air pollution, asthma, triggers & health - research and remediation strategies

AIR POLLUTION & HEALTHA Workshop for Health Professionals

Clean Air Council

Clean Air Council is a member-supported, non-profit environmental organization dedicated to protecting everyone's right to breathe clean air. The Council works through public education, community advocacy, and government oversight to ensure enforcement of environmental laws.

Mission:

Environmental Education Education

Avoiding environmental allergens and irritants is one of the primary goals of good asthma management.(American Academy of Pediatrics 2003)

CLEAN AIR COUNCIL www.cleanair.org

Integrate environmental education into clinical visits.

Not all patients receive this level of comprehensive care.

Comprehensive asthma interventions include in-home trigger inventories and environmental education.


Clinical Barriers

Clinicians may lack knowledge of environmental triggers.

Clinicians may be unaware of mitigation strategies.

Clinics lack information/resources valuable to patients.

Families leave without knowledge of triggers, how to reduce exposure or where to turn if they have questions.

Time limitations.


Improve understanding of health issues associated with air pollution.

Increase knowledge of mitigation strategies.

Provide useful materials and resources.

More effective and efficient care providers.

Increase understanding of types and sources of air pollution.

Workshop Objectives


Increase ability to individualize treatment plans.

Increase capacity for building patient-provider relationships.

Enhance quality of care and increase patient capacity for disease self management.

Improve ability to communicate with patients about environmental exposures.

Workshop Objectives

What is Air Pollution?


Any particle or gas that harms your health, the environment, or causes property damage.

Lead (Pb)Carbon Monoxide (CO)Particulate Matter (PM)Nitrogen Oxides (NOx) Sulfur Dioxides (SO2)Ozone (O3)

EPA Regulated Air Pollutants

What is Air Pollution?What is Air Pollution?


There are 1000s of unregulated compounds, pollutants and irritants that are equally or more dangerous.

Lead: A Toxic Metal


* Gao, Modal & Lawrence, (2007) Lead effects on development and function of bone marrow-derived dendritic cells.

Lead exposure can cause: Brain damage Nervous system disorders Reproductive disorders Kidney damage Gastrointestinal distress Low birth weight Slowed neurological and behavioral development Intensified allergic reactions * Disruption in the development of certain immune system cells *

Sources: Industrial processing. manufacturing, dust.

95% of lead that is inhaled is absorbed into the body.

Carbon Monoxide


Colorless, odorless, tasteless gas.

Common sources: Vehicles, cigarette smoke, furnaces,stoves, gas or oil burning space heaters, etc.

Formed when fuel is not completely burned.

Attaches to hemoglobin, reducing the amount of oxygencarried in bloodstream.

Dangerous to everyone, especially those with asthma.

Created by fuel combustion.

Nitrous Oxides


Highly reactive, chemistry is driven by sunshine, and temperature and depends on surrounding substances.

Created when fuel containing sulfur (ex. coal, oil) is burned.

Sulfur Dioxides


Reacts in air to form sulfate, a form of particulate matter.

Particulate Matter (PM)


Mixture of solid particles and liquid droplets (acids, organic chemicals, metals, dust, soil.)

Common sources of toxic PM: Fuel-burning engines, industry (i.e. power plants, incinerators), wood burning, cigarettes.

PM 10: Airborne particles larger than 2.5 mm but smaller than 10 mm.

PM 2.5: Fine airborne particles that are < 2.5 micrometers in diameter.

Health threat is

proportionate to size

and composition.

Ozone (O3)


NOx + Sunshine/Heat + VOCs Ozone

“Good up high,bad nearby”

Ozone (O3)


Top 25 Most Ozone-Polluted Cities#16 Philadelphia (vs. 567 metropolitan statistical regions)

2009 “State of the Air” Reportwww.stateoftheair.org

Air Pollution in PA


Top 25 Cities with Worst Long-term PM #2 Pittsburgh/ New Castle, Pa. #20 York/Hanover/Gettysburg, PA#21 Lancaster, PA

Top 25 Counties with the Worst Short-Term PM#1 Allegheny County (Pittsburgh)#21 Washington County (Pittsburgh metro area)#24 Philadelphia County

#1 Richmond, VA#8 Philadelphia (#12 2009)

#14 Allentown#15 Scranton#19 Pittsburgh

Most difficult places to live with asthma (out of 100 most-populated U.S. metro areas).

-Asthma prevalence.-Death rate for asthma.-Annual pollen score.-Air quality.-Number of asthma specialists.-100% public smoke-free law.-Poverty rate.-Uninsured rate.-Use of rescue meds.-Use of controller meds.

