Radon and Radon Mitigation Issues in Wyoming Dragan Skropanic PUBH 8165 Section 01 Prof. R. Heick April 24, 2010 Welcome! My name is Dragan Skropanic. I am a student at Walden University working toward a PhD in Epidemiology. This presentation is a project whose primary goal is to show that treating radon gas in homes of Wyoming residents is cheaper than treating negative health outcomes as a result of exposure to unsafe levels of radon. Please relax and follow the presentation on the slides at your own speed. Should you have any questions or comments, do not hesitate to contact me at dragan.skropanic@waldenu.edu (if I do not know the answer, I might be able to find someone who does).

For whom is this written? Elected and appointed public officials in the state of Wyoming Insurance agents General public This presentation is primarily aimed at elected and appointed public officials in the state of Wyoming, insurance agents operating in the state, and the general public. The presentation, however, could be of interest to similar audiences in other states where exposure to radon may be a public health issue.

Goals What is radon? How does radon enter your home? Presence of radon in the U.S. and Wyoming Radon exposure and lung cancer Cost of lung cancer treatment vs. cost of radon mitigation What could the state and insurance companies do? After going through this presentation, one should have a much better idea of what radon is and why it is important to address this issue at the local, county and state levels. A cost-benefit analysis provided in this slide show will hopefully convince you, the elected and appointed public officials and insurance representatives that something can, and probably, should be done to alleviate the current situation and prevent many future cases of lung cancer. We will show that it is much cheaper to mitigate a house than to treat lung cancer.

What is radon? Radon is a naturally occurring radioactive gas (EPA, 2010b) It can be found in the soil, air, and water Human senses cannot detect it (Moeller, 2005, p. 121) It “is a leading cause of lung cancer among non-smokers” (EPA, 2010b) References: Environmental Protection Agency. (EPA). (2010b). Radon. Retrieved March 17 from http://www.epa.gov/radon/index.html Moeller, D. W. (2005). Environmental health (3rd ed.). Cambridge, MA: Harvard University Press. According to EPA (2010b), radon is a naturally occurring radioactive gas that can be found in soil, air, and water. The main problem with this gas is that humans cannot see it or smell it (Moeller, 2005, p. 121). As it will be shown below, exposure to elevated levels of the radon gas presents a health hazard. In particular, 20,000 lives are lost annually due to lung cancer caused by unhealthy exposure to radon (EPA, 2010b).

Where can one find radon? Radon is present everywhere in the world; The U.S. is not an exception; The highest readings are in the Rocky Mountain states, most of the Midwestern states, Appalachian region, and some New England states, as the image on the next slide will show. Because radon is a naturally occurring gas, it can be found everywhere around the world. In the United States, the highest readings have been observed in the Rocky Mountain states, most of the Midwestern states, Appalachian region, and some New England states.

The red states Above image source: Environmental Protection Agency. (EPA). Radon: EPA map of radon zones. Retrieved March 18, 2010 from http://www.epa.gov/radon/zonemap.html The map shows that the highest concentrations (Zone 1 in red) of radon are located in the Midwest, Rocky Mountain states, and some states in the eastern part of the U.S. (some New England states and the Appalachian region). The map clearly shows that radon is (or should be) a great concern for many people across the country. Zone 1 counties and states are most likely to see elevated readings of radon: greater than 4 pci/L (pico curies per liter). One needs to keep in mind that the map does not show local variability in radon level. EPA rightfully cautions that maps such as this one should not be used to estimate radon levels in a particular building. Source: Environmental Protection Agency. (EPA). Radon: EPA map of radon zones. Retrieved March 18, 2010 from http://www.epa.gov/radon/zonemap.html

