Places for intervention

• Intervention alternatives and examples

• Who is doing some notable work

Management by Management by PatientPatient

Management by Management by PatientPatient

Family InvolvementFamily InvolvementFamily InvolvementFamily Involvement

Clinical ExpertiseClinical ExpertiseClinical ExpertiseClinical Expertise

Work/School SupportWork/School SupportWork/School SupportWork/School Support

Community Awareness, Support & ActionCommunity Awareness, Support & ActionCommunity Awareness, Support & ActionCommunity Awareness, Support & Action

Community-Wide Environmental Control MeasuresCommunity-Wide Environmental Control MeasuresCommunity-Wide Environmental Control MeasuresCommunity-Wide Environmental Control Measures

Conducive PoliciesConducive PoliciesConducive PoliciesConducive PoliciesNoreen Clark

PlacePlacePlacePlace

LocationLocationLocationLocation

PurposePurposePurposePurpose

Physical InfrastructurePhysical InfrastructurePhysical InfrastructurePhysical Infrastructure

Policies/PracticesPolicies/PracticesPolicies/PracticesPolicies/Practices

Multiplicity of UsersMultiplicity of UsersMultiplicity of UsersMultiplicity of Users

Governance and Governance and EnforcementEnforcement

Governance and Governance and EnforcementEnforcement

16

Social Environment Stressors

Physical Environment Stressors

Health Outcomes

Intervening Factors

Amy Schulz, et.al.

Stress Process Model

Asthma Influences-Social Environment

• Intense emotional states• Hormonal factors• Family Dysfunction• Low Income• Urban communities• Communities of Color

Selected Asthma Triggers-Physical Environment

• Respiratory infection• Allergen exposure• Respiratory irritants, including air pollutants• Cold air• Exercise and hyperventilation• Medications• Foods

Air Pollutants

Air Pollution and Asthma

• Indoor exposures linked with induction of childhood asthma and with exacerbations (IOM “Clearing the Air” 2000)

• Outdoor exposures thought to act as trigger of asthma exacerbations, though recent evidence suggests possible role in causation of new cases

Air Pollutant Categories

• Criteria Pollutants

–Particulate matter

–Ozone

–Nitrogen dioxide

–Sulfur dioxide

–Lead

–Carbon monoxide

• Air Toxics– Benzene– Formaldehyde– Diesel exhaust

particles– PAHs– Chromium– Many others

Ozone and new asthma – Plausibility?

• Overall risk of asthma in high ozone communities was not increased

• Increased time spent outdoors in high ozone communities was associated with a 1.4-fold increase in risk of asthma

• High activity sports can increase breathing rates by up to 17 times

• Risk increased linearly with the number of sports played

McConnell, et.al. Lancet 2002

Ozone and New-onset Asthma in Adults

• AHSMOG study in California• 3091 nonsmokers (ages 27-87) enrolled in 1977• Questionnaires returned in 1977, 1987, and

1992• Long-term exposure to increased levels of

ozone resulted in doubling of risk for new physician diagnosis of asthma in men, but not women

(Source: McDonnell WF et al, Env Res 1999;80:110-121)

Ultra Fine

10 um1 um0.1 um

SulfatesNitratesAmmoniaCarbonLead (HM)Organics

CoarseFine

SoilDustSilicaSaltsPollenTire Rubber

2.5 um

Particulate Matter Sizes and Composition

Asthma exacerbation and pollen

• 1986 ryegrass pollen study of ER visits to Travis AFB – 40% of annual asthma visits (205/496) over 7 days

in May• OR for ryegrass

sensitization = 69(!), while no difference in sensitization to HDM, cockroach, and cat

(adapted from Pollart SM et al. J Allergy Clin Immunol 1988;82:224-30)

Asthma and fungal spores

• >1 million fungal species; humans routinely exposed to @200

• Allergic sensitization to fungal allergens very common (@15 – 50% of atopics: may be underestimated)

• Several studies suggest increased fungal spore counts are related to mild to life-threatening exacerbations of asthma

Current/Latest Research• Seattle Healthy Homes Project

– Jim Krieger• Children living in areas with more street trees have a lower prevalence of

asthma • Lovasi GS, Quinn JW, Neckerman KM, Perzanowski MS, Rundle A.J

Epidemiol Community Health. 2008 Jul;62(7):647-9. Epub 2008 May 1.• Independent predictors of asthma-related hospitalizations: peeling paint,

plaster, wallpaper, environmental tobacco smoke, written action plan of an asthma-related doctor or emergency department visit, and frequent nocturnal wheeze episodes.

