SETTING THE STAGE health effects of poor iaq, asthma and investigative principles

1. SETTING THE STAGEhealth effects of poor iaq, asthma and investigative principles ITEP Training April 24-27, 2012 Kathleen Norlien Minnesota Department of Health 651-201-4613 Kathleen.norlien@state.mn.us

2. Environmental Exposures • Source (agent) • Chemical and gases (VOCs) • Particulate (dust, glucans, endotoxins) • Biologicals (fungus, bacteria, viruses) • Routes of exposure/ delivery (environment) • Ingestion • Inhalation • Dermal absorption • Occupant (host) • Age • Sex • Genetics • Health status • Behaviors Host Environment Agent

3. Social Risk Factors and Health Increased risk • Poverty • Poor housing quality • Environmental exposures • Poor nutrition/ food insecurity • Safety Decreased access • Language barriers • Geographical barriers • Inadequate health insurance Development of illness or disease Severity of illness or disease Adapted from the Medical Legal Partnership for Children

4. Asthma Facts from Minnesota Currently have asthma 7.6% of Minnesota adults or about 260,000 (about 1 in 13) 7.0% of Minnesota children or about 76,000 (about 1 in 14) Economic impact of asthma is $421 million/ year (AHRQ) $240 million for hospitalizations, emergency department visits and medications $181 million for lost school and work days Minnesotans with asthma Healthcare provider advised changes to home, school, or work environment 42.9% of adults 25.7% of children

7. Exposures

8. Home Inspections:Hazards Found and Goals

9. Home Inspection Hazards (cont.)

10. What is asthma? Chronic disorder of the airways involving • Airflow obstruction • Tightening of the muscles surrounding airways (bronchoconstriction/spasm) • Over-production of sticky mucus in airways • Bronchial hyper-responsiveness • Underlying inflammation (swelling) of airways

11. Normal and Asthmatic Bronchiole

12. Common Symptoms of Asthma • Frequent cough, especially at night • Shortness of breath or rapid breathing • Chest tightness • Chest pain • Wheezing • Fatigue

13. Daily preventative Examples: Flovent, Pulmicort, Advair, QVAR, Singulair • Quick-relief Examples: Albuterol such as Ventolin, Pro-Air, Proventil, Xopenex • Emergency Steroids such as Prednisone, Oraped, Prelone, Prednisolone Asthma Medications

14. Asthma can be controlled! Medical management: EPR-3 guidelines Asthma Action Plan • Provide education about asthma • Review medication plans • Teach self-management skills Trigger management • Help families reduce or eliminate environmental factors in their home that contribute to the to control of asthma (home visits, checklists, RETA-Home) • Provide a “Healthy Home” for all

15. Another tool is a peak flow meter • Measures how well child’s or adult’s lungs are doing at moment compared to personal best peak flow • System to help manage asthma symptoms Green (>80%)-Yellow (50-79%)-Red (<50%) • Helps students and families self-manage asthma by providing objective measure to compare to symptoms • Consistent with asthma action plans

16. Development of Asthma in Sensitive Exacerbation of Asthma in Sensitive Biological Chemical Biological Chemical

17. Exercise/sports Cold air Viral/upper respiratory infections Air pollution (Ex. O3, NO2, SOx) ET– including secondhand smoke Dust mites Fungi & mold Pests Pets Chemical irritants and strong smells Diesel fumes Cleaning supplies Chalk dust Wood smoke Other – Strong emotions, weather changes, some medications Common Triggers

18. Health Effects • In children, secondhand smoke causes • Premature death and disease • Sudden Infant Death Syndrome (SIDS) • Acute respiratory infections • Middle ear disease • More severe asthma • Respiratory symptoms • Slowed lung growth Scientific evidence indicates no risk-free level of exposure to primary or secondhand smoke

19. Health Effects (cont.) • In adults, secondhand smoke causes • Coronary heart disease • Stroke • Chronic lung disease (emphysema, bronchitis, asthma) • Associated with cancer of the lungs, bladder, mouth, esophagus, kidney, stomach, pancreas, blood (acute myeloid leukemia) • Premature death

20. Dust Mites • Microscopic relatives of the spider • Eat skin cells shed by people • Thrive in warm, humid environments • Found in bedding, pillows, mattresses, upholstered furniture, stuffed toys, carpet, etc.

21. Reduce house dust, especially in bedroom • Reduce clutter and dust-collecting items (stuffed toys) • Damp dust book cases and furniture frequently • Vacuum often when people with asthma/allergies are out of area using HEPA-filtered vacuum cleaner • Use allergen-proof (dust mite) covers on bedding • Wash bedding in hot water (130˚F or 54.4 C) • Keep room humidity < 50% if possible • Remove carpeting from bedrooms Dust Mites–Recommendations

22. Cat allergens very “sticky” • Very high levels (Fel d1) found in homes with cat • Lower levels found in schools and homes without a cat • Even lower levels can sensitize a person • Living with cat does not increase sensitization– high levels of exposure may produce tolerance • IgE antibodies for Fel d1 are strongly associated with lung inflammation and symptomatic asthma Libby Kelly et al. Indoor air and Asthma Role of Cat Allergens in Asthma

23. Causal Associations • Strength of the association • Dose-response relationship • Consistency of the association • Temporality of the association • Specificity of the association • Biologic plausibility

24. From the New Yorker Magazine

25. Traditional toxicology The “dose” makes the poison How much (dose) How long (duration) How often (frequency) Route of exposure (ingestion, inhalation, dermal)

26. EHP- Loh, Levy, Spengler, et al.

27. Micro Environments

28. My Nose Knows Estimated 70-80% of citizen-initiated complaints to air pollution control authorities are complaints about environmental odor sources Dr. Susan Schiffman Journal of Agromedicine, 2000

29. Odor is not indicative of the potential for harm Carbon monoxide Benzene Hydrogen sulfide No odor at levels that can cause death Carcinogen at low levels; odor sometimes perceived as “sweet” Smells like rotten eggs at levels lower than health risk occurs

30. Groups Most Sensitive to Odors Asthma sufferers Epileptics ---------------------------------------------- Young vs. old Women vs. men Pregnant women Non-smokers vs. smokers People with an empty stomach Time of day- morning vs. evening

31. Odors can make you sick… Eye, ear, nose and throat irritation Headache Nausea Congestion Shortness of breath Stress Symptoms generally resolve once odor is removed…

32. Chemicals (OSHA Sensory Irritants) Cause inflammation Increases susceptibility to other irritants Increases susceptibility to infectious agents May lead to permanent injury or dysfunction May permit greater absorption of other hazardous materials Adaptation to irritant may increase risk of overexposure

34. www.retahome.org