Housing‐Related Indoor Pollution and Childhood Asthma d Childh d A th
Patrick N. Breysse
P
t i kN B
Johns Hopkins Center for Childhood Asthma in the Urban Environment
Asthma in the Urban Environment Presented at
Delaware Healthy Homes Summit, March 12, 2014
Vital Signs: Asthma Prevalence, Disease Characteristics, and Self‐
Management Education United States, 2001—2009
Management Education ‐‐‐
United States 2001—2009*
• Number of people with asthma continues to grow
– O
One in 12 people (about 25 million, or 8% of the i 12
l ( b t 25 illi
8% f th
population) in 2009
– One in 14 (about 20 million, or 7%) in 2001
• Asthma kills ‐ 2007
– 185 children and 3,262 adults died from asthma 185 children and 3 262 adults died from asthma
• Age differences ‐ 2009
– 1 in 10 children (10%) had asthma
– 1 in 12 adults (8%) had asthma
• Sex differences Sex differences ‐ 2009 2009
– Women were more likely than men
– Boys more likely than girls to have asthma.
• Racial differences – 2009
– One
One in 9 (11%) non
in 9 (11%) non‐Hispanic
Hispanic blacks had asthma
blacks had asthma
– One in 6 (17%) of non‐Hispanic black children had asthma
– The greatest rise in asthma rates was among black children (almost a 50% increase)
* Taken from the National Health Interview Survey
Indoor Air Pollution
• Large literature linking ambient air pollution and disease
pollution and disease
• Less is known about the impact of indoor air pollution on morbidity and
indoor air pollution on morbidity and mortality
• Children, the elderly, and women are ,
y,
the most vulnerable to effects of indoor air pollution
– Spend as much as 90% of their time in the home environment
• Many exposures are housing related
Indoor Air Pollution
Indoor Air Pollution
• People
People can decrease concentrations of specific can decrease concentrations of specific
pollutants inside their homes by taking actions
– Targeting indoor air pollution an attractive target Targeting indoor air pollution an attractive target
for disease prevention
Sources of Indoor Air Pollution
Sources of Indoor Air Pollution
• Complex mixture of agents penetrating from outdoor p
g
p
g
air
– Varies with geographic area
– Varies with housing quality
hh
l
• Agents generated by indoor sources
– Combustion
Combustion by‐products
by products
• Smoking
• Wood‐burning and other biomass burning
– Cleaning activities, i.e. sweeping
– Volatile compounds
– Allergens
All
– Biological agents
Health Effects of Exposure to Indoor Air Pollution
ll i
• Respiratory
– Asthma
– Allergic rhinitis
– Chronic obstructive pulmonary disease
– Infections
• Cardiovascular disease
• Cancer
• Developmental
Asthma Morbidity Studies Asthma
Morbidity Studies
in Baltimore
Many Factors Coalesce
Unfavorably in Inner City
Education
Health Care
Care Access
Poverty
Occupation
Race
Ambient Air Pollution
Food
Allergens
Indoor P ll i
Pollution
Asthma is a Complex Disease with Complex Risk Factors
•
•
•
•
•
Particulate matter
Particulate
matter
Nitrogen oxides
Ozone
Secondhand smoke
All
Allergens
– Pests
– Pets
– Molds
• Endotoxin
Endotoxin and other and other
bacterial components
• Respiratory tract in infections
• Diet
• Psychosocial stress
The Baltimore Indoor Environmental Study of Asthma in Kids
(BIESAK)
• 150 children from Baltimore, Maryland
• Predominant participant characteristics
Predominant participant characteristics
– Between ages 2 and 6 years
– African‐American (91%)
African‐American (91%)
– From households of low socioeconomic status
– Spent 14 out of 24 hours (on average) in their Spent 14 out of 24 hours (on average) in their
homes and half of this time in the room being monitored
Do indoor pollutants Increase
Asthma Morbidity?
