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Cleaning for Allergy and Asthma Control

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Zulkarnain on Oct 04, 2009 Says :

instructive slides

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Notes

Show Notes

Slide 1 :

Cleaning for Allergy and Asthma Control Gary Adamkiewicz, PhD MPHHarvard School of Public Health Simmons College October 25, 2005

Slide 2 :

What is asthma? Asthma is a chronic inflammatory condition of the airways Three characteristics: Reversible airway obstruction Bronchial hyper-responsiveness Chronic inflammation In studying the ‘causes’ of asthma, we must distinguish between development and exacerbation

Slide 3 :

Currently affects 5-10% of US population >17 million Americans 150 million worldwide Incidence, severity increasing Mortality has plateaued still relatively rare Leading serious chronic illness among children Since 1980, prevalence has doubled Leading cause of lost school days In the US, costs exceed $14 billion/yr (NYT, 4/19/2003) The Asthma Problem

Slide 4 :

In general, higher rates in developed countries Some hypotheses “Hygiene hypothesis” Environmental exposures Diet Physical activity/lifestyle ISAAC (1998), Lancet 351:1225-32. Between-population disparities

Slide 5 :

“Hygiene hypothesis” – reduction in infections and microbial exposures early in life may be associated with increased risk of allergy, asthma and autoimmune diseases Based on observations and speculation on: Urban/rural differences Farming/non-farming differences Birth order / small families / day care Early exposure to parasites, allergens, viruses, etc. Between-population disparities

Slide 6 :

Hypotheses Environmental exposures (e.g., ETS, indoor allergens) Housing conditions Obesity Access to adequate health care Genetic variants Intrinsic factors (e.g., premature birth) Social/psychological factors (e.g., stress, exposure to violence) Age- and gender-adjusted asthma hospitalization rates in Boston, 1992 (Gottlieb et al., 1995) Within-population disparities

Slide 7 :

Asthma Interventions Asthma Development Asthma Exacerbation genetics environment medical care environment

Slide 8 :

Asthma: Relevant exposures Chemical Tobacco smoke Building materials Carpet/furniture Combustion products Household chemicals Pesticides Structural Water/moisture Heating,ventilation and air conditioning Deteriorated buildings Appliance disrepair Old carpet and upholstery Social Stress Exposure to violence Biological Bacteria/viruses Cockroaches Dust mites Molds Pets Pollen Rodents

Slide 9 :

Relevant biological exposures Allergens Pets (cats, dogs, rodents, etc.) Pests (cockroach, dust mite) Pollen Fungi (mold) Bacterial Endotoxins Viral Rhinovirus Respiratory Syncytial Virus

Slide 10 :

NAS Report (2000) From: Institute of Medicine. Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National Academy Press: 2000. Factors associated with asthma exacerbation

Slide 11 :

Cleaning and Asthma Effect of cleaning on asthma development has not been studied Based on hygiene hypothesis, infections and microbial exposures early in life may be beneficial Effect of certain types of cleaning for asthmatics has been studied, focusing on allergen reduction It has been suggested that asthma may be elevated among women employed in domestic cleaning (Medina-Ramon et al, 2003)

Slide 12 :

Allergens Dust mite Associated with development and exacerbation of asthma (NAS, 2000) Cockroach Most common allergy among Inner City Asthma Study subjects (Kattan et al. 1997) Early life exposure associated with development of asthma (Litonjua et al. 2001) Mouse Dust allergen levels associated with sensitization (Phipatanakul, 2000) Few studies on the association with asthma development and symptoms Pets Effects of pet exposure depend on many factors: sensitization, time of exposure, etc.

