Asthma

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Asthma the Built Environment

• Rick Kreutzer,
• Chief Division of Occupational Environmental
  Health
• Janet Tobacman,
• Housing Specialist
• California Breathing

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Presentation Agenda

• Overview of California Breathing
• Models to Address Asthma
• Clinical Model vs Socio-Ecological Model
• Strategic Plan for Asthma in CA
• Current Research
• Goal 4Indoor Settings
• Goal 5Outdoor Settings
• SPAC in Action
• Asthma the Built Environment
• Existing communities Planned Developments

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CB Program Components
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Asthma in California
Population 38.3 M.

• Asthma varies by
• Income/poverty
• Race/ethnicity
• Age
• Sex
• Region

Children with asthma 1.7 M.
Adults with asthma 3.7 M.
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Asthma requires the marriage of medicine and
public health

• MEDICINE
• Healthy patient
• Clinical guidelines (expert experience)
• Controlled clinical trials
• Quality improvement
• Provider training
• Access

• PUBLIC HEALTH
• Healthy population
• Strategic plans (stakeholder input)
• Observational data/ surveillance
• Evaluation
• Social marketing and media advocacy
• Liaison to medicine

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Challenges of the Medical and the Population
Health Models

• Medical model expends resources for individual
  patients in hope of changing their outcomes
• Extending medical interventions to large numbers
  of patients is very expensive
• No impacts on overall population data
• Doesnt necessarily change underlying social
  inequalities

• Population health is promoted through measures
  that will influence behaviors or change
  conditions. Impacts will be small across large
  numbers of people, even those without asthma
• Impacts on individual are often small, but
  population data may be shifted
• May target underlying social inequalities further
  upstream

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Strategic Plan for Asthma in California

• Builds upon progress made over the last five
  years
• Designed for State and County agencies,
  non-governmental organizations, health
  organizations, communities, and concerned
  stakeholders
• Intended to guide development of work plans for
  implementation
• Provides framework for evaluating performance in
  addressing asthma
• Highlights need for collaboration and shared
  information and resources

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Strategic Plan for Asthma in CA

• Five goals 40 objectives
• Goal 1 Implementation, Monitoring, Evaluation
  of SPAC
• Goal 2 Surveillance Research
• Goal 3 Healthcare
• Goal 4 Indoor Environments
• Schools
• Childcare
• Housing
• Workplace
• Goal 5 Outdoor Environments
• Five cross-cutting priorities reducing asthma
  disparities, fostering asthma awareness and
  education, focusing on asthma throughout the
  lifespan, changing systems and policies within
  organizations, creating the most health
  protective asthma policies.

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Patient-centric v. Place-centric

• The basis for different actions in the Plan
• Places for intervention
• Intervention alternatives and examples
• Who is doing some notable work

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Management by Patient
Family Involvement
Clinical Expertise
Work/School Support
Community Awareness, Support Action
Community-Wide Environmental Control Measures
Conducive Policies
Noreen Clark
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Place
Location
Purpose
Physical Infrastructure
Policies/Practices
Multiplicity of Users
Governance and Enforcement
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Stress Process Model
Social Environment Stressors
Physical Environment Stressors
Intervening Factors
Health Outcomes
Amy Schulz, et.al.
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Asthma Influences-Social Environment

• Intense emotional states
• Hormonal factors
• Family Dysfunction
• Low Income
• Urban communities
• Communities of Color

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Selected Asthma Triggers-Physical Environment

• Respiratory infection
• Allergen exposure
• Respiratory irritants, including air pollutants
• Cold air
• Exercise and hyperventilation
• Medications
• Foods

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Air Pollutants
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Air Pollution and Asthma

• Indoor exposures linked with induction of
  childhood asthma and with exacerbations (IOM
  Clearing the Air 2000)
• Outdoor exposures thought to act as trigger of
  asthma exacerbations, though recent evidence
  suggests possible role in causation of new cases

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Air Pollutant Categories

• Criteria Pollutants
• Particulate matter
• Ozone
• Nitrogen dioxide
• Sulfur dioxide
• Lead
• Carbon monoxide

• Air Toxics
• Benzene
• Formaldehyde
• Diesel exhaust particles
• PAHs
• Chromium
• Many others

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Ozone and new asthma Plausibility?