Asthma
N=150
Survey
S
Home Inspection
Monitoring
Settled Dust
Control
C
t l
N=150
Survey
S
Home Inspection
PM Monitoring
Settled Dust
0
Survey
S
Home Inspection
Monitoring
Settled Dust
3
Time (months)
Survey
Home Inspection
PM Monitoring
Settled Dust
6
Asthma Morbidity Studies
Baltimore City, Maryland
• Indoor Particulate Matter
I d
P ti l t M tt
• Mouse Allergen
• Indoor NO2
Baltimore Indoor Environmental Study of Asthma in Kids
Study of Asthma in Kids
(BIESAK)
• 150 children from Baltimore, Maryland
150 hild
f
B li
M l d
• Evaluated at baseline, 3, and 6 months
• Predominant participant characteristics
– Between ages 2 and 6 years
– African‐American (91%)
– From households of low socioeconomic status
– Spent 14 out of 24 hours (on average) in their homes and half of this time in the room being monitored
In Home Environmental Sampling
In Home Environmental Sampling
• PM10
• PM2.5
• Real time PM
•
•
•
•
O3
NO2
Nicotine
Allergens in surface dust (air)
Environmental Sampling p g
Equipment
00:02:30
22:18:30
20:34:30
18:50:30
17:06:30
15:22:30
13:38:30
11:54:30
10:10:30
08:26:30
06:42:30
04:58:30
03:14:30
01:30:30
23:46:30
22:02:30
20:18:30
18:34:30
16:50:30
15:06:30
13:22:30
11:38:30
09:54:30
08:10:30
06:26:30
04:42:30
02:58:30
01:14:30
1.2
23:30:30
1.4
21:46:30
20:02:30
18:18:30
16:34:30
PM Conc (mg/m3 )
Indoor Versus Outdoor Particulate Matter
Indoor Versus Outdoor Particulate Matter
Outdoor
Indoor
Central Site
1
0.8
0.6
0.4
0.2
0
100
Distributions of Indoor PM in the Child’s Bedroom
p<0.01
50
p<0.01
0
P M (µ g /m 3 )
EPA annual limit
Indoor Fine
(PM2.5)
Ambient Fine
(PM2.5)
Indoor Coarse
PM2.5-10
Ambient Coarse
PM2.5-10
40
20
Inner City
Suburban
P<0.001
0
m^3
ug/m
60
PM Concentrations in Inner City vs. Suburban Baltimore Homes
b b
li
PM10
PM2.5
Simons et al. 2007.
Summary of determinants of indoor particulate matter in
Baltimore City Homes.
Smoking*
Sweeping*
Stove Use*
P M 2 .5 (µ g /m
m 3)
100
80
60
40
20
0
0
1 20 21-40
1-20
21 40 41-60
41 60 >60
60
Number of Cigarettes
0
13
1-3
46
4-6
>66
Frequency of Sweeping
0
1-3
4-6
>6
Frequency of Stove Use
*Test for trend p<0.05 for each
10
30
• ~60% report having a p
g
smoker in the home • PM2.5 concentrations in homes with smokers is t ice as high as homes
twice as high as homes with non smokers
3
r s= 0.73
p < 0001
p < .0001
n=98
1
PM 2
2.5 (ug/m3)
100
30
00
PM Smoking and Airborne Nicotine
PM, Smoking, and Airborne Nicotine
.
01
.
03
Airborne Nicotine (ug/m3)
1
3
10
Indoor PM Concentrations, Asthma Symptoms, and Rescue Medication Use
and Rescue Medication Use
Coarse PM
(per 10 µg/m3)
Fine PM
(per 10 µg/m3)
IRR
P-value
IRR
P-value
Cough/wheeze/ chest
tightness
1 06
1.06
0 03
0.03
1 03
1.03
0 18
0.18
Slow/stop activities
1.08
0.01
1.04
0.06
Limited speech from
wheeze
1.11
<0.01
1.07
0.04
Nocturnal Symptoms
1 08
1.08
0 02
0.02
1 06
1.06
0 01
0.01
Symptoms with running
1.00
0.81
1.07
<0.01
B t agonist
Beta
i t use
1 06
1.06
0 01
0.01
1 04
1.04
0 05
0.05
Outcomes
Adjusted for age, sex, race, parent education level, season, indoor PM, ambient PM
1
.1
1
rs = 0.52
p < .0001
.01
1
Airborne M
Mus m 1 (ng/m3)
Airborne Mus m 1 in Inner-city Homes
.1
1
10
Settled Dust Mus m 1 (μg/g)
100
• Detectable in air of
84% of bedrooms
• Median ((IQR):
) 0.03
ng/m3 (0.01-0.10)
• 25% homes with
l
levels
l similar
i il tto
occupational levels
• 90% o
of homes
o es with
t
>0.5ug/g of Mus
m 1 had detectable
airborne Mus m 1
Mouse Allergen and Asthma Morbidity
In Mouse Sensitized and Highly Exposed
In Mouse Sensitized and Highly Exposed
Outcome/Symptom
Adjusted
OR or IRR (95% CI)
CI)*
Healthcare use
Unscheduled visit
3.1 (1.5-6.5)
ED visit
2.1 (1.0-4.3)
Hospitalization
Asthma symptoms
Days of symptoms
Days of slowed activity
Days of exercise
exercise-induced
induced
symptoms
Days of cough