Asthma in PA


2010 Asthma & Allergy Foundation ofAmerica (AAFA) Annual “Asthma Capitals” Report

• 11% of Children (312,000) (9.4% nationally)

• 8% of Adults (863,000) (7.3% nationally)

• 15% of Children in Philadelphia• 40% of Children in the most burdened communities.

-2007 PA Behavioral Risk Factor Surveillance System (PA BRFSS)-Pennsylvania Health Care Cost Containment Council (PA PHC4)-Bureau of Community Health Systems, Division of School Health-Department of Public Welfare, Commonwealth of Pennsylvania-CDC 2010

Data Sources:

Asthma in PA


• Over 22,862 in-patient hospitalizations were due to asthma.• Cost approx. $468,270,000 (not including physician charges).•Use of emergency services by children with asthma in Western Pennsylvania is 300 to 400 times the national average.

Cost of Asthma in PA (2007)

Air Pollution Research


Assumption: Air pollution has a negative impact on our health.

What is the evidence?

How does air pollution affect asthma related outcomes?

Devlin et al. (1997) • Exposed healthy individuals to ozone (in lab).

BAL results:• Temporary increases in inflammation.• Long-term increases in lactate dehydrogenase (enzyme

released from injured epithelial cell walls).

* Variable and complex immune response.

Exposure Research


Devlin et al. (1997) • 2 hours of exposure to typical concentrations of ozone.• 1 hour of heavy exercise during exposure.

Results:• Least-responsive individuals may experience no symptoms

or lung function changes.• Most-responsive individuals experienced up to a 50%

decrease in FEV1 (lung function) and have severe coughing, shortness of breath, or pain on deep inspiration.

* Response to ozone can vary greatly by individual.

Exposure Research


Kerhl et al. (2009) • Pre and post-ozone exposure dust mite challenge.• 8-hour ozone challenge.

BAL Results:• Increases in inflammation 24 hours post ozone exposure (in

comparison to pre-exposure inflammation).

*Ozone increases airway reactivity/intensity of allergic response.

Exposure Research


Morishita et al. (2004) • Induced an allergic airway disease in a group of rats (oval-

bumin exposure).• Exposed allergic and non-allergic to air from urban Detroit

air (mobile lab).

BAL Results: • Exposure to particulate matter induced inflammation

(eosinophils, proteins) most in rats with the allergic disease.

* Non-specific allergic response is triggered by particulates found in urban air.

Exposure Research


Rossi et al. (1993)• Measured air pollution levels and emergency room visits in

an industrial town (population 100,000).• 1 year = 232 emergency room visits for asthma.

Results: • Significant correlation between air pollution levels and

emergency room visits for asthma.

* Air pollution linked to asthma exacerbations and health care usage.

Exposure Research


Burnett et al. (1994)• Tracked air pollution levels, health care usage, and

absenteeism.• 16 cities• 10 years • 720,519 asthma-related admissions.

Results: • Days with higher ozone levels were associated with higher

rates of absenteeism, and more visits to doctors, hospitals and emergency rooms.

Exposure Research


Jerrett et al. (2009)• Paired air pollution data in 96 cities with cause of death data

for almost 500,000 people (118,777).

Results: • Significant increase in the risk of death from respiratory

causes associated with increases in ozone concentration.

Exposure Research


Gordon et al. (2000) (Review article) “Cardiovascular Toxicity of Inhaled Ambient Particulate Matter”

• PM exposure increases:-Blood pressure-Heart rate-Heart rate variability-Changes in blood plasma and blood coagulation-Risk of heart attack, stroke, etc.

Exposure Research


Most at risk?


Individuals with existing health conditions.

People engaging in work or heavy exercise outdoors.

Children

Elderly

Outdoors• Urban environments (ie. industrial, manufacturing,

transportation and goods movement-related activities, etc).• Neighborhood/community level (ie. motor traffic, autobody shops, dry-

cleaners, nail salons, etc).• Rural environments (ie. pollen).

Indoors• Home• Homes of friends, family, etc• School• Work

Environmental Asthma Triggers


• Ozone • Particulate Matter• Industrial Processing (metal dust, toxic fumes, etc)• Vehicle exhaust• Road dust• Pollen• Mold spores• Cold weather• Auto-body practices (paint, engine work, etc)• Dry-cleaning emissions• Construction• Chlorine• BBQ/Grill• Fires, Burn barrels• Fireworks

Outdoor Asthma Triggers & Sources


Reducing Exposure to Outdoor Asthma Triggers

Tools for Minimizing Exposure:

-Air Quality Data (pollution, weather, pollen)

-Advocacy (patient, community, political)

Reduce time spent outdoors on days with higher concentrations of air pollution & pollen.