• Overall risk of asthma in high ozone communities
  was not increased
• Increased time spent outdoors in high ozone
  communities was associated with a 1.4-fold
  increase in risk of asthma
• High activity sports can increase breathing rates
  by up to 17 times
• Risk increased linearly with the number of sports
  played

McConnell, et.al. Lancet 2002
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Ozone and New-onset Asthma in Adults

• AHSMOG study in California
• 3091 nonsmokers (ages 27-87) enrolled in 1977
• Questionnaires returned in 1977, 1987, and 1992
• Long-term exposure to increased levels of ozone
  resulted in doubling of risk for new physician
  diagnosis of asthma in men, but not women

(Source McDonnell WF et al, Env Res
199980110-121)
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Particulate Matter Sizes and Composition
Ultra Fine
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Asthma exacerbation and pollen

• 1986 ryegrass pollen study of ER visits to Travis
  AFB 40 of annual asthma visits (205/496) over
  7 days
• in May
• OR for ryegrass sensitization 69(!), while no
  difference in sensitization to HDM, cockroach,
  and cat

(adapted from Pollart SM et al. J Allergy Clin
Immunol 198882224-30)
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Asthma and fungal spores

• gt1 million fungal species humans routinely
  exposed to _at_200
• Allergic sensitization to fungal allergens very
  common (_at_15 50 of atopics may be
  underestimated)
• Several studies suggest increased fungal spore
  counts are related to mild to life-threatening
  exacerbations of asthma

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Current/Latest Research

• Seattle Healthy Homes Project
• Jim Krieger
• Children living in areas with more street trees
  have a lower prevalence of asthma
• Lovasi GS, Quinn JW, Neckerman KM, Perzanowski
  MS, Rundle A.J Epidemiol Community Health. 2008
  Jul62(7)647-9. Epub 2008 May 1.
• Independent predictors of asthma-related
  hospitalizations peeling paint, plaster,
  wallpaper, environmental tobacco smoke, written
  action plan of an asthma-related doctor or
  emergency department visit, and frequent
  nocturnal wheeze episodes.
• Lambertino A, Turyk ME, Curtis L, Persky VW. J
  Asthma. 2009 Mar46(2)202-6.
• Children exposed to higher levels of Penicillium
  in the bedroom had more frequent asthma symptoms,
  whereas those exposed to higher levels of
  cockroach allergen in the bedroom had a higher
  number of asthma symptoms.
• Environmental allergens and asthma morbidity in
  low-income children. Turyk M, Curtis L, Scheff
  P, Contraras A, Coover L, Hernandez E, Freels S,
  Persky V. J Asthma. 2006 Aug43(6)453-7.

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Federal Involvement with the Healthy Housing
Model
HUDs Vision for Healthy Homes Programs To lead
the nation to a future where homes are both
affordable and designed, constructed,
rehabilitated,and maintained in a manner that
supports the health and safety of occupants.
HUD OHHLHC Mission To reduce health and safety
hazards in housing in a comprehensive and cost
effective manner, with a particular focus on
protecting the health of children and other
sensitive populations in low income households.
References from page 6 of the HUD Healthy Homes
Strategic Plan http//www.hud.gov/offices/lead/lib
rary/hhi/DraftHHStratPlan_9.10.08.pdf
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On Asthma and Healthy Homes

• About 21 of asthma cases in the U.S. are linked
  to dampness and mold,
• at an annual cost of approximately 3.5 billion
• A recent study of asthma among inner city
  children found that 69
• were allergic to cockroaches and33 to rodents
• Excess moisture, poor indoor air quality, and
  high levels of
• contaminated dust are common root causes for
  residential health hazards.
• The key overarching healthy homes principles are
  to keep the home dry, clean,
• pest-free, free from contaminants, safe, and
  well-maintained.

References from page 5 of the HUD Healthy Homes
Strategic Plan http//www.hud.gov/offices/lead/li
brary/hhi/DraftHHStratPlan_9.10.08.pdf
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The Surgeon Generals Call to Action To Promote
Healthy Homes 2009
From the Title Page A healthy home is sited,
designed, built, renovated, and maintained in
ways that support the health of residents.
http//www.surgeongeneral.gov/topics/healthyhomes/
calltoactiontopromotehealthyhomes.pdf
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Built Environment Related Goals/Objectives

• Goal 4 Indoor Environments
• Schools
• 4.A.1 Comprehensive and coordinated asthma
  policies and procedures (Starlight/Starbright
  Asthma Toolkit
• 4.A.2 Assess compliance with existing codes and
  best practices ensure laws adequately address
  indoor environmental quality issues (Green
  Schools Pilot Project)
• 4.A.3 Minimize exposure to contaminated outdoor
  air and promote safe and healthy outdoor school
  environments (General Plan Update Process Fresno)

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Built Environment Related Goals/Objectives