Radon in Wyoming Above image source: Environmental Protection Agency. (EPA). (2010d). Radon: Wyoming. Retrieved March 17, 2010 from http://www.epa.gov/radon/states/wyoming.html The map above shows that most of the Wyoming’s counties are in the red, meaning, that in most counties, the radon readings are usually high and above the safe standards (above 4 pci/L). Again, we emphasize that maps such as this one do not account for variability of radon concentrations within counties and neighborhoods. In other words, It may not be unusual for one house to have a high reading, while the house next door or across the street has a normal or below normal reading. Source: Environmental Protection Agency. (EPA). (2010d). Radon: Wyoming. Retrieved March 17, 2010 from http://www.epa.gov/radon/states/wyoming.html

How does radon enter your home? It may come in from the soil through foundation cracks and other openings. Radon is present in water. It can be released into air while showering (EPA, 2010a). Radon can be released into the air by operating washing machines (Ishikawa, Yasuoka, Tokonami, Takahashi, & Suda, 2008, p. 719). References: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html Ishikawa, T., Yasuoka, Y., Tokonami, S., Takahashi, H., & Suda, H. (2009). Characterization of airborne radon released by domestic showering and the use of a washing machine. Journal of Radioanalytical and Nuclear Chemistry, 279(3), 719-724. In this country, the most common way that radon enters a building is through the cracks in the foundation and other openings. Because the pressure inside a building is lower that the pressure in the soil, a building “acts like a vacuum” (EPA, 2010a), and radon can enter your home through any crack or opening. Radon is also present in water, and, therefore, can be released into the air when water is used (washing dishes, taking showers and baths, using washing machines, etc.) (EPA, 2010a; Ishikawa, Yasuoka, Tokonami, Takahashi, & Suda, 2008). In a recent study, the highest concentrations of radon in the air were recorded approximately “20-50 minutes after the start of water use” (Ishikawa et al., 2008, p. 723). References: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html Ishikawa, T., Yasuoka, Y., Tokonami, S., Takahashi, H., & Suda, H. (2009). Characterization of airborne radon released by domestic showering and the use of a washing machine. Journal of Radioanalytical and Nuclear Chemistry, 279(3), 719-724.

Radon test kits availability Wyoming Radon Test Kit Program is available online at http://www.radon.com/sub/wy/ The price is low: one can get 2 kits for $6.95. Many states offer radon test kit programs. In the state of Wyoming, the Wyoming Department of Health (WDH) offers this at http://www.radon.com/sub/wy/. The price is very low and most people can afford it. The same web site offers a (probably very complete) list of certified radon professionals in Wyoming. The list provides the name, telephone number, and email address.

Radon exposure and health Exposure to radon may cause lung cancer in both non-smokers and smokers (EPA, 2010c). University of Iowa study shows a 11 to 21 percent increased risk of developing lung cancer at 3 pci/L of air during the time period of 5 to 30 years (University of Iowa, 2005). Recall that the U.S. EPA’s current “action level” is set at 4 pci/L. References: Environmental Protection Agency. (EPA). (2010c). Radon: Health risks. Retrieved March 18, 2010 from http://www.epa.gov/radon/healthrisks.html University of Iowa. (2005). Study shows link between residential radon exposure and lung cancer. Retrieved April 16, 2010 from http://www.uihealthcare.com/news/news/2005/03/21radon.html Why are testing for radon, and radon mitigation important? Why should anyone be concerned? Because, research has shown that exposure to unsafe levels of radon can be detrimental to one’s health. In particular, according to EPA (2010c), 20,000 people die from lung cancer caused by exposure to radon in this country. It is worth mentioning that radon, smoking, and second-hand smoke “are the leading causes of lung cancer.” (EPA, 2010c, para. 2). University of Iowa researchers, who were a part of a multi-center study examining the association between radon exposure and lung cancer found that even at levels below what EPA considers safe (4 pci/L) there was an 11 to 21 percent increased risk of developing lung cancer where the exposure lasted 5 to 30 years (University of Iowa, 2005). This is significant enough to be a cause for concern. The risk, naturally, increased as the radon concentration increased. Another study conducted in France concluded that out of 25,134 deaths due to lung cancer (in 1999), up to 12% can be blamed on unsafe indoor radon exposure (Catelinois et al., 2006, p. 1366). References: Catelinois, O., Rogel, A., Laurier, D., Billon, S., Hemon, D., Verger, P., & Tirmarche, M. (2006). Lung cancer attributable to indoor radon exposure in France: Impact of the risk models and uncertainty analysis. Environmental Health Perspectives, 114(9), 1361-1366. Environmental Protection Agency. (EPA). (2010c). Radon: Health risks. Retrieved March 18, 2010 from http://www.epa.gov/radon/healthrisks.html University of Iowa. (2005). Study shows link between residential radon exposure and lung cancer. Retrieved April 17, 2010 from http://www.uihealthcare.com/news/news/2005/03/21radon.html

