Pathways and sources of lead exposure: Michigan Children's Lead Determination (the MI CHILD study).

There has been little research on childhood lead exposure pathways since the 1990s. New data from Michigan in 2017-2021 for 429 children in 345 homes included lead in blood, paint, dust, soil, water, and other housing, demographic, and behavioral metrics. Fifty-three percent of these children had blood lead (BPb) ≥5 µg/dL. A repeated measures pathway model that accounted for multiple children in the same home was constructed using weighted least squares mean estimation and included variance-covariance model multiple imputation. Results showed that children's BPb was directly predicted by lead in settled floor house dust, child's age, season, and mouthing behavior and indirectly predicted by window sill and trough dust lead (DPb), bare soil lead (SPb), proportion of floors with carpets, and exterior building deteriorations. Paint lead (PPb) was also an indirect predictor of BPb through the soil and settled dust pathways. Water lead (WPb), water consumption and other lead sources/pathways were not significant predictors of BPb in this cohort. Although risk factors for individual children are highly variable and worthy of investigation to pinpoint their exposures, this study shows that the main direct and indirect pathways of lead exposure for most children in older housing remain paint and the contaminated dust and soil it generates. Pathway analyses in other jurisdictions using current data should be performed to confirm these results. This study suggests both DPb and BPb in high-risk homes may have declined since the 1990s and that lead in dust, soil, and paint all should be measured to predict risk and target remediation. Because most homes still have not been assessed for lead hazards and remediated, too many children remain at needless risk.

Aging Gracefully in Place: An Evaluation of the Capability of the CAPABLE© Approach.

As American adults live longer, society must prioritize effective strategies promoting safe aging-in-place and decreasing institutional health care costs. Social determinants of health, especially housing, critically influence older adult health, particularly for disadvantaged, low-income older adults. Johns Hopkins University developed Community Aging in Place-Advancing Better Living for Elders (CAPABLE©), a client-centered, home-based program to improve older adults' function and capacity to age in place. This evaluation studied CAPABLE's long-term effectiveness in four distinct locations in California, North Carolina, Pennsylvania, and Vermont. Seven months after CAPABLE, intervention group participants experienced greater improvements than the control group in activities of daily living limitations (2-point vs. 0.7-point improvement, p = .012), falls efficacy (8.9-point improvement vs. 0.1-point worsening, p = .012), depression (1.3-point improvement vs. 0.4-point worsening, p = .021), and pain (1.5-point improvement vs. 0.3-point worsening, p = .002). These results add to existing research on short-term effectiveness in urban locales, showing CAPABLE yields long-term health improvement for older adults in micropolitan and small urban locations, with different implementation organizations, housing stocks, and clients.

CAPABLE program improves disability in multiple randomized trials.

BACKGROUND: Programs to reduce disability are crucial to the quality of life for older adults with disabilities. Reducing disability is also important to avert unnecessary and costly hospitalizations, relocation, or nursing home placements. Few programs reduce disability and few have been replicated and scaled beyond initial research settings. CAPABLE is one such program initially tested in a randomized control trial and has now been tested and replicated in multiple settings. CAPABLE, a 10-session, home-based interprofessional program, provides an occupational therapist, nurse, and handyworker to address older adults' self-identified functional goals by enhancing individual capacity and home environmental supports. We examine evidence for the CAPABLE program from clinical trials embedded in different health systems on outcomes that matter most to older adults with disability. METHODS: Six trials with peer-reviewed publications or reports were identified and included in this review. Participants' outcomes included basic and instrumental activities of daily living (ADLs, IADLs), fall efficacy, depression, pain, and cost savings. RESULTS: A total of 1144 low-income, community-dwelling older adults with disabilities and 4236 matched comparators were included in the six trials. Participants were on average ≥74-79 years old, cognitively intact, and with self-reported difficulty with ≥1 ADLs. All six studies demonstrated improvements in ADLs and IADLs, with small to strong effect sizes (0.41-1.47). Outcomes for other factors were mixed. Studies implementing the full-tested dose of CAPABLE showed more improvement in ADLS and cost savings than studies implementing a decreased dose. CONCLUSIONS: The CAPABLE program resulted in substantial improvements in ADLs and IADLs in all six trials with other outcomes varying across studies. A dose lower than the original protocol tested resulted in less benefit. The four studies examining cost showed that CAPABLE saved more than it costs to implement.

