The Role of Healthy Indoor Environments in Children’s Health Susan Buchanan, MD, MPH Great Lakes Center for Children’s Environmental Health University of Illinois at Chicago

Disclosures/Acknowledgements I have no commercial, financial, or other conflicts of interest to disclose. This material was developed by the Great Lakes Center for Children’s Environmental Health and funded under the cooperative agreement award number 1U61TS000118-05 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. 2

Environmental Medicine “ If you want to learn about the health of a population, look at the air they breathe, the water they drink, and the place that they live.” Hippocrates Air, Water, Places

AIR WATER PLACE Particulate Matter Ozone Sulfur dioxide Lead Carbon monoxide Mold and moisture Formaldehyde Cigarette smoke Asbestos Radon Pesticides Bacteria, viruses Chemical contamination 4

Children as High Risk Population Developing brain Different physiology Different diets Longer life span High risk behaviors Don’t make their own risk management decisions Children are not little adults

A Child’s Environment Is All Around Her Eating Drinking Breathing Touching

Oral Behaviors Children have frequent touching and mouthing behaviors Child Video Study Children have frequent touching and mouthing behaviors median [range] touches to surfaces 83/hr [11-405] hand to mouth area 35/hr [16-129] hand/object in mouth 21/hr [4-126] Ko et al, J Expo Sci Environ Epid 2007

Indoor pollutants may be more important than outdoor pollutants! *Americans spend more than 90% of their time indoors (home, work, school, daycare) Allergens Dust mites Cockroaches Pets Mold Irritant chemicals (cleaners, formaldehyde) Pesticides Inhaling irritants or allergens can cause coughing, wheezing, and asthma attacks. 8

Asthma

CDC, 2012

CDC, 2012

CDC, 2012

CDC, 2012

How do environmental factors exacerbate an asthma attack? Act as a trigger to incite an attack in individual with hyperresponsiveness (susceptibility) Worsen airway inflammation  mucous production, airway contraction

Indoor allergens – cockroaches, mold 36% cockroach sensitization rate in inner-city asthmatic children Mold - 60 species of molds are allergenic 15

Common Lead Sources-Children Deteriorated leaded paint, dust Lead contaminated soil Occupational sources (take-home) Folk remedies Food & food containers (including lead-glazed ceramics) Lead-contaminated drinking water Imported cosmetics (Kohl, Surma) Other (fishing sinkers, lead shot) Plenary A - Susan Cummins, MD, MPH

Geometric Mean Blood Lead, g/dL Geometric Mean Blood Lead Levels in Children 1 to 5 years National Health & Nutrition Surveys 16 88% 10 g/dL 14 14.9 12 10 Geometric Mean Blood Lead, g/dL 8 6 1.6% 10 g/dL 4 3.6 2 2.7 1.9 1976-1980 1988-1991 1991-1994 1999-2002 NHANES II NHANES III NHANES III NHANES IV Source: CDC Plenary A - Susan Cummins, MD, MPH

Neurobehavioral Effects No “safe” blood lead level for neurobehavioral effects Loss of IQ Behavioral problems Poor school performance

Summary: Blood Lead & IQ Verbal IQ Cumulative Frequency Distribution Blood lead 1 to 10 ug/dL lowers IQ by ~4-6 points Effects not reversible

Pesticides As defined by the US Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) of 1970: “any substance intended for preventing, destroying, repelling, or mitigating any insects, rodents, nematodes, fungi, weeds, or any other forms of life declared to be pests.”

Who is exposed to pesticides? In early 1990s, nationwide survey found urinary metabolites of chlorpyrifos and parathion in 82% and 41% of those tested. An average of 12 different pesticides per home were measured in carpet dust and average of 11 pesticides in indoor air (non-agricultural households) Hill RH, Head SL Jr, Baker S. Pesticide residues in urine of adults living in the United States: reference range concentrations. Environ Res 71:99-108 (1995)

How are children exposed to unsafe levels? Accidental or deliberate ingestion Mispackaged or container re-use Pica (eating dirt, sand, clay) Dust ingestion Inadequate ventilation in recently treated areas household sprays, mispackaged pesticides (look like drinks), concentrates, pica & household contamination, groundwater contamination, container re-use, grain storehouses & bait (looting), locally grown food. 22

Health effects of exposure to pesticides at unsafe levels Respiratory (lungs) Asthma Wheezing Lung infections Neurologic (brain and nerves) Dermal (skin)

Mechanism of action of OP pesticides Acetycholine Cholinesterase Enzyme inhibition Nerve Ending Neuromuscular Junction

Symptoms of OP poisoning DUMBELS diarrhea urination miosis bronchospasm emesis lacrimation salivation www.sehondrugs.nl/.../ogen_miosis.html

Neurologic effects of pesticide exposure 4 year old Yaqui children 5 year old Yaqui children Yaquii children in Mexico: high levels of multiple pesticides in cord blood and breast milk. Cases and controls with similar social background, only difference was exposure. Found decreases in stamina, gross and fine eye-hand coordination, 30-minute memory, and the ability to draw a person. Guillette 1998: EHP 106. Guillette 1998: EHP 106.

Prenatal Exposure to Organophosphate Pesticides and IQ in 7-Year-Old Children. Bouchard et al. (2011). Environ Health Perspect, 119(8), 1189-1195. Birth cohort study of Latino farmworker families DAP metabolites from children at 6 months and 1, 2, 3.5, and 5 yo WISC-4 to 329 children at 7 yrs, adjusted for maternal education and intelligence, HOME score This chart does not show statistical significance. The red box is used only to show which results the quote is referring to. Table 3 in this article shows that for DAP a 10-fold increase in level resulted in stati sig decrease in all tests. “Children in the highest quintile of maternal DAP concentrations had an average deficit of 7.0 IQ points compared with those in the lowest quintile”

Providing Adequate Outdoor Air Ventilation Can Improve Student Health and Performance In most schools, ventilation rates are below recommended levels Growing evidence suggests that increasing outdoor air intake can improve student and teacher performance increase test scores reduce airborne transmission of infection

Pediatric Environmental Health Specialty Units (PEHSU) Funded by federal ATSDR, EPA Staffed by: Occupational/Environ-mental Med physician Peds or Family Med physician Medical toxicologist Pediatric health nurse Industrial hygienist Plenary A - Susan Cummins, MD, MPH 29 29

PEHSU Services Provide clinical consultation Telephone consults to health care providers and families Clinic visits at UIC, Stroger Hospital, Cincinnati Children’s Hospital, Lurie Children’s Memorial Consult to public health and environmental agencies Train physicians, nurses, and other health professionals in children’s environmental health 30 30

Region 5 PEHSU UIC School of Public Health Great Lakes Center University of Illinois at Chicago (Drs. Susan Buchanan, Dan Hryhorczuk, Peter Orris) UIC School of Public Health Great Lakes Center University Health Service (Occupational Medicine Clinic) Residency in Occupational and Environmental Medicine John H. Stroger, Jr. Hospital of Cook County (Drs. Mark Mycyk, Steve Aks, Ann Naughton, RN) Division of Toxicology, Department of Emergency Medicine Toxikon Consortium (Dr. Jerrold Leiken) Cincinnati Children’s Hospital Center for Children’s Environmental Health (Dr. Nicholas Newman) Lurie Children’s Memorial Hospital Lead Clinic (Dr. Helen Binns) 31

Great Lakes Center for Children’s Environmental Health Region 5 Pediatric Environmental Health Specialty Unit (PEHSU) (312) 636-0081 or (866) 967-7337 32 32

Questions?