1. Environmental Burden of Disease Associated with Inadequate Housing David E. Jacobs PhD, CIH Research Director National Center for Healthy Housing Director, WHO/PAHO Collaborating Center on Healthy Housing Research and Training Healthy Homes Conference Nashville, TN May 2014

2. Historical Overview Review of the Evidence Environmental Burden of Disease Methodology Conclusion

3. Florence Nightingale “The connection between health and the dwelling of the population is one of the most important that exists.” Cited in Lowry, S, BMJ, 1991, 303, 838- 840

4. Miasma & Housing-Related Disease

5. National Human Activity Pattern Survey

7. Sufficient Evidence (WHO, 2005) ► PHYSICAL FACTORS : – Heat and cold - excess winter & summer mortality – Energy efficiency of housing and respiratory health – Radon exposure in dwellings and lung cancer – Neighborhood and building noise and mental health ► SOCIAL FACTORS : – Multifamily housing, high-rise housing, housing quality and mental health ► CHEMICAL FACTORS : – ETS exposure in dwellings and respiratory and allergic effects – Lead-related health effects ► BIOLOGIC FACTORS: – Humidity and mold in dwellings and respiratory health effects – Hygrothermal conditions and house dust mite exposure (asthma)

8. Some Evidence (WHO, 2005) ► PHYSICAL FACTORS: – Ventilation in the dwelling and respiratory and allergic effects ► CHEMICAL FACTORS: – VOCs and respiratory, cardiovascular and allergic effects ► BIOLOGICAL FACTORS: – Cockroaches and rodents in dwellings and respiratory and allergic effects – Cats, dogs and mites in dwellings and respiratory and allergic effects – Pets and mites and respiratory, allergic or asthmatic effects ► BUILDING FACTORS: – Sanitation and hygiene conditions and related physical health effects ► SOCIAL FACTORS: – Social conditions of housing and fear/fear of crime – Poverty and social exclusion and related health effects – Crowding and related health effects – Social factors/social climate and mental health

9. Allergens & Asthma HUD National Survey of Lead and Allergens over 80% of homes in the U.S. have detectable levels of house dust mite allergen in the bedroom 46% had levels associated with sensitization 24% had levels associated with asthma morbidity Allergens were most highly concentrated in low- income housing (Arbes et al., 2003).

10. Integrated Pest Management ► Severe asthma reduced from 37% to 9% following IPM 1 ► Insecticides were lower in air and absent in maternal blood 2 ► More effective against pests than routine spraying 3 Selected References 1 Sandel et al. Can IPM Impact Urban Children With Asthma? 2 Williams et al. An Intervention to Reduce Residential Insecticide Exposure During Pregnancy Among An Inner City Cohort. EHP 114: 1684-1689 3 Miller & Meek 2004. Cost and Efficacy Comparison of IPM with Monthly Spray Insecticide Applications J Econ Entymology 97 552-569

11. Multi-Faceted Asthma Interventions (Education, Management, Coordinated Care, Housing Structural Improvements) ► Symptom Days ► Medical Care (ER) ► Missed School ► Improved Quality of Life Source: Crocker et al. 2009. Home-Based Environmental Interventions to Reduce Asthma Morbidity. CDC Task Force on Community Services ► Asthma-$18.3 billion a year – $10.1 billion in direct medical costs – $8.2 billion in lost work/school Source: asthma and allergy foundation http://www.aafa.org/display.cfm?id=6&sub=63

12. Injuries PlaceTotal Injury Visits/yr Home4,010,000 School811,000 Public2,210,000 Other841,000 Unknown2,341,000 Source: Phalen et al. 2005. Residential Injuries in US Children and Adolescents. Pub Health Reports 120: 63-70

13. 150 preschool children with asthma Indoor air sampling in child’s bedroom over 3 days: NO 2 PM 10, PM 2.5 Outcomes: – Symptoms in the past 2 weeks – Rescue medication use in past 2 weeks Breysee et al 2014 Indoor air pollution: Asthma Baltimore Baltimore Indoor Environmental Study of Asthma in Kids

14. Indoor NO 2 Exposure and Asthma Symptom RR per 20 ppb increase in NO 2 Limited speech 1.15* Coughing without a cold 1.10* Nocturnal symptoms 1.09* Symptoms while running1.07 Slowing activity1.06 Daytime wheezing, coughing or chest tightness 1.03 Adjusted for age, sex, race, mother’s education level, PM 2.5, SHS, season; *p-value<0.05 Hansel 2008

15. Unvented gas stove Stove replacement Ventilation hood installation Air purifier Randomized trial to evaluate the effectiveness and feasibility of interventions aimed at reducing indoor NO 2 concentrations in Baltimore City homes Intervention: Target NO 2 Breysee et al. 2014

16. Replacing gas stoves with electric stoves or placement of air purifiers with HEPA and carbon filters can decrease indoor NO 2 concentrations up to 51% Ventilation hood installation over stove did not significantly change indoor NO 2 concentrations over 3 months of follow up

17. Indoor NO 2 exposure associated with worse outcomes in asthma and COPD – Even at relatively low pollutant burden Clinical guidelines recommend avoidance of indoor air pollution Indoor NO 2 concentrations – Reduced by HEPA Air purifier with carbon filter – Reduced by replacing gas stove with electric stove Indoor PM concentrations – Reduced by HEPA Air purifier

18. WHO EBD Report 2011

19. Example of EBD Calculation - 1

20. Example of EBD Calculation - 2

21. EBD- 1

22. EBD - 2

23. EBD - 3

24. Environmental Burden of Disease from Inadequate Housing Feasible to Quantify Not Completed for US (yet) Huge Interventions Exist International Conventions are in place

27. New Paint Lead Levels CountryMedian Paint Lead (ppm) Maximum Paint Lead (ppm) China3,28073,400 India16,720187,200 Malaysia21,300143,000 Singapore93,500

28. Calling for a Global Ban on Lead Use in Residential Indoor and Outdoor Paints, Children’s Products, and All Nonessential Uses in Consumer Products Policy Date: 11/5/2007 Policy Number: LB-07-01

29. Global Alliance to End Lead Paint WHO/United Nations Environment Program

31. “Until effective standards for the domestic environment are devised, it is likely that children will continue to be employed as biological indicators of substandard housing.” Donald Barltrop, 1974

32. Contact Information David Jacobs, PhD, CIH Research Director National Center for Healthy Housing Washington DC Director, WHO/PAHO Collaborating Center on Healthy Housing Research and Training djacobs @nchh.org www.nchh.org