Reduce intensity and duration of outdoor activity during times that pollution is highest.



Seasons and weather conditions- Pollution is more severe in Summer.- High pollution days are typically sunny, hot, humid with light winds.- Winter “inversions” can trap pollution at ground-level.

Time of day-In morning, the sun comes out, and temperature rises, creating the conditions in which ozone is formed. -Ozone levels increase throughout the day, peaking in the afternoon.-Plan activities for early in the day or late evening.


• 0 - 50: Good. Air quality poses little/no risk.

• 51 - 100: Moderate. Some risk for unusually sensitive individuals.

• 101 - 150: Unhealthy for sensitive groups. Sensitive groups include children, adults active outdoors, and lung disease patients.

• 151 - 200: Unhealthy. Risk for anyone active outdoors.

• 201- 300: Very Unhealthy. Risks for general population.

• 301 – 500: Hazardous. Emergency conditions.

http://airnow.govwww.cleanair.org


• E-mail or text message notification.


Filing Air Pollution Complaints

Air Management Services (AMS)City of Philadelphia Department of Public Health

Call (215)685-7580 (or 311) • Dust• Odor• Noise• Idling• Smoke• Vibration


-Time of day, duration-Wind direction-See, smell, taste-Irritation


Pollen.com-Create a pollen diary.-E-mail notifications.-Pollen-type specific.

- Spend less time outdoors on day with high pollen counts.


Reducing Exposure Through Advocacy


Encourage families to be advocates for their own health.

Parents should make connections with other who have a stake in their child’s health.-Relatives-Parents of friends-School nurses-Physical education teachers-Coaches

Reducing Exposure Through Environmental Action

• Use less-polluting forms of transportation.

• Conserve energy.

• Consider alternative energy sources.

• Stay abreast of environmental news, contact legislators, submit letters to the editor, join advocacy organizations, attend environmental rallies.


Advocacy Solutions for Community-level Pollutants

• Reduce vehicle emissions- IdleFreePhilly.org

• Approach polluting businesses- Auto-body shops- Nail salons- Dry cleaners

*Non or less toxic solutions may be available.


Indoor Air Pollution

According to the EPA people spend nearly 90% of their time indoors.


Pets (furry or feathered)-Remove pet from home.-Brush/comb pet outside and more often.-Bath pet more often.-Wash hands after touching pet.-Vacuum and clean often areas where pets frequent.-Keep pet out of patient’s bedroom.-Have someone besides the patient clean litter boxes, or cages.

Dust-Dust carries dust mites. Wipe surfaces with damp cloth. -Dust all surfaces more frequently and clean only when the patient is out of the room or house.

Pests (mice, rats, insects) -Eliminate standing food and water. -Fill holes in walls and around fixtures with steel wool. -Integrated Pest Management for professional help. paipm.cas.psu.edu/

Indoor Triggers & Solutions


Carpets and Rugs-Remove if possible. Wood flooring is easier to keep clean. -Use small area rugs that can be washed easily. -Use vacuums with HEPA bags and filters. Steam clean.-Vacuum when patient is out of the house

Upholstered Furniture and Drapes-If possible, wash furniture covers and drapes.-Vacuum with HEPA bags and filters.-Steam cleaning can help eliminate the harmful effects of pet dander, dust and pollen.

Bedding-Wash in hot water frequently.-Use dust mite/allergy proof covers for pillows and mattress. -Avoid feather stuffed products.



Stuffed Animals-Limit the number in the bedroom. -Wash more frequently, drying completely.

Arts and Crafts Supplies (markers, paints, glue, etc)-Use non-toxic supplies.-Use with extra ventilation. -Keep well contained.

Clutter, Stacks of Papers, Magazines, etc-They attract dust and create safe havens for insects and rodents.

-Organize, store in boxes, etc.



Cooking-Cook with fans and vents running. -Keep patient out of room.

Fragrance & Personal Care Products -Perfume, air fresheners, hair spray, nail polish, etc.-Discontinue use.-Use only away from patient.

Cleaning Products (with Ammonium, Phthalates, etc). -Check ingredients.-Replace with cleaners that are made of organic ingredients such as plant derivatives and essential oils. -Keep patients out of room when using irritating products.