Radon and moisture impacts from interventions integrated with housing energy retrofits.

Energy retrofits can reduce air exchange, raising the concern of whether indoor radon and moisture levels could increase. This pre/post-intervention study explored whether simple radon interventions implemented in conjunction with energy retrofits can prevent increases in radon and moisture levels. Treatment homes (n = 98) were matched with control (no energy retrofits or radon intervention) homes (n = 12). Control homes were matched by geographic location and foundation type. t-tests were used to determine whether post-energy retrofit radon and moisture level changes in treatment homes significantly differed from those in control homes. The radon interventions succeeded in preventing statistically significant increases in first floor radon using arithmetic (p = 0.749) and geometric means (p = 0.120). In basements, arithmetic (p = 0.060) and geometric (p = 0.092) mean radon levels statistically significantly increased, consistent with previous studies which found that basement radon levels may increase even if first floor levels remain unchanged. Changes in infiltration were related to changes in radon (p = 0.057 in basements; p = 0.066 on first floors). Only 58% of the change in infiltration was due to air sealing, with the rest due to weather changes. There was no statistically significant association between air sealing itself and radon levels on the first floor (p = 0.664). Moisture levels also did not significantly increase.

Replacing Windows Reduces Childhood Lead Exposure: Results From a State-Funded Program.

CONTEXT: Despite considerable evidence that window replacement reduces childhood lead exposure and improves energy conservation and market value, federal policies in childhood lead poisoning, home improvement, and weatherization programs all tend to discourage it. OBJECTIVE AND INTERVENTION: To evaluate a state bond-financed pilot program that replaced old lead-contaminated windows with new lead-free energy efficient ones. DESIGN AND SETTING: Pre-/post evaluation in 1 urban and 1 rural jurisdiction. PARTICIPANTS: Low-income households (n = 96). MAIN OUTCOME MEASURES: Dust wipe sampling, visual assessment, and physical and mental self-reported health at baseline and 1 year. RESULTS: Geometric mean lead dust (PbD) from baseline to 1 year for interior floors, interior sills, and exterior troughs declined by 44%, 88%, and 98%, respectively (P < .001); 1 year later, levels remained well below baseline but rose slightly compared with clearance sampling just after intervention. PbD declined significantly on both sills and troughs in both the urban and rural jurisdictions from baseline to 1 year. On interior floors, PbD significantly declined by 58% (P = .003) in the rural area and 25% (P = .38) in the urban area, where the decline did not reach statistical significance. Households reported improvements in uncomfortable indoor temperatures (P < .001) and certain health outcomes. Economic benefits were estimated at $5 912 219 compared with a cost of $3 451 841, resulting in a net monetary benefit of $2 460 378. Residents reported that they were "very satisfied" with the window replacement work (87%). CONCLUSION: Local and state governments should fund and operate window replacement programs to eliminate a major source of childhood lead exposure, improve energy bills, increase home market value, and create local construction and industrial jobs. Federal agencies should encourage (not discourage) replacement of old windows contaminated with lead. In budget climates such as Illinois with reduced public expenditures, making wise investments such as lead-safe window replacement is more important than ever.

Self-reported health outcomes associated with green-renovated public housing among primarily elderly residents.

