Transcript The Genesis of Healthy Homes - Oregon Environmental Health

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 Inspections
City 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:
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Asthma
Lead poisoning
Household Injuries
Estimated 40% of doctor diagnosed asthma is
due to residential exposure
Meta-analysis Megan Sandel MD MPH
Boston 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
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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
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Develops strength-based collaborative family plan
Environmental Health Specialist
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Conducts environmental assessments
Community Health Workers
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Provides follow-up to support provision of incentives and
interventions
Evaluators
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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
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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
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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
___________________________
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• 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 hyperreactivity
• Controllable, potentially with
improvement, but not
“curable”
• Involving changes in the
airways
– Inflammation
– bronchospasm
Knowledge /
triggers, irritants,
and allergens
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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
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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 dosedependent
• 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:
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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
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Home: kitchen, bathroom, basement, bedroom
School, daycare, car, boy scouts, girl scouts
Workplace
Outdoors
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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 Triggers
Does 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
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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 allergenimpermeable 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
Cockroaches
• 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.
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
• Mold spores are everywhere!
• Mold growth in a home can affect your asthma in
three ways:
1.Allergen
2.Mycotoxins (toxic mold) –VERY RARE
3.VOCs can irritate the airways and worsen
asthma symptoms.
• Grow everywhere: wood surfaces, insulation
materials, beneath carpets, inside duct work,
bathroom tiles…...
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 of
secondhand 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
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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 Results
August 2007 to February 2008
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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, 1-800SOS-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
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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
[email protected]
(503) 988-3400