Slide 13 :

Controlling Allergen Exposure Source ? Airborne allergen Generally associated with small particles suspended in air, released directly, or from reservoir Possible strategies Source control/reduction Cleaning Air Reservoirs (carpet, floor, bed, couch) Ventilation

Slide 14 :

Controlling Allergen Exposure Examples

Slide 15 :

Controlling Dust Mites Dust mites are microscopic organisms that feed on dead skin scales Dust mite growth is a function of Food source (skin scales) Temperature Humidity (55 – 73% optimal, Arlian et al. 2001) Reservoirs - upholstered furniture, carpets, mattresses, pillows

Slide 16 :

Controlling Dust Mites Dust mites are too small to be seen Tips: Wash sheets, pillows, blankets, clothes, and cloth toys once/week in hot water and dry in a clothes dryer Use allergy-proof mattress and pillow encasings Avoid high humidity in your home Clean often with vacuum that has a HEPA filter and dust with a damp cloth

Slide 17 :

Controlling cockroaches Integrated Pest Management (IPM) is an approach to pest control using multiple strategies that emphasize modification of pest environments with the minimum use of pesticides.

Slide 18 :

Controlling cockroaches Inspection and assessment Monitoring Pest populations Identifying pests Determining where the pest are living and why Developing a pest management plan Implementing the pest management plan Continuing to monitor pest populations

Slide 19 :

Healthy Public Housing Initiative

Slide 20 :

60 families with asthmatic children from Boston Housing Authority developments enrolled in intervention study: West Broadway Washington Beech Franklin Hill Health data Environmental Measurements Interventions Clinical – Asthma case management: training, access to peak flow meters, monthly diaries and maintaining an appropriate medication regimen. Environmental – IPM, new mattresses, pillow covers, air purifier, plastic ware, minor home improvements, industrial cleaning. Healthy Public Housing Initiative

Slide 21 :

Public/Government Boston Housing Authority Boston Public Health Commission Universities Boston University School of Public Health Harvard University School of Public Health Tufts University School of Medicine Community Committee for Boston Public Housing, Inc. Franklin Hill Tenant Task Force, Inc. West Broadway Tenant Task Force, Inc. Public Health Initiative, South Boston Community Health Center Private Peregrine Energy Group Urban Habitat Initiatives HPHI Collaborators

Slide 22 :

Project goals Improve home environments to improve health & increase quality of life for residents of public housing in Boston Build capacity within city agencies, community organizations, & resident groups to sustain effort Impact national policy on housing design and health care financing for asthma Design Asthmatic children/caregivers from 3 BHA developments enrolled Followed for 3-6 mo. prior to interventions, 6-12 mo. after interventions Q: Do health outcomes improve after interventions? Healthy Public Housing Initiative

Slide 23 :

Boston Public Housing Facts Largest apartment owner in Boston 15,000 units in 68 developments 25,000 residents (10,000 children) Average Income: 17% of Boston-area median < $10,000 for a family of four Boston Public Housing

Slide 24 :

Resident education Industrial Cleaning Mattress Replacement Integrated Pest Management (IPM) An effective method of pest control based on modifying the physical environment and reducing the use of chemicals. Techniques include: eliminate sources of food and water block entry reduce habitation sites monitor infestation sites Environmental Measurements Temperature/Humidity Allergen levels Roach counts Pesticide levels Air exchange rates Nitrogen dioxide HPHI Activities

Slide 25 :

Intervention- Cleaning and Resident Education Modified HUD Lead cleaning protocol: Removing debris (scraping and vacuuming) Washing Surfaces (walls) Floor Mopping Minor Repairs (e.g., caulking) IPM, including resident training: control of home environment Prevent pests’ access to food, shelter, water and entry. Use of Work Order as a tool

Slide 26 :

Outline - Preliminary Results Allergen levels Pesticide levels

Slide 27 :

Objectives – Allergen Study Objectives To determine if cockroach allergen levels can be reduced in public housing. To determine if reductions in allergen levels can be maintained Rationale To see if the type of interventions worked. To determine whether interventions should be part of BHA’s operation. To determine conditions that have to be dealt with for interventions to be successful.

