IEUBK Modeling of Children's Blood Lead Levels in Homes Served by Private Domestic Wells in Three Illinois Counties.

Lead is known to impair neurocognitive development in children. Drinking water is routinely monitored for lead content in municipal systems, but private well owners are not required to test for lead. The lack of testing poses a risk of lead exposure and resulting health effects to rural children. In three Illinois counties, we conducted a cross-sectional study (n = 151 homes) examining water lead levels (WLLs), water consumption, and water treatment status to assess risk of lead exposure among residents using private water wells. Since blood lead levels (BLLs) were not available, EPA's Integrated Exposure Uptake Biokinetic (IEUBK) modeling was used to estimate the incremental contribution of WLL to BLL, holding all other sources of lead at their default values. Nearly half (48.3%) of stagnant water samples contained measurable lead ranging from 0.79 to 76.2 µg/L (median= 0.537 µg/L). IEUBK modeling showed BLLs rose from 0.3 to 0.4 µg/dL when WLLs rose from 0.54 µg/L (the tenth percentile) to 4.88 µg/L (the 90th percentile). Based on IEUBK modeling, 18% of children with a WLL at the 10th percentile would have a BLL above 3.5 µg/dL compared to 27.4% of those with a WLL at the 90th percentile. These findings suggest that the consumption of unfiltered well water likely results in increased blood lead levels in children.

Housing and health: an updated glossary.

Recent crises have underscored the importance that housing has in sustaining good health and, equally, its potential to harm health. Considering this and building on Howden-Chapman's early glossary of housing and health and the WHO Housing and Health Guidelines, this paper introduces a range of housing and health-related terms, reflecting almost 20 years of development in the field. It defines key concepts currently used in research, policy and practice to describe housing in relation to health and health inequalities. Definitions are organised by three overarching aspects of housing: affordability (including housing affordability stress (HAS) and fuel poverty), suitability (including condition, accessibility and sustainable housing) and security (including precarious housing and homelessness). Each of these inter-related aspects of housing can be either protective of, or detrimental to, health. This glossary broadens our understanding of the relationship between housing and health to further promote interdisciplinarity and strengthen the nexus between these fields.

A Cost-Benefit Analysis of a State-Funded Healthy Homes Program for Residents With Asthma: Findings From the New York State Healthy Neighborhoods Program.

CONTEXT: Despite considerable evidence that the economic and other benefits of asthma home visits far exceed their cost, few health care payers reimburse or provide coverage for these services. OBJECTIVE: To evaluate the cost and savings of the asthma intervention of a state-funded healthy homes program. DESIGN: Pre- versus postintervention comparisons of asthma outcomes for visits conducted during 2008-2012. SETTING: The New York State Healthy Neighborhoods Program operates in select communities with a higher burden of housing-related illness and associated risk factors. PARTICIPANTS: One thousand households with 550 children and 731 adults with active asthma; 791 households with 448 children and 551 adults with asthma events in the previous year. INTERVENTION: The program provides home environmental assessments and low-cost interventions to address asthma trigger-promoting conditions and asthma self-management. Conditions are reassessed 3 to 6 months after the initial visit. MAIN OUTCOME MEASURES: Program costs and estimated benefits from changes in asthma medication use, visits to the doctor for asthma, emergency department visits, and hospitalizations over a 12-month follow-up period. RESULTS: For the asthma event group, the per person savings for all medical encounters and medications filled was $1083 per in-home asthma visit, and the average cost of the visit was $302, for a benefit to program cost ratio of 3.58 and net benefit of $781 per asthma visit. For the active asthma group, per person savings was $613 per asthma visit, with a benefit to program cost ratio of 2.03 and net benefit of $311. CONCLUSION: Low-intensity, home-based, environmental interventions for people with asthma decrease the cost of health care utilization. Greater reductions are realized when services are targeted toward people with more poorly controlled asthma. While low-intensity approaches may produce more modest benefits, they may also be more feasible to implement on a large scale. Health care payers, and public payers in particular, should consider expanding coverage, at least for patients with poorly controlled asthma or who may be at risk for poor asthma control, to include services that address triggers in the home environment.

Health and housing outcomes from green renovation of low-income housing in Washington, DC.

