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1.  Housing Interventions and Control of Asthma-Related Indoor Biologic Agents: A Review of the Evidence 
Subject matter experts systematically reviewed evidence on the effectiveness of housing interventions that affect health outcomes, primarily asthma, associated with exposure to moisture, mold, and allergens. Three of the 11 interventions reviewed had sufficient evidence for implementation: multifaceted, in-home, tailored interventions for reducing asthma morbidity; integrated pest management to reduce cockroach allergen; and combined elimination of moisture intrusion and leaks and removal of moldy items to reduce mold and respiratory symptoms. Four interventions needed more field evaluation, one needed formative research, and three either had no evidence of effectiveness or were ineffective. The three interventions with sufficient evidence all applied multiple, integrated strategies. This evidence review shows that selected interventions that improve housing conditions will reduce morbidity from asthma and respiratory allergies.
doi:10.1097/PHH.0b013e3181ddcbd9
PMCID: PMC3934496  PMID: 20689369
asthma; moisture; allergens; dust; mites; cockroaches; rats; mice; prevention; housing
2.  Nurse Case Management and Housing Interventions Reduce Allergen Exposures: The Milwaukee Randomized Controlled Trial 
Public Health Reports  2011;126(Suppl 1):89-99.
Objective
We examined the impact of a combination of home environmental interventions and nurse case management services on total settled dust loadings and on allergen concentrations in the homes of asthmatic children.
Methods
Using a randomized longitudinal controlled trial study design, we randomly assigned homes of asthmatic children in Milwaukee to either a control (n=64) or an intervention (n=57) group. Control group homes received a visual assessment, education, bed/pillow dust mite encasings, and treatment of lead-based paint hazards. The intervention group received these same services plus nurse case management that included tailored, individual asthma action plans, provision of minor home repairs, home cleaning using special vacuuming and wet washing, and integrated pest management. Dust vacuum samples were collected from measured surface areas of floors in the TV room, kitchen, and child's bedroom at baseline and at three-, six-, and 12-month follow-up visits. Dust loading (mass per surface area) is a means of measuring total dust and the total amount of allergen present.
Results
For the intervention group, geometric mean dust loadings declined significantly from baseline (39 milligrams per square foot [mg/ft2]) to post-intervention (11 mg/ft2) (p<0.001). Baseline dust loading, treatment group, visit, and season were significant predictors of follow-up dust loadings. Mean post-intervention dust loadings were 72% higher in the control group. The total amount of allergen in settled house dust declined significantly following the intervention because total dust loading declined; the concentration of allergens in settled dust did not change significantly.
Conclusion
The combination of nurse case management and home environmental interventions promotes collaboration between health and housing professionals and is effective in reducing exposures to allergens in settled dust.
PMCID: PMC3072907  PMID: 21563716
3.  Health Outcomes and Green Renovation of Affordable Housing 
Public Health Reports  2011;126(Suppl 1):64-75.
Objective
This study sought to determine whether renovating low-income housing using “green” and healthy principles improved resident health and building performance.
Methods
We investigated resident health and building performance outcomes at baseline and one year after the rehabilitation of low-income housing using Enterprise Green Communities green specifications, which improve ventilation; reduce moisture, mold, pests, and radon; and use sustainable building products and other healthy housing features. We assessed participant health via questionnaire, provided Healthy Homes training to all participants, and measured ventilation, carbon dioxide, and radon.
Results
Adults reported statistically significant improvements in overall health, asthma, and non-asthma respiratory problems. Adults also reported that their children's overall health improved, with significant improvements in non-asthma respiratory problems. Post-renovation building performance testing indicated that the building envelope was tightened and local exhaust fans performed well. New mechanical ventilation was installed (compared with no ventilation previously), with fresh air being supplied at 70% of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers standard. Radon was <2 picocuries per liter of air following mitigation, and the annual average indoor carbon dioxide level was 982 parts per million. Energy use was reduced by 45% over the one-year post-renovation period.
Conclusions
We found significant health improvements following low-income housing renovation that complied with green standards. All green building standards should include health requirements. Collaboration of housing, public health, and environmental health professionals through integrated design holds promise for improved health, quality of life, building operation, and energy conservation.
