Environmental Burden of Disease Associated with

Inadequate HousingDavid E. Jacobs PhD, CIH

Research DirectorNational Center for Healthy Housing

Director, WHO/PAHO Collaborating Center on Healthy Housing Research and Training

Healthy Homes ConferenceNashville, TN

May 2014

• Historical Overview• Review of the Evidence• Environmental Burden of Disease

Methodology• Conclusion

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

Miasma & Housing-Related Disease

National Human Activity Pattern Survey

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)

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

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).

Integrated Pest Management

► Severe asthma reduced from 37% to 9% following IPM1

► Insecticides were lower in air and absent in maternal blood2

►More effective against pests than routine spraying3

Selected References1 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: 1684-16893 Miller & Meek 2004. Cost and Efficacy Comparison of IPM with Monthly Spray

Insecticide Applications J Econ Entymology 97 552-569

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/schoolSource: asthma and allergy foundationhttp://www.aafa.org/display.cfm?id=6&sub=63

InjuriesPlace Total Injury Visits/yr

Home 4,010,000

School 811,000

Public 2,210,000

Other 841,000

Unknown 2,341,000Source: Phalen et al. 2005. Residential Injuries in US Children and Adolescents. Pub Health Reports 120: 63-70

• 150 preschool children with asthma• Indoor air sampling in child’s

bedroom over 3 days:• NO2 • PM10, PM2.5

• 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

Indoor NO2 Exposure and Asthma

SymptomRR per 20 ppb increase

in NO2

Limited speech 1.15*Coughing without a cold 1.10*Nocturnal symptoms 1.09*Symptoms while running 1.07Slowing activity 1.06Daytime wheezing, coughing or chest tightness 1.03

Adjusted for age, sex, race, mother’s education level, PM2.5, SHS, season; *p-value<0.05 Hansel 2008

Unvented gas stove

Stove replacement

Ventilation hood installation

Air purifier

Randomized trial to evaluate the effectiveness and feasibility of interventions aimed at reducing indoor NO2 concentrations in Baltimore City homes

Intervention: Target NO2

Breysee et al. 2014

• Replacing gas stoves with electric stoves or placement of air purifiers with HEPA and carbon filters can decrease indoor NO2 concentrations up to 51%

• Ventilation hood installation over stove did not significantly change indoor NO2 concentrations over 3 months of follow up

• Indoor NO2 exposure associated with worse outcomes in asthma and COPD– Even at relatively low pollutant burden

• Clinical guidelines recommend avoidance of indoor air pollution

• Indoor NO2 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

WHO EBD Report 2011

Example of EBD Calculation - 1

Example of EBD Calculation - 2

EBD- 1

EBD - 2

EBD - 3

Environmental Burden of Disease from Inadequate Housing

• Feasible to Quantify• Not Completed for US (yet)• Huge• Interventions Exist• International Conventions are in place

New Paint Lead Levels

Country Median Paint Lead (ppm)

Maximum Paint Lead (ppm)

China 3,280 73,400

India 16,720 187,200

Malaysia 21,300 143,000

Singapore 9 3,500

• 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: 11/5/2007Policy Number: LB-07-01

Global Alliance to End Lead Paint

WHO/United Nations Environment Program

“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

Contact Information

David Jacobs, PhD, CIHResearch DirectorNational Center for Healthy HousingWashington DCDirector, WHO/PAHO Collaborating Center on

Healthy Housing Research and Training

djacobs @nchh.orgwww.nchh.org