• Lambertino A, Turyk ME, Curtis L, Persky VW. J Asthma. 2009 Mar;46(2):202-6.

• Children exposed to higher levels of Penicillium in the bedroom had more frequent asthma symptoms, whereas those exposed to higher levels of cockroach allergen in the bedroom had a higher number of asthma symptoms.

• Environmental allergens and asthma morbidity in low-income children. Turyk M, Curtis L, Scheff P, Contraras A, Coover L, Hernandez E, Freels S, Persky V. J Asthma. 2006 Aug;43(6):453-7.

Federal Involvement with

the Healthy Housing Model

HUD’s Vision for Healthy Homes Programs “To lead the nation to a future where homes

are both affordable and designed, constructed, rehabilitated,and maintained in a manner

that supports the health and safetyof occupants.”

HUD OHHLHC Mission “To reduce health and safety hazards in housing in a comprehensive and cost effective manner, with a particular focus on protecting the health

of children and other sensitive populations in low income households.”

References from page 6 of the HUD Healthy Homes Strategic Plan http://www.hud.gov/offices/lead/library/hhi/DraftHHStratPlan_9.10.08.pdf

On Asthma and Healthy Homes

•About 21% of asthma cases in the U.S. are linked to dampness and mold, at an annual cost of approximately $3.5 billion

•A recent study of asthma among inner city children found that 69% were allergic to cockroaches and33% to rodents

•Excess moisture, poor indoor air quality, and high levels of contaminated dust are common root causes for residential health hazards.

•The key overarching healthy homes principles are to keep the home dry, clean,pest-free, free from contaminants, safe, and well-maintained.

References from page 5 of the HUD Healthy Homes Strategic Plan http://www.hud.gov/offices/lead/library/hhi/DraftHHStratPlan_9.10.08.pdf

The Surgeon General’s Call to Action To Promote Healthy Homes 2009

From the Title Page

“A healthy home is sited, designed, built, renovated, and maintained in ways that support

the health of residents.”

http://www.surgeongeneral.gov/topics/healthyhomes/calltoactiontopromotehealthyhomes.pdf

Built Environment Related Goals/Objectives

• Goal 4: Indoor Environments– Schools

• 4.A.1: Comprehensive and coordinated asthma policies and procedures (Starlight/Starbright Asthma Toolkit

• 4.A.2: Assess compliance with existing codes and best practices & ensure laws adequately address indoor environmental quality issues (Green Schools Pilot Project)

• 4.A.3: Minimize exposure to contaminated outdoor air and promote safe and healthy outdoor school environments (General Plan Update Process Fresno)

Built Environment Related Goals/Objectives

• Goal 4: Indoor Environments

– Childcare• 4.B.1: Comprehensive and coordinated

asthma policies and procedures (CB Childcare Asthma Toolkit)

• 4.A.4: Minimize exposure to contaminated outdoor air and promote safe and healthy outdoor school environments (CB Childcare Asthma Toolkit)

Built Environment Related Goals/Objectives

• Goal 4: Indoor Environments– Homes, Housing, & Institutional Settings

• 4.C.1: Improve understanding of asthma trigger exposure in home environments and assess effectiveness of exposure reduction interventions (e.g., the problem of second and smoke in multi-unit housing environments).

• 4.C.2: Develop and promote standards, guidelines, and model policies for asthma-safe healthy housing that minimize indoor environmental risk factors that contribute to asthma

• 4.C.4: Ensure healthy home environments for people with asthma through augmenting home assessments, remediation, and legal advocacy. (Sonoma County Asthma Coalition)

• 4.C.5: Reduce asthma morbidity and exposure to asthma triggers for people in institutional settings, such as foster and group homes, prisons, nursing homes, and mental health institutions (Green Cleaning).

