Multnomah County Health Department

Healthy Homes

Greig Warner, MS, REHS, Certified Lead Risk Assessor

April 28, 2008

The Genesis of Healthy Homes

Partnering with the community to identify priority environmental concerns from a community perspective in an environmental justice model. 2002

Environmental Justice

• Create solutions for people of color and people in poverty being disproportionately exposed to environmental hazards

• Overcoming health disparities

• Using community assessment data to apply for a 3-year HUD Healthy Home grant.

People of Color

People in Poverty

Exposure to Multiple Environmental Problems

Exposure to Multiple Environmental Problems

Multi Family Dwelling InspectionsCity of Portland

• 39% potential air quality citations (water leakage, mold, mildew, ventilation)

• 23% insect or rodent infestation citations

• 17% trash/debris/unsanitary condition citations

• 5% bare wood exposed citations (potential lead issues)

*Approximately 311 Inspected, July ’03 – June ’04

Linking Housing to Health

Substandard housing conditions are intimately linked with three of the leading pediatric health concerns: • Asthma• Lead poisoning• Household Injuries

Estimated 40% of doctor diagnosed asthma is due to residential exposure

Meta-analysis Megan Sandel MD MPHBoston University Medical School

Asthma Mapping

The Goals

• Support families in identifying asthma triggers and prioritizing interventions to improve health and quality of life

• Focus on low income families of color to support overcoming health disparities

• Revise public policy to support the intersection between health and housing

The Partnerships

• Bureau of Housing and Community Development (BHCD)• Portland Regional Lead Hazard Reduction Program (PDC)• Housing Authority of Portland (HAP)• Community Alliance of Tenants (CAT)• City of Portland Office of Neighborhood Involvement (ONI)• Community Energy Project (CEP)• Fair Housing Council of Oregon (FHCO)• American Lung Association Portland Office (ALAO)• Josiah Hill Clinic• Multnomah Co. Health Department Primary Care Clinics and Other

Community Health Clinics)• Community Environmental Health Resource Center (CEHRC

The Healthy Homes Model

Public Health Nurse• Develops strength-based collaborative family plan

Environmental Health Specialist• Conducts environmental assessments

Community Health Workers • Provides follow-up to support provision of incentives and

interventions

Evaluators• Analyze project, recommend revisions, verify outcomes

Cohort 1 Triggers

• 58.9% at least partially beyond the control of the occupant

• 5.3% occupant use

• 36.8% unknown

19 of first 36 dwellings

First 36 Dwellings

• Over half of households had mold/ moisture/ ventilation problems

• One-quarter had evidence of past or present roach or rodent infestation

• Over one-quarter had old, dirty carpet

Cohort 1 and 2 Participation

• 89 families have been enrolled

• 63% of families are Spanish speaking

• Majority of families are people of color • Over 90% retention in the program

Environmental Interventions

• Education

• Mattress and pillow covers

• Vacuum cleaners/cleaning supplies

• Fragrance Identification and elimination

• Walk of mats/Shoe removal

• Mold

• Furnace Filter Replacement

Outcomes for RN Component of MC HHC

Medication• States if control or relief (when

results)• Current med accessible• Refill date congruent• Technique (Correct use devices)

– Prime– Shake– Spacer &/or mask– Slow inhalation (age)– Pause– Rinse & spit (age)

• Has plan re when/how to renew med– Controller– Rescue

• Can locate expiration date/ # doses• Can state risk of fx relief s rx’d

controller• Can state common side effects• Can state how to maintain devices

Health Care• OHP or other

resource________________• Referral need

_______________________– Date completed

______________________– Results

_____________________________

• WCC UTD• Plan for continued WCC• Fall flu shot?_______ Plan?

___________• Calls Advice RN appropriately• Expresses method or concept of

self-advocacy

RN COMPONENT

Knowledge / asthma basics

Can verbalize some framework for understanding asthma as:

• Chronic, having to do with hypersensitivity &/or hyper-reactivity

• Controllable, potentially with improvement, but not “curable”

• Involving changes in the airways– Inflammation– bronchospasm

Knowledge / triggers, irritants, and allergens

• exercise• URI’s• cold, dry air• tobacco smoke• animal dander• dust (mites &/or pollen)• mold• pests• scents, candles, scented

products, strong cleansers• other

RN COMPONENT

Knowledge/action plan• Has written action plan – can find it• Refers to and interprets AAP• States daily plan, including trigger

management• States s/s for rescue med• States s/s for which to call AN• States s/s for which to go to ER• States s/s for which to call 911

4 Questions

• What is your greatest worry/fear about your child’s asthma?

• Do you have a concern about your home? Is there something about your home that you think could make your child’s asthma worse?

• What is your most important hope or goal about your child’s asthma?

• What goals or plans do you have about your home?

NURSING ASSESSMENT

Flow sheet

History• Family (asthma, also

strengths and stressors)

• Client (include typical symptoms)

• Clinic/ER/Admissions/

ICU

Knowledge• Asthma basics• Triggers, irritants,

allergens• AAP• Medications (see, check

dates, demo, ph# of pharmacy)

Objective Data

ASTHMA TRIGGERS

Asthma Trigger Reduction

We wish to identify and reduce exposures to allergens and irritants and other factors that may cause asthma and/or increase asthma symptoms.

