Multnomah County Health Department Healthy Homes

1. Multnomah County Health Department Healthy Homes Greig Warner, MS, REHS, Certified Lead Risk Assessor April 28, 2008

2. The Genesis of Healthy Homes Partnering with the community to identify priority environmental concerns from a community perspective in an environmental justice model. 2002

3. 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.

4. People of Color

5. People in Poverty

6. Exposure to Multiple Environmental Problems

7. Exposure to Multiple Environmental Problems

8. 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

9. 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 MPH Boston University Medical School

10. Asthma Mapping

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Environmental Interventions • Education • Mattress and pillow covers • Vacuum cleaners/cleaning supplies • Fragrance Identification and elimination • Walk of mats/Shoe removal • Mold • Furnace Filter Replacement

18. 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 Outcomes for RN Component of MC HHC

19. 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

20. 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

21. 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?

22. 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 NURSING ASSESSMENT

28. ASTHMA TRIGGERS

29. 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. • Allergens • Irritants • Other factors • Environmental exposures • Tobacco Smoke • Viral Illnesses • Food Additives

30. 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 Allergensvs. Irritants

31. 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?

32. 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

33. 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

34. Animal Allergens Dust Mites Cockroach Allergens Indoor Fungi Tobacco Smoke Common Triggers in the Home

35. 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.

36. 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!

37. 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

38. 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

39. 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.

40. 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

41. 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

42. Mold • Mold spores are everywhere! • Mold growth in a home can affect your asthma in three ways: • Allergen • Mycotoxins (toxic mold) –VERY RARE • VOCs can irritate the airways and worsen asthma symptoms. • Grow everywhere: wood surfaces, insulation materials, beneath carpets, inside duct work, bathroom tiles…...

45. A Mold Problem is a Moisture Problem

46. Three Types of Moisture Problems • Overall high humidity • Cold walls • Water infiltration

47. 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.

48. Solution to Confined, Surface Contamination • Add more ventilation • Increase air circulation • Avoid dead air spaces • Add a good dehumidifier • Change habits • Clean it up

49. Mold Contamination due to Structural Problems

50. 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