Radon’s contribution to mortality The above graph clearly illustrates that exposure to unsafe levels of radon contribute more to mortality rates than drunk driving, falls at home, drownings, and home fires in this country (EPA, 2010). Reference: Source: Environmental Protection Agency. (2010). Radon: A citizen’s guide to radon . Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/citguide.html Source: Environmental Protection Agency. (2010). Radon: A citizen’s guide to radon . Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/citguide.html

Radon – lung cancer connection Level For smokers, exposure over lifetime, out of 1000 people For non-smokers, exposure over lifetime, out of 1000 people What to do? Stop smoking and 20 pci/L 260 could get lung cancer 36 could get lung cancer Fix your home! 10 pci/L 150 could get lung cancer 18 could get lung cancer 8 pci/L 120 could get lung cancer 15 could get lung cancer 4 pci/L 62 could get lung cancer 7 could get lung cancer 2 pci/L 32 could get lung cancer 4 could get lung cancer Consider fixing to between 2 and 4 pci/L 1.3 pci/L 20 could get lung cancer 2 could get lung cancer Reducing below this level may be difficult Source: Environmental Protection Agency. (EPA). Radon: Health risks. Retrieved March 17, 2010 from http://www.epa.gov/radon/healthrisks.html The above is adapted from: Environmental Protection Agency. (2010c). Radon: Health risks. Retrieved March 17, 2010 from http://www.epa.gov/radon/healthrisks.html We see from this table that people are strongly urged to fix their homes if the readings are at or above 4 pci/L.

Lung cancer by state Source: The Centers for Disease Control and Prevention. (CDC). Lung cancer rates by state. Retrieved April 17, 2010 from http://www.cdc.gov/cancer/lung/statistics/state.htm The above rates date from 2006. The rates are per 100,000 people. Observe that, in Wyoming, the rate is estimated at 28-61.2 per 100,000. Let us assume that the rate is 44.6 (the midpoint of the range) per 100,000 people. The current population of Wyoming is around 500,000. Therefore, the rate is approximately 223 per total population. Now, if we multiply this by the average cost of lung cancer treatment over 10 year (see slide 15), about $107,000 (in 1996 dollars), we get $23,861,000 (in 1996 dollars). The total burden on Wyoming’s taxpayers and the state’s health care system most likely exceeds this value in 2010 dollars. We see that this is a serious issue. Addressing radon and encouraging radon mitigation may alleviate this burden in the future. Source: The Centers for Disease Control and Prevention. (CDC). Lung cancer rates by state. Retrieved April 17, 2010 from http://www.cdc.gov/cancer/lung/statistics/state.htm

Deaths from lung & bronchus cancer by state Source: Centers for Disease Control and Prevention. (CDC). (2010). Lung cancer rates by state. Retrieved April 17, 2010 from http://www.cdc.gov/cancer/lung/statistics/state.htm Again, the rates are from 2006, per 100,000 people. Just as previously commented, maps like these do not reveal natural variability between and within counties. One needs to keep in mind that variability always exists. Therefore, in some Wyoming counties, or towns, the death rate from lung cancer may exceed 47.2/100,000, while in others, it may be below 23.4/100,000. Centers for Disease Control and Prevention. (CDC). (2010). Lung cancer rates by state. Retrieved April 17, 2010 from http://www.cdc.gov/cancer/lung/statistics/state.htm