PMCID: PMC3072905  PMID: 21563714
4.  Residential Light and Risk for Depression and Falls: Results from the LARES Study of Eight European Cities 
Public Health Reports  2011;126(Suppl 1):131-140.
Objectives.
We examined the relationship between self-reported inadequate residential natural light and risk for depression or falls among adults aged 18 years or older.
Methods.
Generalized estimating equations were used to calculate the odds of depression or falls in participants with self-reported inadequate natural residential light vs. those reporting adequate light (n=6,017) using data from the World Health Organization's Large Analysis and Review of European Housing and Health Survey, a large cross-sectional study of housing and health in representative populations from eight European cities.
Results.
Participants reporting inadequate natural light in their dwellings were 1.4 times (95% confidence interval [CI] 1.2,1.7) as likely to report depression and 1.5 times (95% CI 1.2, 1.9) as likely to report a fall compared with those satisfied with their dwelling's light. After adjustment for major confounders, the likelihood of depression changed slightly, while the likelihood of a fall increased to 2.5 (95% CI 1.5, 4.2).
Conclusion.
Self-reported inadequate light in housing is independently associated with depression and falls. Increasing light in housing, a relatively inexpensive intervention, may improve two distinct health conditions.
PMCID: PMC3072912  PMID: 21563721
6.  Housing Interventions and Control of Injury-Related Structural Deficiencies: A Review of the Evidence 
Subject matter experts systematically reviewed evidence on the effectiveness of housing interventions that affect safety and injury outcomes, such as falls, fire-related injuries, burns and drowning, carbon monoxide poisoning, heat-related deaths, and noise-related harm, associated with structural housing deficiencies. Structural deficiencies were defined as those deficiencies for which a builder, landlord, or homeowner would take responsibility (ie, design, construction, installation, repair, monitoring). Three of the 17 interventions reviewed had sufficient evidence for implementation: installed, working smoke alarms; 4-sided isolation pool fencing; and preset safe hot water temperature. Five interventions needed more field evaluation, 8 needed formative research, and 1 was found to be ineffective. This evidence review shows that housing improvements are likely to help reduce burns and scalds, drowning in pools, and fire-related deaths and injuries.
doi:10.1097/PHH.0b013e3181e28b10
PMCID: PMC2965780  PMID: 20689373
burns; drowning; falls; fires; housing; injury; prevention; scalds
7.  The high cost of improper removal of lead-based paint from housing: a case report. 
Environmental Health Perspectives  2003;111(2):185-186.
The costs of lead-based paint hazard control in housing are well documented, but the costs of cleanup after improper, inherently dangerous, methods of removing lead-based paint are not. In this article we report a case of childhood lead poisoning and document the costs of decontamination after uncontained power sanding was used to remove paint down to bare wood from approximately 3,000 ft(2) of exterior siding on a large, well-maintained 75-year-old house in a middle-income neighborhood. After the uncontrolled removal of lead-based paint, interior dust lead levels ranged from 390 to 27,600 micro g Pb/ft(2) (on floors and windowsills) and bare soil lead levels ranged from 360 ppm in the yard to 3,900 ppm along the foundation to 130,000 ppm in the child's play area, well above applicable U.S. Department of Housing and Urban Development/U.S. Environmental Protection Agency standards. The hard costs of decontamination were over $195,000, which greatly exceeds the incremental cost of incorporating lead-safe work practices into repainting. This case report highlights the need to incorporate lead-safe work practices into routine repainting, remodeling, and other renovation and maintenance jobs that may disturb lead-based paint.
PMCID: PMC1241348  PMID: 12573903
8.  The prevalence of lead-based paint hazards in U.S. housing. 
Environmental Health Perspectives  2002;110(10):A599-A606.
