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


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

• [email protected]

• 202-471-4829

• 866-622-2341

http://www.childrensnational.org/MACCHE

http://www.childrensnational.org/MACCHE

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.


Visions of Housing & Health


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


New Building - Existing Building

• NewSiting issuesBuilding materialsRemoval of wasteDesign issues

– Lighting– Ventilation

• ExistingCleaningMaintenanceRenovation


Housing & Human Health

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


Radon


How Radon Enters a House

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


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 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



• 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


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 [email protected] 304-356-4322

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


> 4 pCi/L

2-4 pCi/L

< 2 pCi/L

mailto:[email protected]

Lead


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


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


Younger Children at Greater Risk

• 1-2 year olds


Impact of Lead on the Body

• Function ofAge of child

– GI absorption

Amount ingestedLength of time of exposurePeak BLL vs. cumulative



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

problemsDecreased IQDecreased linear growth



• 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


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


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


MOLD


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


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


MOLD & DISEASE


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


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


Allergic Symptoms

• NasalClear nasal

dischargeNasal congestionSneezingPost-nasal drip with

sore throatCoughingHoarsenessNasal obstruction

• PulmonaryAsthma attacks in

sensitized individuals

New onset of asthma


Molds & Volatile Organic Compounds

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

• VOC production varies with growth conditions


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


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


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


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?


Indoor Allergens


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


Asthma & Housing

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


Cockroaches

• Need warmth• Need water• Need source of

foodKitchenWhere food is

consumed– Kitchen– TV viewing area


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


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


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


Indoor Allergens & Homes

• Maintenance• Humidity control – not too much, not

too little


Housing Structure & Injuries



• Issues are a function of age of residentsKidsElderly

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



• 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?


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,



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

heatersAir condition during heat waves Window guards


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


QUESTIONS?


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