69.9 (5.8-838.9)
1.5 (1.1-2.0)
1.5 (1.1-2.2)
1 6 (1
1.6
(1.1-2.2)
1 2 2)
1.6 (1.1-2.4)
Nights
g
of wakening
g
1.3 ((0.9-1.9))
Days of β-agonist use
1.8 (1.3-2.5)
*Adjusted for age, sex, atopy, cockroach sensitization and exposure, public health insurance and study visit
insurance and study visit
Risk of Asthma Symptoms Per 20‐ppb Increase in NO2
Exposure
Symptom
Cough, wheezing, chest
tightness
Slow down of activity due to
symptoms
Limited speech
IRR (95% CI)*
CI)
1.04 (0.97-1.12)
1.08 (0.94-1.15)
1 17 (1
1.17
(1.08-1.27)
08 1 27)
Symptoms with running
1.09 (1.01-1.17)
C
Coughing
hi without
ith t a cold
ld
1 15 (1
1.15
(1.07-1.23)
07 1 23)
Nocturnal symptoms
1.12 (1.04-1.19)
IRR, incidence rate ratio
IRR
*adjusted for PM; second hand smoke; distance from the curb; type of street
in front of house; season of sampling; age, sex, and race of child; and
mothers education level.
Conclusions from BIESAK
Conclusions from BIESAK
• Asthma exacerbated by
– Indoor particulate matter (particularly the coarse fraction)
– NO2
– Mouse allergen
• All factors that are amenable to in‐home interventions
Vital Signs: Asthma Prevalence, Disease Characteristics, and Self‐Management Education ‐‐‐
g
United States, ,
2001—2009*
• Promote
Promote improvements in indoor air quality improvements in indoor air quality
for people with asthma through measures such as smoke‐free air laws and policies, healthy schools and workplaces, and improvements in h l
d
k l
d
outdoor air quality
• Avoid asthma triggers at school, work, home, A id th
ti
t h l
k h
and outdoors
– Parents
Parents of children with asthma should not smoke, of children with asthma should not smoke
or if they do, smoke only outdoors and not in their cars
• Take steps to fix indoor air quality problems
Smoking and Asthma ‐ Particulate Reduction Education in City Homes
Reduction Education in City Homes (PREACH)
Smoking and Asthma Smoking
and Asthma ‐ Particulate Reduction Particulate Reduction
Education in City Homes (PREACH)
• 3‐arm randomized control trial
3
d i d
l i l
– Test the efficacy of home based behavioral and environmental SHS reduction strategies
environmental SHS reduction strategies
• Air cleaners + health coaching • Air cleaners alone
• Control group (delayed air cleaner)
– SHS smoke
• Self reports
• Urinary cotinine
• Airborne nicotine
Airborne nicotine
Smoking and Asthma ‐ Particulate Reduction Education in City Homes (PREACH)
• Indoor air quality I d
i
li
– PM10, PM2.5
– Airborne nicotine
Ai b
i i
• Asthma morbidity
• Health care utilization
• Participants
– Children with persistent asthma 6‐12 years of age residing with a smoker
• 6 months study
h
d
Smoking and Asthma Smoking
and Asthma ‐ Particulate Reduction Particulate Reduction
Education in City Homes (PREACH)
• 126 were consented to participate
126
d
i i
• 115 completed the study
• Demographics
– 55% male
– 95% African American
– Mean age – 9 years old
– 80% persistent asthma
PREACH Results
– Increase in 33 SFDs per year 100
5
0
0
• No changes in nicotine or cotinine
• Air cleaner plus health coach group reported the highest increase in symptom free days
increase in symptom free days 1.63 over previous 2 weeks -1
100 -50
– Air cleaner groups had a 18.0 ug/m3
decease in PM
Mean difference in PM
M concentratio
on
• The
The addition of health coach did addition of health coach did
not provided increase in PM reduction
Control
Air cleaners +
Air cleaners and health coach
Home Interventions to Reduce Home
Interventions to Reduce
Nitrogen Dioxide Concentrations
Nitrogen Dioxide
Nitrogen Dioxide • Generated by burning of fossil fuels
Generated by burning of fossil fuels
• Outdoor sources: Traffic, power plants • NAAQS
– 53 ppb annual average
– 100 ppb 1 hour limit
b h
l
Indoor NO2 and ambient NO2
are not correlated
.