Gold Standard for New Communities/Development

• Insulated slab to keep floor warm and dry

• Exterior grade plywood• Airtight drywall with low-emission

joint compound• Cement board exterior siding/rain

screen• Low emission doors, trim, cabinets,

finishes, adhesives• Hard surface floors• Enhanced ventilation (HEPA whole

house continuous fan, kitchen/bath fans with timers)

• Radiant/Hydronic baseboard heat to decrease humidity

Results:• Decreased condensation, water

damage, visible mold, roaches, rodents & pests

Seattle-Kings County Breathe Easy Homes Pilot Project

Healthy Building Retrofits

• Multi-pronged organizing approaches – Partnerships among local governments, community

groups, builders, managers

– Proactive code enforcement policies with effective training and implementation

– Partnerships with local housing and health-related ngo’s

• Additional Opportunities: weatherization programs, green jobs initiatives, etc.

Built Environment Related Goals/Objectives

• Goal 5: Outdoor Environments• 5.1:Support policies and community plans (Fresno DPH)• 5.2:Ensure public awareness, participation, and transparency

in public policy decisions and improve communication between AQMDs and communities (SPIG partners)

• 5.3:Target elimination of disproportionate exposure to outdoor air pollution among specific groups (Pacific Institute)

• 5.4:Reduce air pollution from sources such as goods movement & stationary industries, & trans (CCAEJ)

Built Environment Relationship to Nature

Rice Acreage BurnedBuilt Environment Relationship to Agriculture

http://www.epa.gov/airnow

Descriptor Index Value Risk Message

Good 0 - 50 No message

Moderate 51 - 100 Unusually sensitive individuals (ozone)

Unhealthy for Sensitive Groups

101 - 150 Identifiable groups at risk – different groups for different pollutants

Unhealthy 151 - 200 General public at risk; groups at greater risk

Very Unhealthy 201 - 300 General public at greater risk; groups at greatest risk

Strategic Growth Council

• California voters passed the Safe Drinking Water, Water Quality and Supply, Flood Control, River and Coastal Protection Bond Act of 2006 (Proposition 84) on November 7, 2006. Proposition 84 added Division 43, Chapter 9, Section 75065 (a) to the Public Resources Code, authorizing the Legislature to appropriate $70 million for urban greening projects that reduce energy consumption, conserve water, improve air and water quality, and provide other community benefits. The purpose of the chapter includes reducing urban communities’ contribution to global warming and increasing their adaptability to climate change while improving the quality of life in those communities.

• Chapter 13, Statutes of 2008 (SB 732 Steinberg) added to the Public Resources Code and established the Strategic Growth Council (SGC). The SGC is composed of agency secretaries from the Business Transportation and Housing Agency, the California Health and Human Services Agency, the California Environmental Protection Agency, the California Natural Resources Agency, the director of the Governor's Office of Planning and Research, and a public member, appointed by the Governor. One of SGC’s many objectives is managing and awarding financial assistance to cities, counties, and nonprofit organizations for the preparation, planning, and implementation of urban greening projects.

Sample Language Suggested for Fresno County General Plan Update

Element Health Language & Area in General Plan

Agriculture & Land Use •Prioritize new infill development near transit nodes (Page 2-33)•Identify protecting and developing tree cover as a priority (Page 2-33) •Update building codes to support compliance with green building practices (Page 2-34)•Protect schools from major sources of outdoor air pollution and reduce the prevalence of asthma and other chronic respiratory conditions by locating schools at least 500 feet from highways

Element Health Language & Area in General Plan

Transportation and Circulation

• Minimize the pollution associated with stop and go traffic by implementing traffic calming techniques (Page 3-9 Streets and Highways)

• Designated truck routes through urban areas to be located >500 feet from housing and schools to reduce exposure to air pollutants (Page 3-12 add to Policy)

Open Space and Conservation

• Locate sensitive uses, such as schools and family housing, >500 feet from highways (Page 5-12)

Housing • Support mixed-sue residential, commercial, and office zoning to encourage walkability (Page 7-92)

Examples of local action around the built environment (summary)

• Healthy Housing• Green Building• Green Cleaning Initiative in Schools • Location of sensitive spaces in relation to traffic

exposure• General Plan Update Process• Community Design• Ports & Freight Transportation• Access to open spaces/parks

Resources

• California Breathing

www.californiabreathing.org• Public Health Law and Policy

www.phlpnet.org

www.phlpnet.org/healthy-planning• NACCHO

www.naccho.org

www.naccho.org/topics/environmental/landuseplanning/index.cfm

Thank you!