Green building systems have proliferated recently, but studies are limited of associated health and housing outcomes. The authors measured self-reported resident physical and mental health, allergens, and building conditions at baseline and one-year follow-up in a low-income housing development being renovated in accordance with green healthy housing improvements (Enterprise Green Communities standards and Leadership in Energy & Environmental Design [LEED] gold certification). Self-reported general health in adults significantly improved from 59% to 67% (p = .026), with large statistically significant improvements in water/ dampness problems, cockroaches and rodents, and reduced pesticide use. Median cockroach (Bla g1) and mouse (Mus m1) allergen dust loadings showed large and statistically significant reductions from baseline to three months postintervention and were sustained at one year (both p < .05). Energy and water cost savings were 16% and 54%, respectively. Incorporating Enterprise Green Communities and LEED standards in low-income housing renovation improves health and housing conditions and can help to reduce disparities. All green housing standards should include health-related requirements.

Housing and child health.

The connection between housing and health is well established. Physical, chemical, and biological aspects of the child's home, such as cleanliness, moisture, pests, noise, accessibility, injury risks, and other forms of housing environmental quality, all have the potential to influence multiple aspects of the health and development of children. Basic sanitation, reduced household crowding, other improvements in housing and expanded, and improved housing regulations have led to advances in children's health. For example, lead poisoning prevention policies have profoundly reduced childhood lead exposure in the United States. This and many other successes highlight the health benefits for families, particularly children, by targeting interventions that reduce or eliminate harmful exposures in the home. Additionally, parental mental health problems, food insecurity, domestic violence, and the presence of guns in children's homes all are largely experienced by children in their homes, which are not as yet considered part of the Healthy Homes agenda. There is a large movement and now a regulatory structure being put in place for healthy housing, which is becoming closely wedded with environmental health, public health, and the practice of pediatrics. The importance of homes in children's lives, history of healthy homes, asthma, and exposures to lead, carbon monoxide, secondhand/thirdhand smoke, radon, allergy triggers is discussed, as well as how changes in ambient temperature, increased humidity, poor ventilation, water quality, infectious diseases, housing structure, guns, electronic media, family structure, and domestic violence all affect children's health.

Window replacement and residential lead paint hazard control 12 years later.

Window replacement is a key method of reducing childhood lead exposure, but the long-term effectiveness has not been previously evaluated. Windows have the highest levels of interior lead paint and dust compared to other building components. Our objective was to conduct a follow-up study of residential window replacement and lead hazard control 12 years after homes were enrolled in an evaluation of the HUD Lead Hazard Control Grant Program, sampling settled lead dust in housing in four cities (n=189 homes). Previous work evaluated lead hazard controls up to 6 years after intervention using dust lead measurements and two years after intervention using both dust and blood lead data. But the earlier work could not examine the effect of window replacement over the longer time period examined here: 12 years. The individual homes were assigned to one of three categories, based on how many windows had been replaced: all replacement, some replacement, or non-replacement. Windows that were not replaced were repaired. We controlled for covariates such as site, housing condition, presence of lead paint, and season using longitudinal regression modeling. Adjusted floor and sill dust lead geometric mean dust lead loadings declined at least 85% from pre-intervention to 12 years after the intervention for homes with all replacement windows, some windows replaced and no windows replaced. Twelve years after intervention, homes with all replacement windows had 41% lower interior floor dust lead, compared to non-replacement homes (1.4 versus 2.4 µg/ft2, p<0.001), and window sill dust lead was 51% lower (25 versus 52 µg/ft2, p=0.006) while controlling for covariates. Homes with some windows replaced had interior floor and window sill dust lead loadings that were 28% (1.7 versus 2.4 µg/ft2, p=0.19) and 37% (33 versus 52 µg/ft2, p=0.07) lower, respectively, compared to non-replacement homes. The net economic benefit of window replacement compared to window repair (non-replacement) is $1700-$2000 per housing unit. Homes in which all windows were replaced had significantly lower lead dust. New windows are also likely to reduce energy use and improve home value. Lead-safe window replacement is an important element of lead hazard control, weatherization, renovation and housing investment strategies and should be implemented broadly to protect children.

Environmental health disparities in housing.