.5
1
logkitbas e
1.5
2
Pearson’ss r=0.06 p
Pearson
r=0 06 p‐value=0
value=0.64
64
1.3
1.4
1.5
logambase
1.6
1.7
The indoor environment: NO2
The indoor environment: NO
% of homes
β
NO2 (ppb)
Gas stove
83
15*
Gas heater
72
7*
Housing characteristics
Daily activities over the monitoring period
Space heater use
Space heater use 5
16*
16
Stove/oven for heat 12
12*
Sweeping
85
1
Cigarettes
56
0
Open windows
85
0
Candles/incense
Candles/incense 32
‐2
2
Air purifier use
1
‐9
*p-value<0.05
Hansel 2008
Epidemiologic studies of indoor exposure
Epidemiologic studies of indoor exposure
• Yale
Yale Childhood Asthma Study
Childhood Asthma Study
– 20ppb increase in mean indoor NO2
• Increased wheeze (OR=1.52) Increased wheeze (OR=1 52)
• Increased chest tightness (OR=1.51)
• National Cooperative Inner‐City Asthma Study
National Cooperative Inner‐City Asthma Study
– Increased frequency of asthma symptoms
Homes with gas stoves 31 4ppb
• Homes with gas stoves 31.4ppb
• Electric stoves 15.9ppb Belanger K et al. Association of indoor nitrogen dioxide exposure with respiratory symptoms in children with asthma. Am J Respir Crit
Care Med. 2006 Feb 1;173(3):297-303. Epub 2005 Oct 27.
Garrett MH et al. Respiratory symptoms in children and indoor exposure to nitrogen dioxide and gas stoves. Am J Respir Crit Care
Med. 1998 Sep;158(3):891-5.
PM and NO2 concentrations associated with severe COPD exacerbations
Models adjusted for age, sex, education, season of sampling, and baseline prebronchodilator % predicted FEV1
Hansel 2013
Clinical guidelines
Clinical guidelines
Expert Panel Report 3 (EPR3): Guidelines for Expert
Panel Report 3 (EPR3): Guidelines for
the Diagnosis and Management of Asthma • “The Expert Panel recommends that “Th E
P l
d h
clinicians advise patients to avoid, if possible, exposure to gas stoves and ibl
t
t
d
appliances that are not vented to the outside…..(Evidence C).”
t id
(E id
C) ”
Intervention: Target NO2
Intervention: Target NO
Randomized trial to evaluate the effectiveness and
feasibility of interventions aimed at reducing indoor NO2
concentrations in Baltimore City homes
U
Unvented
d gas stove
Stove
replacement
Air purifier
Ventilation hood
installation
Feasibility of home interventions
Feasibility of home interventions
• Stove
Stove replacement
replacement
• Ventilation
Ventilation hood hood
– $300‐500 up front, plus cost – $65 up front, plus cost of of installation
installation
– No additional maintenance
– Housing structure may prohibit installation
– Quality of cooking – Must turn on in order for it to Must turn on in order for it to
– Single source of pollution
Single source of pollution
work
• Air purifier – Single source of pollution
– ~$500 up front
– Filter replacement
– Must turn on in order for it to work
– Multiple sources of pollution Acknowledgements
•
•
•
•
•
•
•
Gregory Diette
G
Di tt
Elizabeth Matsui
Arlene Butz
Arlene Butz
Meredith McCormack
Nadia Hansel
D’Ann Williams
Timothy Green
• USEPA
• NIEHS
Thank You
Questions?