Lung & Bronchus Cancer in Wyoming According to the National Cancer Institute (NCI), the highest (age-adjusted) incidence rates are recorded in Wyoming’s central region (note the three counties in red: Natrona, Converse, and Sublette). (NCI, 2010). Reference: National Cancer Institute. (NCI). (2010). State cancer profiles: Wyoming lung & bronchus. Retrieved April 24, 2010 from http://statecancerprofiles.cancer.gov/cgi-bin/quickprofiles/profile.pl?56&047#RT_ForACancer Source: National Cancer Institute. (NCI). (2010). State cancer profiles: Wyoming lung & bronchus. Retrieved April 13, 2010 from http://statecancerprofiles.cancer.gov/cgi-bin/quickprofiles/profile.pl?56&047#RT_ForACancer

Lung & Bronchus Cancer in Wyoming (cont’d) We see that the highest (age-adjusted) death rates are recorded in the northeastern part of Wyoming (counties in red: Weston, Converse, and Campbell). The lowest rates can be found in the state’s southwestern region (NCI, 2010). Reference: National Cancer Institute. (NCI). (2010). State cancer profiles: Wyoming lung & bronchus. Retrieved April 24, 2010 from http://statecancerprofiles.cancer.gov/cgi-bin/quickprofiles/profile.pl?56&047#RT_ForACancer Source: National Cancer Institute. (NCI). (2010). State cancer profiles: Wyoming lung & bronchus. Retrieved April 13, 2010 from http://statecancerprofiles.cancer.gov/cgi-bin/quickprofiles/profile.pl?56&047#RT_ForACancer

Cost of lung cancer treatment Average cost per patient for three periods of treatment could cost $30,000 in 1996 dollars (EPA, 2002, p. 14) Total medical costs through 10 years of treatment after diagnosis can reach $107,000 in 1996 dollars (EPA, 2002, p. 22) Estimated total burden on the state of Wyoming: $23,861,000 in 1996 dollars (see slide 13) Estimates in 2010 dollars are higher Reference: Environmental Protection Agency. (EPA). (2002). Cost of lung cancer. Retrieved April 16, 2010 from http://www.epa.gov/oppt/coi/pubs/II_5.pdf Lung cancer treatment in this country (as well as in all other developed countries) is extremely expensive. According to the U.S. Environmental Protection Agency (EPA), in 2002, the estimates were placed at $30,000 for the first three periods of treatment after diagnosis. Also, given that the patient lives 10 years from the time of diagnosis, expected medical costs of lung cancer treatment are likely to exceed $100,000 in 1996 dollars (EPA, 2002). Estimated total burden on the state of Wyoming, in 2010 dollars, is likely to exceed 30 million dollars (Red Desert Clinic, personal communication, April 12, 2010). Reference: Environmental Protection Agency. (EPA). (2002). Cost of lung cancer. Retrieved April 16, 2010 from http://www.epa.gov/oppt/coi/pubs/II_5.pdf

Radon mitigation Why radon mitigation? Because it can reduce the unsafe levels of the gas, and, thus, reduce the risk of lung cancer significantly. What to do? EPA (2010a) recommends: Select a qualified radon mitigation contractor to reduce the radon levels in your home.  Determine an appropriate radon reduction method.  Maintain your radon reduction system. (EPA, 2010a) Reference: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html If after the radon test it has been determined that the levels are consistently above 4 pci/L, radon mitigation is strongly recommended. The U.S. Environmental Protection Agency (EPA) recommends the following: (1) Be sure to select a qualified contractor (again, consult the Wyoming Department of Health Department, WDH); (2) Depending on the location and the architecture of your home or business, appropriate radon reduction method should be selected – these are discussed on the next three slides; (3) It is extremely important to maintain the system that was installed to ensure that it is working properly and that it is efficient in reducing radon levels; testing radon levels on a regular basis is highly recommended. Reference: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html