In this study we estimated the number of housing units in the United States with lead-based paint and lead-based paint hazards. We included measurements of lead in intact and deteriorated paint, interior dust, and bare soil. A nationally representative, random sample of 831 housing units was evaluated in a survey between 1998 and 2000; the units and their occupants did not differ significantly from nationwide characteristics. Results indicate that 38 million housing units had lead-based paint, down from the 1990 estimate of 64 million. Twenty-four million had significant lead-based paint hazards. Of those with hazards, 1.2 million units housed low-income families (< 30,000 US dollars/year) with children under 6 years of age. Although 17% of government-supported, low-income housing had hazards, 35% of all low-income housing had hazards. For households with incomes greater than or equal to 30,000 US dollars/year, 19% had hazards. Fourteen percent of all houses had significantly deteriorated lead-based paint, and 16% and 7%, respectively, had dust lead and soil lead levels above current standards of the U.S. Department of Housing and Urban Development and the U.S. Environmental Protection Agency. The prevalence of lead-based paint and hazards increases with age of housing, but most painted surfaces, even in older housing, do not have lead-based paint. Between 2% and 25% of painted building components were coated with lead-based paint. Housing in the Northeast and Midwest had about twice the prevalence of hazards compared with housing in the South and West. The greatest risk occurs in older units with lead-based paint hazards that either will be or are currently occupied by families with children under 6 years of age and are low-income and/or are undergoing renovation or maintenance that disturbs lead-based paint. This study also confirms projections made in 2000 by the President's Task Force on Environmental Health Risks and Safety Risks to Children of the number of houses with lead-based paint hazards. Public- and private-sector resources should be directed to units posing the greatest risk if future lead poisoning is to be prevented.
PMCID: PMC1241046  PMID: 12361941
9.  The Relationship of Housing and Population Health: A 30-Year Retrospective Analysis 
Environmental Health Perspectives  2008;117(4):597-604.
Objective
We analyzed the relationship between health status and housing quality over time.
Methods
We combined data from two nationally representative longitudinal surveys of the U.S. population and its housing, the National Health and Nutrition Examination Survey and the American Housing Survey, respectively. We identified housing and health trends from approximately 1970 to 2000, after excluding those trends for which data were missing or where we found no plausible association or change in trend.
Results
Changes in housing include construction type, proportion of rental versus home ownership, age, density, size, moisture, pests, broken windows, ventilation and air conditioning, and water leaks. Changes in health measures include asthma, respiratory illness, obesity and diabetes, and lead poisoning, among others. The results suggest ecologic trends in childhood lead poisoning follow housing age, water leaks, and ventilation; asthma follows ventilation, windows, and age; overweight trends follow ventilation; blood pressure trends follow community measures; and health disparities have not changed greatly.
Conclusions
Housing trends are consistent with certain health trends over time. Future national longitudinal surveys should include health, housing, and community metrics within a single integrated design, instead of separate surveys, in order to develop reliable indicators of how housing changes affect population health and how to best target resources. Little progress has been made in reducing the health and housing disparities of disadvantaged groups, with the notable exception of childhood lead poisoning caused by exposure to lead-based paint hazards. Use of these and other data sets to create reliable integrated indicators of health and housing quality are needed.
doi:10.1289/ehp.0800086
PMCID: PMC2679604  PMID: 19440499
American Housing Survey (AHS); asthma; health disparities; healthy housing; housing; lead poisoning; National Health and Nutrition Examination Survey (NHANES)
10.  Exposure of U.S. Children to Residential Dust Lead, 1999–2004: II. The Contribution of Lead-Contaminated Dust to Children’s Blood Lead Levels 
Environmental Health Perspectives  2008;117(3):468-474.
Background
The U.S. Centers for Disease Control and Prevention collected health, housing, and environmental data in a single integrated national survey for the first time in the United States in 1999–2004.
Objectives
We aimed to determine how floor dust lead (PbD) loadings and other housing factors influence childhood blood lead (PbB) levels and lead poisoning.
Methods
We analyzed data from the 1999–2004 National Health and Nutrition Examination Survey (NHANES), including 2,155 children 12–60 months of age with PbB and PbD measurements. We used linear and logistic regression models to predict log-transformed PbB and the odds that PbB was ≥ 5 and ≥ 10 μg/dL at a range of floor PbD.