Slide 28 :

Results: Study Population

Slide 29 :

Measurements

Slide 30 :

Bedroom Cockroach Allergen Levels

Slide 31 :

Estimated Kitchen Cockroach Allergen Levels

Slide 32 :

Allergen Levels by Sources of Food, Shelter and Access (p-value=0.02) By “Clutter” level By “Holes in Walls” (p-value=0.08)

Slide 33 :

Other studies Several studies have shown reductions in cockroach allergen levels through cleaning McConnell et al. (2003) – cleaning effective for households with high initial cockroach counts Arbes et al. (2003) – randomized trial – substantial reduction seen in inner city homes Dust mite studies have also been effective Vojta et al. (2001) – Carpet cleaning reduced allergen loadings; Bed levels reduced through cleaning and encasement Effect of cleaning and allergen reduction on symptoms have been mixed

Slide 34 :

Mattress replacement Mattress replacement was successful. However, baseline dust mite levels in this cohort were low

Slide 35 :

Conclusions – Allergen Study Interventions can reduce cockroach allergen levels. May need to do building-wide. May need to implement on an on-going basis to maintain results. Need to address sources of food and hiding spaces. Need to address pest entry ways.

Slide 36 :

Pesticides, an urban issue Residential Pesticide Use in Inner City Misuse & illegal use (Landrigan et al.1993, Whyatt et al.2003) Preference for high impact pesticides (Pogoda, Preston-Martin 1997) Increased use of pyrethroids, due to removal of products from residential market (e.g., chlorpyrifos and diazinon) (Adgate et al. 2000) High exposure formulations Foggers, aerosols, ‘street’ pesticides (Tres Pasitos, Chinese Chalk, Tempo) Low exposure formulations Baits, gels, traps Integrated Pest Management used to reduce pesticide exposures while controlling pest populations

Slide 37 :

“Street” pesticides Tres Pasitos (illegal) From Dominican Republic/Mexico Made of aldicarb (highly toxic) Chinese Chalk (illegal) From China; common in Chinatown Unknown ingredients (likely deltamethrin) Looks like regular chalk Tempo (legal only for commercial use) Commonly used by Hispanic populations Contains cyfluthrin Used at 200-400 times recommended dosage, applied improperly

Slide 38 :

Pesticide Data from Environmental Questionnaire Note: Preliminary data – do not cite

Slide 39 :

Pesticide residues were widespread in our households Pesticides detected most frequently among the four developments were permethrin, diazinon, chlorpyrifos, cypermethrin and cyfluthrin. These compounds were detected in more than 60% of our homes. Preliminary Results – Pesticide Analysis

Slide 40 :

Preliminary results/recommendations Many environmental risks in our cohort Interventions can reduce allergen levels Pesticide residues are widespread Indoor NO2 levels are high in heating season Indoor NO2 levels are a strong function of air exchange Interventions can be designed to control exposures: e.g. Increased ventilation for pollutants IPM for allergen and pesticide reduction

Slide 41 :

Symptom changes – start vs. finish Note: Preliminary data – do not cite

Slide 42 :

Symptom changes – start vs. finish Note: Preliminary data – do not cite

Slide 43 :

10 Steps to make your home asthma-friendly Eliminate secondhand smoke Control dust mites Limit outdoor activity on high pollution days Reduce everyday dust If allergic, limit exposure to pets Eliminate sources of food, water, shelter and access for pests Limit your use of high-impact pesticides Control mold and moisture Control moisture by fixing leaks and increasing ventilation Plan before the attack – work with your doctor to develop asthma action plan Source: US EPA “ Clearing the Air of Asthma Triggers” May 2004

Slide 44 :

Acknowledgements The HPHI team Rhona Julien Junenette Peters Beatriz Vinas Ami Zota Funders: HUD, Boston Foundation, Jesse B. Cox Charitable Trust, W.K. Kellogg Foundation For more information: www.hsph.harvard.edu/hphi

Slide 45 :

THANK YOU

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