Cost of radon mitigation Technique Typical radon reduction Cost of installation Annual operating cost Subslab suction 50% - 99% $800 - $2,500 $50 - $200 Passive subslab suction 30% - 70% $550 - $2,250 Some energy penalties Draintile suction $800 - $1,700 Block-wall suction $1,500 - $3,000 $100 - $400 Sump-wall suction $50 - $250 Crawlspace depressurization $1,000 - $2,500 Cost of radon mitigation may be a concern for many Wyoming residents. We see from the table above that these costs can reach $3,000, a significant amount for many Wyoming households. One needs to keep in mind that the costs listed above are estimates. For example, depending on the location, architecture and other factors of a particular home, the cost of sump-wall suction may exceed $2,500 or may fall below $800. Source: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html

Cost of radon mitigation (cont’d) Technique Typical radon reduction Cost of installation Annual operating cost/loss Natural ventilation in a crawlspace 0% - 50% $200 - $500 if additional vents installed Some energy penalties Sealing of radon entry routes Variable; not easy to determine $100 - $2,000 None Home (basement) pressurization 50% - 99% $500 - $1,500 $150 - $500 Natural ventilation Variable; temporary $100 - $700 Note that a couple of cheaper techniques, such as natural ventilation and sealing of radon entry routes, may provide a temporary and below-50% reduction in radon gas. Source: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html

Most effective and most expensive methods Technique Typical radon reduction Cost of installation Annual operating cost/loss Private well water systems: aeration 95% - 99% $3,000 - $4,500 $50 - $150 Private well water systems: granular activated carbon 85% - 99% $1,000 - $3,000 None It is interesting to note that the most effective radon mitigation methods are, on average, the most expensive. Radon mitigation can significantly reduce the risk of developing lung cancer (see slide 12). Even the most expensive mitigation techniques are still much cheaper than an average lung cancer treatment. Source: Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html

What could the state do? Provide incentives to contractors and construction companies to test for radon and install radon mitigation systems before a home is sold Provide incentives to home owners who install a mitigation system Provide financial assistance to those at or below poverty line to install a mitigation system Work with health insurance companies to offer lower insurance premiums to those who have installed a radon mitigation system Educate the general public What could the state elected and appointed officials do? They can work toward a system that would: (1) Provide incentives to contractors and construction companies to test for radon and install a radon mitigation system before a newly constructed home is sold; (2) Provide incentives to home owners who have installed a mitigation system by reducing their property taxes over a period of time to make up for the cost of the mitigation system; (3) Provide financial assistance to those at or below poverty line so that they too can have a mitigation system installed in their homes; (4) Work with the health insurance companies to offer lower insurance premiums to those who have installed a radon mitigation system; (5) Invest appropriate resources into education of the general public about radon and its effects on human health; encourage and support Wyoming Department of Health’s presence in the media and communities Why are these important? Often times, after a house has been tested for radon, and it was discovered that the levels are unsafe, people do not go through the mitigation system installation because of the cost (see slides 16-18; see also Moeller, 2005, p. 123). Mandating certain standards without any incentives and/or financial assistance is usually counterproductive and unpopular in almost any community. Keep in mind that small steps lead to great results over time. It is in everyone’s interest to lower the risk of lung cancer (as well as other chronic diseases). Because there is no cure for cancer, preventive measures (such as radon mitigation) and behavioral changes are our only hope at this time. Hopefully, we have been successful in showing that radon mitigation is cheaper that any lung cancer treatment. We have shown that radon is linked to lung cancer, and that it is the public’s interest as well the interest of the Wyoming’s health care system to reduce the risk of developing lung cancer. Should you have any questions or comments, do not hesitate to contact me at dragan.skropanic@waldenu.edu. Thank you for your attention. Reference: Moeller, D. W. (2005). Environmental health (3rd ed.). Cambridge, MA: Harvard University Press.