Results
The population-weighted geometric mean (GM) PbB was 2.0 μg/dL (geometric standard error = 1.0). Age of child, race/ethnicity, serum cotinine concentration, poverty-to-income ratio, country of birth, year of building construction, floor PbD by floor surface and condition, windowsill PbD, presence of deteriorated paint, home-apartment type, smoking in the home, and recent renovation were significant predictors in either the linear model [the proportion of variability in the dependent variable accounted for by the model (R2) = 40%] or logistic model for 10 μg/dL (R2 = 5%). At floor PbD = 12 μg/ft2, the models predict that 4.6% of children living in homes constructed before 1978 have PbB ≥ 10 μg/dL, 27% have PbB ≥ 5 μg/dL, and the GM PbB is 3.9 μg/dL.
Conclusions
Lowering the floor PbD standard below the current standard of 40 μg/ft2 would protect more children from elevated PbB.
doi:10.1289/ehp.11918
PMCID: PMC2661919  PMID: 19337524
blood lead; dust lead; housing; lead poisoning; National Health and Nutrition Examination Survey; NHANES
11.  Exposure of U.S. Children to Residential Dust Lead, 1999–2004: I. Housing and Demographic Factors 
Environmental Health Perspectives  2008;117(3):461-467.
Background
Lead-contaminated house dust is a major source of lead exposure for children in the United States. In 1999–2004, the National Health and Nutrition Examination Survey (NHANES) collected dust lead (PbD) loading samples from the homes of children 12–60 months of age.
Objectives
In this study we aimed to compare national PbD levels with existing health-based standards and to identify housing and demographic factors associated with floor and windowsill PbD.
Methods
We used NHANES PbD data (n = 2,065 from floors and n = 1,618 from windowsills) and covariates to construct linear and logistic regression models.
Results
The population-weighted geometric mean floor and windowsill PbD were 0.5 μg/ft2 [geometric standard error (GSE) = 1.0] and 7.6 μg/ft2 (GSE = 1.0), respectively. Only 0.16% of the floors and 4.0% of the sills had PbD at or above current federal standards of 40 and 250 μg/ft2, respectively. Income, race/ethnicity, floor surface/condition, windowsill PbD, year of construction, recent renovation, smoking, and survey year were significant predictors of floor PbD [the proportion of variability in the dependent variable accounted for by the model (R2) = 35%]. A similar set of predictors plus the presence of large areas of exterior deteriorated paint in pre-1950 homes and the presence of interior deteriorated paint explained 20% of the variability in sill PbD. A companion article [Dixon et al. Environ Health Perspect 117:468–474 (2009)] describes the relationship between children’s blood lead and PbD.
Conclusion
Most houses with children have PbD levels that comply with federal standards but may put children at risk. Factors associated with PbD in our population-based models are primarily the same as factors identified in smaller at-risk cohorts. PbD on floors and windowsills should be kept as low as possible to protect children.
doi:10.1289/ehp.11917
PMCID: PMC2661918  PMID: 19337523
dust lead; housing; lead; National Health and Nutrition Examination Survey; NHANES
13.  Control of Nitrous Oxide Exposure in Dental Operatories Using Local Exhaust Ventilation 
Anesthesia Progress  1986;33(5):235-242.
An experimental portable local exhaust ventilation system was installed in three dental operatories where nitrous oxide was used routinely. Standard methods of exhaust ventilation design used in industry to control exposures to toxic airborne substances were applied to the dental operatory setting. The concentration of nitrous oxide in the dentists' breathing zones was measured before and after installation to determine the efficiency of the system in reducing occupational exposures. Results indicate that placement of the exhaust opening and exhaust air flow rate are important in determining the degree of control achieved. After the system had been installed in one operatory, peak exposures declined from over 600 parts per million (ppm) to less than 70 ppm: the time-weighted average exposure was below the NIOSH recommended level of 25 ppm. A permanently installed local exhaust ventilation system modeled after the portable one used in this pilot study may be feasible for most operatories and should not interfere with dental procedures. The results suggest that nitrous oxide exposures can be greatly reduced if dental operatories are equipped with local exhaust ventilation.
Images
PMCID: PMC2177485  PMID: 3465259
14.  Lead Exposures in U.S. Children, 2008: Implications for Prevention 
Environmental Health Perspectives  2008;116(10):1285-1293.