The physical infrastructure and housing make human interaction possible and provide shelter. How well that infrastructure performs and which groups it serves have important implications for social equity and health. Populations in inadequate housing are more likely to have environmental diseases and injuries. Substantial disparities in housing have remained largely unchanged. Approximately 2.6 million (7.5%) non-Hispanic Blacks and 5.9 million Whites (2.8%) live in substandard housing. Segregation, lack of housing mobility, and homelessness are all associated with adverse health outcomes. Yet the experience with childhood lead poisoning in the United States has shown that housing-related disparities can be reduced. Effective interventions should be implemented to reduce environmental health disparities related to housing.

The relationship of housing and population health: a 30-year retrospective analysis.

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.

An examination of interventions to reduce respiratory health and injury hazards in homes of low-income families.

We evaluated whether combining asthma trigger reduction with housing structural repairs, device disbursement and education in low-income households with children would improve self-reported respiratory health and reduce housing-related respiratory health and injury hazards (convenience sample of n=67 homes with 63 asthmatic and 121 non-asthmatic children). At baseline, a visual assessment of the home environment and a structured occupant interview were used to examine 29 potential injury hazards and 7 potential respiratory health hazards. A home-specific intervention was designed to provide the children's parents or caretakers with the knowledge, skills, motivation, supplies, equipment, and minimum housing conditions necessary for a healthy and safe home. The enrolled households were primarily Hispanic and owned their homes. On average, 8 injury hazards were observed in the homes at baseline. Four months following intervention, the average declined to 2.2 hazards per home (p<0.001), with 97% of the parents reporting that their homes were safer following the interventions. An average of 3.3 respiratory health hazards were observed in the homes at baseline. Four months following intervention, the average declined to 0.9 hazards per home (p<0.001), with 96% of parents reporting that the respiratory health of their asthmatic children improved. A tailored healthy homes improvement package significantly improves self-reported respiratory health and safety, reduces respiratory health and injury hazards, and can be implemented in concert with a mobile clinical setting.

Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement.

Previous estimates of childhood lead poisoning prevention benefits have quantified the present value of some health benefits, but not the costs of lead paint hazard control or the benefits associated with housing and energy markets. Because older housing with lead paint constitutes the main exposure source today in the US, we quantify health benefits, costs, market value benefits, energy savings, and net economic benefits of lead-safe window replacement (which includes paint stabilization and other measures). The benefit per resident child from improved lifetime earnings alone is $21,195 in pre-1940 housing and $8685 in 1940-59 housing (in 2005 dollars). Annual energy savings are $130-486 per housing unit, with or without young resident children, with an associated increase in housing market value of $5900-14,300 per housing unit, depending on home size and number of windows replaced. Net benefits are $4490-5,629 for each housing unit built before 1940, and $491-1629 for each unit built from 1940-1959, depending on home size and number of windows replaced. Lead-safe window replacement in all pre-1960 US housing would yield net benefits of at least $67 billion, which does not include many other benefits. These other benefits, which are shown in this paper, include avoided Attention Deficit Hyperactivity Disorder, other medical costs of childhood lead exposure, avoided special education, and reduced crime and juvenile delinquency in later life. In addition, such a window replacement effort would reduce peak demand for electricity, carbon emissions from power plants, and associated long-term costs of climate change.

A qualitative review of housing hazard assessment protocols in the United States.

While the general link between substandard housing and poor health has received increased attention recently, there are currently no widely accepted standardized protocols to assess and remediate multiple housing-related health hazards. This paper compares several protocols that assess housing health hazards, including the Hazard Assessment and Reduction Program, the American Healthy Homes Survey, the Public Housing Assessment System, the Housing Quality Standards, the American Housing Survey, the Community Environmental Health Resource Center protocol, and the National Energy Audit Tool. The comparison shows considerable variability across the protocols, particularly in the collection of environmental samples or measurements. This may be due in part to differing end uses, as well as the fact that the intersection of housing and health issues is not clearly in the domain of either profession. Housing professionals typically focus on durability and affordability, while environmental health professionals are frequently focused on specific disease or injury vectors, not on place-based interventions. Validation studies at both the national and the international level are needed to determine how well both the hazard assessment and the resulting interventions predict health outcome. Standardizing and validating such protocols can help move beyond the existing limited categorical approaches and will help improve both substandard housing quality and public health.

The high cost of improper removal of lead-based paint from housing: a case report.

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.