• Goal 4 Indoor Environments
• Childcare
• 4.B.1 Comprehensive and coordinated asthma
  policies and procedures (CB Childcare Asthma
  Toolkit)
• 4.A.4 Minimize exposure to contaminated outdoor
  air and promote safe and healthy outdoor school
  environments (CB Childcare Asthma Toolkit)

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Built Environment Related Goals/Objectives

• Goal 4 Indoor Environments
• Homes, Housing, Institutional Settings
• 4.C.1 Improve understanding of asthma trigger
  exposure in home environments and assess
  effectiveness of exposure reduction interventions
  (e.g., the problem of second and smoke in
  multi-unit housing environments).
• 4.C.2 Develop and promote standards, guidelines,
  and model policies for asthma-safe healthy
  housing that minimize indoor environmental risk
  factors that contribute to asthma
• 4.C.4 Ensure healthy home environments for
  people with asthma through augmenting home
  assessments, remediation, and legal advocacy.
  (Sonoma County Asthma Coalition)
• 4.C.5 Reduce asthma morbidity and exposure to
  asthma triggers for people in institutional
  settings, such as foster and group homes,
  prisons, nursing homes, and mental health
  institutions (Green Cleaning).

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Gold Standard for New Communities/Development

• Insulated slab to keep floor warm and dry
• Exterior grade plywood
• Airtight drywall with low-emission joint compound
• Cement board exterior siding/rain screen
• Low emission doors, trim, cabinets, finishes,
  adhesives
• Hard surface floors
• Enhanced ventilation (HEPA whole house continuous
  fan, kitchen/bath fans with timers)
• Radiant/Hydronic baseboard heat to decrease
  humidity
• Results
• Decreased condensation, water damage, visible
  mold, roaches, rodents pests

Seattle-Kings County Breathe Easy Homes Pilot
Project
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Healthy Building Retrofits

• Multi-pronged organizing approaches
• Partnerships among local governments, community
  groups, builders, managers
• Proactive code enforcement policies with
  effective training and implementation
• Partnerships with local housing and
  health-related ngos
• Additional Opportunities weatherization
  programs, green jobs initiatives, etc.

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Built Environment Related Goals/Objectives

• Goal 5 Outdoor Environments
• 5.1Support policies and community plans (Fresno
  DPH)
• 5.2Ensure public awareness, participation, and
  transparency in public policy decisions and
  improve communication between AQMDs and
  communities (SPIG partners)
• 5.3Target elimination of disproportionate
  exposure to outdoor air pollution among specific
  groups (Pacific Institute)
• 5.4Reduce air pollution from sources such as
  goods movement stationary industries, trans
  (CCAEJ)

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Built Environment Relationship to Nature
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Rice Acreage Burned
Built Environment Relationship to Agriculture
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http//www.epa.gov/airnow
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Strategic Growth Council

• California voters passed the Safe Drinking Water,
  Water Quality and Supply, Flood Control, River
  and Coastal Protection Bond Act of 2006
  (Proposition 84) on November 7, 2006. Proposition
  84 added Division 43, Chapter 9, Section 75065
  (a) to the Public Resources Code, authorizing the
  Legislature to appropriate 70 million for urban
  greening projects that reduce energy consumption,
  conserve water, improve air and water quality,
  and provide other community benefits. The
  purpose of the chapter includes reducing urban
  communities contribution to global warming and
  increasing their adaptability to climate change
  while improving the quality of life in those
  communities.
• Chapter 13, Statutes of 2008 (SB 732 Steinberg)
  added to the Public Resources Code and
  established the Strategic Growth Council (SGC).
  The SGC is composed of agency secretaries from
  the Business Transportation and Housing Agency,
  the California Health and Human Services Agency,
  the California Environmental Protection Agency,
  the California Natural Resources Agency, the
  director of the Governor's Office of Planning and
  Research, and a public member, appointed by the
  Governor. One of SGCs many objectives is
  managing and awarding financial assistance to
  cities, counties, and nonprofit organizations for
  the preparation, planning, and implementation of
  urban greening projects.

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Sample Language Suggested for Fresno County
General Plan Update
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Examples of local action around the built
environment (summary)

• Healthy Housing
• Green Building
• Green Cleaning Initiative in Schools
• Location of sensitive spaces in relation to
  traffic exposure
• General Plan Update Process
• Community Design
• Ports Freight Transportation
• Access to open spaces/parks

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Resources

• California Breathing
• www.californiabreathing.org
• Public Health Law and Policy
• www.phlpnet.org
• www.phlpnet.org/healthy-planning
• NACCHO
• www.naccho.org
• www.naccho.org/topics/environmental/landuseplanni
  ng/index.cfm

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• Thank you!