Objective
We reviewed the sources of lead in the environments of U.S. children, contributions to children’s blood lead levels, source elimination and control efforts, and existing federal authorities. Our context is the U.S. public health goal to eliminate pediatric elevated blood lead levels (EBLs) by 2010.
Data sources
National, state, and local exposure assessments over the past half century have identified risk factors for EBLs among U.S. children, including age, race, income, age and location of housing, parental occupation, and season.
Data extraction and synthesis
Recent national policies have greatly reduced lead exposure among U.S. children, but even very low exposure levels compromise children’s later intellectual development and lifetime achievement. No threshold for these effects has been demonstrated. Although lead paint and dust may still account for up to 70% of EBLs in U.S. children, the U.S. Centers for Disease Control and Prevention estimates that ≥30% of current EBLs do not have an immediate lead paint source, and numerous studies indicate that lead exposures result from multiple sources. EBLs and even deaths have been associated with inadequately controlled sources including ethnic remedies and goods, consumer products, and food-related items such as ceramics. Lead in public drinking water and in older urban centers remain exposure sources in many areas.
Conclusions
Achieving the 2010 goal requires maintaining current efforts, especially programs addressing lead paint, while developing interventions that prevent exposure before children are poisoned. It also requires active collaboration across all levels of government to identify and control all potential sources of lead exposure, as well as primary prevention.
doi:10.1289/ehp.11241
PMCID: PMC2569084  PMID: 18941567
children’s health; environmental health; lead poisoning; primary prevention
15.  Linking Public Health, Housing, and Indoor Environmental Policy: Successes and Challenges at Local and Federal Agencies in the United States 
Environmental Health Perspectives  2007;115(6):976-982.
We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of “shared commons” and the “polluter pays” is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities.
doi:10.1289/ehp.8990
PMCID: PMC1892139  PMID: 17589610
built environment; healthy housing; housing; indoor air quality; indoor environmental quality; policy; public health
16.  Sources of Blood Lead in Children 
Environmental Health Perspectives  2006;114(1):A18-A19.
PMCID: PMC1332675  PMID: 16393641
17.  Housing and health—Current issues and implications for research and programs 
This article provides an overview of the ways in which the home environment can affect human health, describes how specific health hazards in housing are related, and considers implications of these concerns for research and programs to address the health-housing connection. The widespread availability of decent housing has contributed greatly to improvements in health status in developed countries through, for example, provision of safe drinking water, proper sewage disposal, and protection from the elements. However, a lack of decent housing and homelessness among a significant number of Americans remains a significant public health concern. In addition, a number of specific health hazards can be found even in housing that is in good condition and provides all basic amenities. Specific health hazards related to housing include unintentional injuries, exposure to lead, exposure to allergens that may cause or worsen asthma, moisture and fungi (mold), rodent and insect pests, pesticide residues, and indoor air pollution. A number of these specific hazards share underlying causes, such as excess moisture, and all may be influenced by factors in the community environment or by occupant behaviors. We make recommendations for developing programs and research efforts that address multiple housing problems in an integrated way, rather than categorically, and for closer collaboration between housing and public health programs.
doi:10.1007/BF02350959
PMCID: PMC3456605  PMID: 10741839
Housing; Environmental; Exposures; Public Health; Social Factors
18.  Occupational Exposure to Nitrous Oxide in Dental Operatories 
Anesthesia Progress  1986;33(2):91-97.
Occupational exposures to nitrous oxide (N20) were measured in numerous dental operatories. In all cases, the National Institute of Occupational Safety and Health (NIOSH) recommended time-weighted average (for one operation) of 25 ppm was exceeded by wide margins (NIOSH considers 50 ppm to be attainable in dental operatories). However, a new risk assessment is necessary to determine appropriate exposure limits. Many of the operatories were not equipped with scavenging systems and none of them used a scavenging device in combination with a local exhaust ventilation system. Scavenging devices and local exhaust ventilation should be used to control nitrous oxide exposures. Leaks in N20 delivery systems, which were found to be commonplace, should also be controlled. Research and development efforts are needed to improve upon the already existing scavenging devices, and provision for local exhaust ventilation needs to be included in the design of dental operatories.
PMCID: PMC2175458  PMID: 3459383

Results 1-18 (18)