Tobacco Smoke-Help smoker quit (provide materials, support, meds, etc). 1-800-QuitNow www.quitnow.net -Have smoker smoke outside in a smoking jacket.

Vehicles in Garage-Do not idle vehicles. -Keep garage door open to allow emissions to completely clear.

Mold and Mildew-Clean with water and light bleach. -Remove and replace materials with mold. -If renting, exercise tenant rights to have mold removed.



Old Housing Stock-Replace crumbling materials. Contact the landlord for improvements. -May contain asbestos and formaldehyde which must be removed professionally.

Humidifiers and De-humidifiersUse de-humidifiers to keep basements dry (avoid mold and mildew). Clean water basins frequently.

Air purifiers, Ion and Ozone Generators-Clean filters as recommended.-Look into specific product information and owners manuals, some emit unsafe amounts of ozone.-Discontinue use, especially if the product is an old model.



Nitrogen dioxide– Comes from fuel and kerosene burning stoves, space heaters, etc.-Discontinue use.-Use ventilation that leads outside.

Radon -A natural, radioactive, colorless, odorless gas-Increases risk of lung cancer.-More common in lower levels.-Enters homes through dirt floor, cracks in concrete walls and floor, floor drains, and sometimes well water.-Radon test kits are commercially available.



• Discuss with patients how environmental triggers impact health, and how avoiding exposure is a crucial part of asthma management.

• Environmental Checklists: Have patient fill out at home. Use during visit.

• Discuss environmental issues specific to the patient.• Provide environmental resources with other materials given to

patients (e.g. prescription slip).• Discuss approaches to addressing community-level triggers.• Include environmental trigger profiles in EMRs.

Clinical Solutions


• Clean Air Council www.cleanair.org (215) 567-4004

• Environmental Protection Agency.

http://www.epa.gov

• IdleFreePhilly.org www.idlefreephilly.org or (877)853-1552


Environmental Health Resources

• Asthma Community Network: Communities in Actionhttp://www.asthmacommunitynetwork.org/ - New website!


Asthma Resources

http://www.asthmacommunitynetwork.org/

• 1-800-QuitNow

• Smoke Free Phillyhttp://www.smokefreephilly.com/


Tobacco Cessation Resources

Lead Prevention and Inspection Pennsylvania Department of Health Lead Information Line -

(717) 782-2884

Philadelphia Health Department Lead Poisoning Prevention Program - (215) 685-2797

"Get the Lead Out!" Hotline: (215) 685-2797 (24-hour; English, Spanish, and Vietnamese)


Housing Resources

• Integrated Pest Management

(814) 863-0604

• www.allergysolution.com


Housing Resources

• American Council for an Energy-Efficient Economy www.aceee.org/

• Alliance to Save Energy

http://ase.org/

• Clean Air Council

cleanair.org


Energy Resources

• Department of Housing and Urban Development (PA)

http://www.hud.gov/local/pa/renting/tenantrights.cfm

• City of Philadelphia Fair Housing Commission• City of Philadelphia Department of Licenses and

Inspections (L&I)

• Tenant Union Representative Network (TURN) • Community Legal Services of Philadelphia• Philadelphia Legal Assistance


Tenants Resources

The Children's Advocacy Project – This site provides names and contact information of social service agencies

in over 20 categories. Also provides information about the Pennsylvania Children's Health Insurance Program (CHIP) expansion, Cover All Kids.

•After School Programs/Camps •Child Abuse •Childcare •Domestic Violence •Early Intervention Services •Education •Employment •Food and Nutrition •Health Insurance •Housing •Immigration/Refugee Services

•Legal Services •Literacy •Mental Health •Parenting Resources •Physical Health •Pregnancy Resources and Infants •Safety •Shelters •Special Needs •Teen Resources

Resources:

www.cap4kids.org


Human Services Resources

• Air pollution is a major risk factor, especially for the young, the old and those with pre-existing conditions.

• Everyone reacts differently to air pollution.

• Summer is the worst time for air pollution.

• Exposure to many of the most common triggers can be avoided.


Conclusions


Discussing environmental factors can:

-Serve as opportunities to build patient-provider relationships.

Enhance quality of care, increase patient capacity for disease self management & IMPROVED OUTCOMES!

HCPs with a more specific knowledge of environmental asthma triggers and the available resources can provide more comprehensive care.

Conclusions

-Increases patient’s awareness.

-Empower patients to create and ask for change in their homes and their communities.

Questions?

Comments?

Feedback?


Thank you!


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