References Catelinois, O., Rogel, A., Laurier, D., Billon, S., Hemon, D., Verger, P., & Tirmarche, M. (2006). Lung cancer attributable to indoor radon exposure in France: Impact of the risk models and uncertainty analysis. Environmental Health Perspectives, 114(9), 1361-1366. Centers for Disease Control and Prevention. (CDC). (2010). Lung cancer rates by state. Retrieved March 17, 2010 from http://www.cdc.gov/cancer/lung/statistics/state.htm Environmental Protection Agency. (EPA). (2002). Cost of lung cancer. Retrieved April 16, 2010 from http://www.epa.gov/oppt/coi/pubs/II_5.pdf Environmental Protection Agency. (2010a). Consumer’s guide to radon reduction: How to fix your home. Retrieved March 17, 2010 from http://www.epa.gov/radon/pubs/consguid.html Environmental Protection Agency. (2010b). Radon. Retrieved March 17, 2010 from http://www.epa.gov/radon/index.html Environmental Protection Agency. (2010c). Radon: Health risks. Retrieved March 17, 2010 from http://www.epa.gov/radon/healthrisks.html

References (cont’d) Environmental Protection Agency. (2010d). Radon: Wyoming. Retrieved March 17, 2010 from http://www.epa.gov/radon/states/wyoming.html Ishikawa, T., Yasuoka, Y., Tokonami, S., Takahashi, H., & Suda, H. (2009). Characterization of airborne radon released by domestic showering and the use of a washing machine. Journal of Radioanalytical and Nuclear Chemistry, 279(3), 719-724.   Moeller, D. W. (2005). Environmental health (3rd ed.). Cambridge, MA: Harvard University Press. National Cancer Institute. (NCI). (2010). State cancer profiles: Wyoming lung & bronchus. Retrieved April 24, 2010 from http://statecancerprofiles.cancer.gov/cgi-bin/quickprofiles/profile.pl?56&047#RT_ForACancer University of Iowa. (2005). Study shows link between residential radon exposure and lung cancer. Retrieved April 16, 2010 from http://www.uihealthcare.com/news/news/2005/03/21radon.html

Further sources Agency for Toxic Substances and Disease Registry. (ATSDR). (2000). Case studies in environmental medicine: Radon toxicity. Retrieved March 17, 2010 from http://www.atsdr.cdc.gov/csem/radon/ American Association of Radon Scientists and Technologists. (AARST). (2010). The dawn of a new era for radon proficiency. Retrieved April 13, 2010 from http://www.aarst.org/aarst/education.shtml Environmental Protection Agency. (EPA). (2010a). Radon. Retrieved April 13, 2010 from http://www.epa.gov/radon/index.html Environmental Protection Agency. (EPA). (2010b). Radon: A citizen’s guide to radon. Retrieved April 23, 2010 from http://www.epa.gov/radon/pubs/citguide.html Gray, A., Read, S., McGale, P., & Darby, S. (2009). Lung cancer deaths from indoor radon and the cost effectiveness and potential of policies to reduce them. British Medical Journal, 338(7688), 1-11. Heartland Radon Research and Education Program. (HRREP). (2006). The Iowa radon lung cancer study. Retrieved April 23, 2010 from http://www.cheec.uiowa.edu/misc/radon.html Radon1.com. (2010). Radon education: Facts & Myths. Retrieved April 13, 2010 from http://www.radon1.com/education.htm Wyoming Department of Health. (WDH). (2010). Wyoming radon project. Retrieved March 17, 2010 from http://wdh.state.wy.us/PHSD/radon/index.html