1. Allergens

2. Irritants

3. Other factors Environmental exposures Tobacco Smoke Viral Illnesses Food Additives

Allergens vs. Irritants

Allergens– Require sensitization– Affects only those that are

sensitized to the allergen– Not usually dose-

dependent• Examples

– Tree pollen (spring)– Grass pollen (summer)– Weed pollen (fall)– House dust mite

(perennial)– Furred animals (perennial)– Fungi/mold (fall to

perennial)

Irritants– Dose dependent response– Will affect everyone at high

enough dose• Examples

– Tobacco smoke– Ozone– Exhaust fumes/diesel

fumes– Sulfur dioxide– Nitrogen dioxide– Perfumes– VOCs

Assess Environment

Identify & control triggers to: Prevent symptoms Prevent hospitalizations & ED visits Improve quality of life and self-management skills Reduce medications

ASK: Have you noticed anything in your home, work, or school that makes your asthma worse?

Multiple Environments

• Home: kitchen, bathroom, basement, bedroom• School, daycare, car, boy scouts, girl scouts• Workplace• Outdoors

• Two good reasons to focus on indoor triggers:• People spend up to 90% of their time indoors• Much easier to control indoor vs. outdoor

Assess Home TriggersDoes the patient:• keep a pet?• have signs of pest infestation in any part of home? • have visible mold in any part of home?• smoke or live with a smoker?• have a wood-burning stove or fireplace?• have unvented stoves or heaters?

• EPA Asthma Home Environment Checklist for Home Visitors: http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf

• NEETF Environmental History Form for Pediatric Asthma Patient • http://www.neetf.org/health/asthma/asthmahistoryform.htm

Common Triggers in the Home

• Animal Allergens• Dust Mites• Cockroach Allergens• Indoor Fungi• Tobacco Smoke

Animal Allergens

All warm-blooded animals produce dander, urine, feces, and saliva that can cause allergic reactions • 100 million cats & dogs• 1 study of 111 children with

asthma = 67% allergic to dogs, 62% cats

• Cat allergen, remarkably stable and small, penetrates very deep into the lung.

Strategies to Reduce Animal Allergens

– Keep animals out of house- bedroom always!

– Wash hands and clothes after contact

– If possible, remove upholstered furniture and carpets from the home or isolate the pet

– Wash pet weekly

– Non-allergic cat or dog? – NO!

Dust Mites• Are relatives of spiders, and feed off

of dead skin• Require humidity and warmth to live • Size? 3-4 end to end = 1 mm• Reasonable evidence for only one

causative factor for asthma in the indoor environment – this is it (J Adv Nurs 2005 Nov52(3):328-39)

• 50% - 75% of children with asthma allergic

• Sources: Bedroom, bedding, pillows, mattress, upholstered furniture, carpets, drapery.

• Same conditions that encourage mold growth

Dust Mites - Control

• Encase the pillow and mattress in an allergen-impermeable cover

• Get mattress up off floor• Wash all bedding in warm water weekly (the use

of a clothe dryer is probably very important)• Keep humidity below 50%• Remove carpets from the bedroom• Avoid sleeping or lying on upholstered furniture• In children’s beds, minimize the number of stuffed

toys and wash the toys weekly in hot water

• Produce allergens that come from the saliva, feces, and dead body parts

• Children with asthma who are sensitive to cockroaches tend to get more severe asthma attacks compared to children who are not.

• Between 40% and 60% of asthmatic children are allergic to cockroaches.

• Homes with no sign of living cockroaches have measurable amounts of cockroach allergens.

Cockroaches

Preventing Cockroaches

• Fix plumbing leaks and other moisture problems; secure all foodstuffs

• Take piles of boxes, newspapers, and other items where cockroaches may hide out of your home

• Seal all entry points• Make sure trash in your home is properly stored in

containers with lids that close securely, and remove trash daily

• Try using poison baits, boric acid, or traps first before using pesticide sprays

Other Common Home Triggers

• Molds: Basements, Bathrooms

• Smoke and Gases: Kerosene heaters, wood stoves, fireplaces

• Volatile Organic Compounds (VOCs) - Hairspray, cooking spray and odors, furniture polish, new carpets, perfumes

• Tobacco Smoke

• Mold spores are everywhere!• Mold growth in a home can affect your asthma in

three ways: 1.Allergen2.Mycotoxins (toxic mold) –VERY RARE3.VOCs can irritate the airways and worsen

asthma symptoms. • Grow everywhere: wood surfaces, insulation

materials, beneath carpets, inside duct work, bathroom tiles…...

Mold

A Mold Problem is a Moisture Problem

Three Types of Moisture Problems

• Overall high humidity

• Cold walls

• Water infiltration

Size Matters

• As the size of the housing unit increases, the ratio of volume to surface area increases.

• Therefore, the larger the undivided housing unit, the less likely to have a humidity problem.

