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
• 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 [email protected] 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