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Grants & Training program addressing built environment. Surveillance of asthma in workplace ... Builds upon progress made over the last five years ... – PowerPoint PPT presentation

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Title: Asthma

Asthma the Built Environment
  • Rick Kreutzer,
  • Chief Division of Occupational Environmental
  • Janet Tobacman,
  • Housing Specialist
  • California Breathing

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

CB Program Components
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.
Asthma requires the marriage of medicine and
public health
  • Healthy patient
  • Clinical guidelines (expert experience)
  • Controlled clinical trials
  • Quality improvement
  • Provider training
  • Access
  • Healthy population
  • Strategic plans (stakeholder input)
  • Observational data/ surveillance
  • Evaluation
  • Social marketing and media advocacy
  • Liaison to medicine

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
  • 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

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

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

Management by Patient
Family Involvement
Clinical Expertise
Work/School Support
Community Awareness, Support Action
Community-Wide Environmental Control Measures
Conducive Policies
Noreen Clark
Physical Infrastructure
Multiplicity of Users
Governance and Enforcement
Stress Process Model
Social Environment Stressors
Physical Environment Stressors
Intervening Factors
Health Outcomes
Amy Schulz,
Asthma Influences-Social Environment
  • Intense emotional states
  • Hormonal factors
  • Family Dysfunction
  • Low Income
  • Urban communities
  • Communities of Color

Selected Asthma Triggers-Physical Environment
  • Respiratory infection
  • Allergen exposure
  • Respiratory irritants, including air pollutants
  • Cold air
  • Exercise and hyperventilation
  • Medications
  • Foods

Air Pollutants
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

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

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

McConnell, Lancet 2002
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
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)
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
  • 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.

Federal Involvement with the Healthy Housing
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//
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

References from page 5 of the HUD Healthy Homes
Strategic Plan http//
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.
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)

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

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).

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,
  • Hard surface floors
  • Enhanced ventilation (HEPA whole house continuous
    fan, kitchen/bath fans with timers)
  • Radiant/Hydronic baseboard heat to decrease
  • Results
  • Decreased condensation, water damage, visible
    mold, roaches, rodents pests

Seattle-Kings County Breathe Easy Homes Pilot
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.

Built Environment Related Goals/Objectives
  • Goal 5 Outdoor Environments
  • 5.1Support policies and community plans (Fresno
  • 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

Built Environment Relationship to Nature
Rice Acreage Burned
Built Environment Relationship to Agriculture
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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
  • 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.

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

  • California Breathing
  • Public Health Law and Policy

  • Thank you!
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