Solution to Confined, Surface Contamination

• Add more ventilation• Increase air

circulation• Avoid dead air spaces• Add a good

dehumidifier• Change habits• Clean it up

Mold Contamination due to Structural Problems

Mold

• Moisture control = mold control, so - ACT QUICKLY. If wet or damp materials or areas are dried 24-48 hours after a leak or spill, in most cases mold will not grow.

• Scrub mold off hard surfaces with detergent and water; dry completely.

• Absorbent or porous materials, such as ceiling tiles and carpet, may have to be thrown away.

"A Brief Guide to Mold and Moisture in Your Home"EPA Publication #402-K-02-003

Smoke & Gases

• Appliances that burn gas, oil or wood such as furnaces, stoves, kerosene lamps, and space heaters

• NO2 the worst! - lung irritant and can increase your sensitivity to other asthma triggers

Smoke & Gases- Minimize production

• Have the heating system inspected annually.

• Inspect and keep clear the chimney clean-out opening

• Do not use unvented space heaters • Do not use stoves for heating • Do not use wood burning fireplaces • Use kitchen exhaust fans • Do not let the car idle in the garage

Volatile Organic Compounds (VOCs)

• Group of chemicals with similar properties

• # of common sources in most homes

• Off-gassing from pressed wood and dry cleaning

• Strategies – limit use and store properly

Tobacco Smoke

• Most dangerous irritant!• Research showing

causative links to asthma (especially in pregnancy)

• Estimated 46.5 M adults in the US smoke = 23.25 M deaths

• 440,000 deaths each year, 1:5 die

Source: ALA “Trends in Tobacco Use”

Secondhand Smoke

Respiratory Effects ofsecondhand smoke:

• Acute lower respiratory tract infections in children

• Asthma induction & exacerbation in children

• Chronic respiratory symptoms in children

• Eye & nasal irritation in adults

• Middle ear infections in children

Message to person with asthma or caregiver: Quit or at least smoke outside. Provide cessation support if possible.

Secondhand Smoke Causative Links

Recent study from BU and Harvard: of 4,331 children whose moms smoke at least ½ pack/day 2x as likely as to develop asthma

Infants with a predisposition to asthma usually develop the disease earlier in life if parents smoke. Delaying onset has long-term benefits because children who contract asthma before age one usually need more emergency treatment and are less likely to outgrow the disease

Techniques That May Modify Indoor Air

• Vacuuming 1-2 times/week• Damp Mopping• Air conditioning during warm weather is

recommended for asthma patients • Dehumidifiers will reduce house-dust mite levels

in high-humidity areas• HEPA filters can reduce airborne cat dander

mold spores and particulate tobacco smoke – not a substitute for more effective measures

Principles of a Healthy Home

• Keep it:• Dry• Clean• Well Ventilated• Combustion Product

Free• Pest Free• Toxic Chemical Free• Comfortable

Health Outcomes

There are ‘net’ improvements in asthma control, asthma symptoms (Asthma Control Test Scores), and in knowledge about asthma, medication management, and household asthma triggers.

Cohort 3 ResultsAugust 2007 to February 2008

N=37

• ACT (Asthma Control Test) = mean increase of 2.5

• Number of ER visits = decrease of 1.5

• Number of days lost from school, play, etc. = decrease of 8.4

• Environmental score = decrease of 5.5 (R:3, 22)

Healthy Home Evolution

• Community Assessment prioritized healthy home issues

• 3-year HUD Healthy Home grant to improve control of asthma and decrease asthma trigger in low-income family homes

• 3-year CDC Capacity Building grant to create healthy home policy

Policy Efforts to Improve Substandard Rental Housing

• Gresham Rental Inspection Program: regular inspection and complaint driven inspections

• Avoids problem of 30-day no fault evictions• Based on EPA’s Mold Remediation, in Schools,

and Commercial Buildings• Portland: Quality Rental Housing Workgroup

(QRHW) about to issue recommendations to link health and housing

• Unincorporated Multnomah County developing rental housing inspection program

Radon

• Kits available in most hardware stores

• Or, call National Radon Hotline, 1-800-SOS-RADON

Asbestos

• Samples to be sent to private analytical laboratories per document DEQ Analytical Laboratories

LeadLine 503-988-4000 or 1-800-368-5060

LeadLine Response (1 year):• 2744 Contacts (phone, email, printed materials); • 2048 of 2744 were phone calls• 2416 pertained to lead in water• 240 were of special concern: parents or soon to be

parents living in homes built before 1978; sent info, especially regarding PRLHCP

Children Tested by Multnomah County Immunization Clinic:• (Capillary Tests) : N800/Yr• Last Quarter: 198 < 5 mg/dl; 11 between 5-9 mg/dl• 30 active EBLL (10 + mg/dl) cases being monitored

Factors Involved in 15 EBLL Investigations

• 6 lead dust• 5 remodels• 5 soil• 5 old lead paint• 4 ducts and vents• 4 recently lived in foreign country• 3 parents’ occupational exposure• 3 make-up (kohl)• 3 unknown factors

Greig Warner, MS, REHS

Greig.m.warner@co.multnomah.or.us

(503) 988-3400