OBJECTIVES: Assess the benefits of green renovation on self-reported health of primarily elderly residents of a low-income public housing apartment building. DESIGN AND SETTING: Using questions from the Medicare Health Outcomes Survey, we interviewed residents at baseline and 1 year after green renovation of their 101-unit building in Mankato, Minnesota, comparing self-reported mental and physical health outcomes of 2 sets of residents (all-ages: median, 66 years, n = 40; elder: median, 72 years, n = 22) with outcomes for 2 same-aged low-income Minnesota comparison groups taken from Medicare Health Outcomes Survey participants (n = 40 and 572, respectively). STUDY GROUP: Mankato apartment building residents. INTERVENTIONS: Green renovation including building envelope restoration; new heating, electrical, and ventilation systems; air sealing; new insulation and exterior cladding; window replacement; Energy-Star fixtures and appliances; asbestos and mold abatement; apartment gut retrofits; low volatile organic chemical and moisture-resistant materials; exercise enhancements; and indoor no-smoking policy. MAIN OUTCOME MEASURES: Self-reported health status including Activities of Daily Living and Veteran's Rand 12 (VR-12) survey results; housing condition visual assessment; indoor environmental sampling; and building performance testing. RESULTS: The all-ages study group's mental health improved significantly more than the comparison group's mental health on the basis of mean number of good mental health days in the past month (P = .026) and mean VR-12 mental component score (P = .023). Sixteen percent fewer all-ages study group people versus 8% more comparison group people reported falls (P = .055). The elder study group's 9% improvement in general physical health was not statistically significantly better than the elder comparison group's decline (6%) (P = 0.094). Significantly fewer people in the all-ages group reported smoke in their apartments because of tobacco products (20% vs 0%, P = .005), likely reflecting the new no-smoking policy. CONCLUSIONS: Green healthy housing renovation may result in improved mental and general physical health, prevented falls, and reduced exposure to tobacco smoke.

An investigation into porch dust lead levels.

Lead in porch dust can expose children through direct contact or track-in to the home, but has not been adequately evaluated. At homes undergoing lead hazard control in Rochester, NY, we sampled settled dust lead on exterior porch floors at baseline, immediately post-lead hazard control and one-year post-work (n=79 homes with complete data) via wipe sampling and collected housing, neighborhood and soil data. Baseline GM porch floor dust lead loading (PbPD) was 68 µg/ft(2), almost four times more than baseline GM interior floor dust lead (18 µg/ft(2)). Immediate post-work PbPD declined 55% after porch floor replacement and 53% after porch floor paint stabilization (p=0.009 and p=0.041, respectively). When no porch floor work was conducted but lead hazard control was conducted elsewhere, immediate post-work PbPD increased 97% (p=0.008). At one-year, GM PbPD continued to decline for porch replacement (77% below baseline) and paint stabilization (72% below baseline), but where no porch floor work was done, GM PbPD was not significantly different than baseline (p<0.001, p=0.028 and p=0.504, respectively). Modeling determined that porch floor replacement had significantly lower one-year PbPD than stabilization when baseline PbPD levels were higher than 148 µg/ft(2) (the 77th percentile) but not at lower levels. Treatment of porches with lead paint results in substantial declines in PbPD levels. It is of concern that PbPD levels increased significantly at immediate post-work when lead hazard control was not conducted on the porch but was conducted elsewhere. Standards for porch lead dust should be adopted to protect children from inadequate clean-up after lead hazard control.

Moving into green healthy housing.

BACKGROUND: Green building systems have proliferated but health outcomes and associated costs and benefits remain poorly understood. OBJECTIVE: To compare health before and after families moved into new green healthy housing with a control group in traditionally repaired housing. DESIGN AND SETTING: Mixed methods study in 3 Chicago housing developments. PARTICIPANTS: Public housing and low-income subsidized households (n = 325 apartments with 803 individuals). MAIN OUTCOME MEASURES: Self-reported health status, visual assessment of housing condition, indoor air sampling, and Medicaid expenditure and diagnostic data. Medicaid expenditures and International Classification of Diseases, Ninth Revision codes were modeled using a generalized linear model with γ distribution and log-link. RESULTS: Housing conditions and self-reported physical and mental health improved significantly in the green healthy housing study group compared with both the control group and the dilapidated public housing from which the residents moved, as did hay fever, headaches, sinusitis, angina, and respiratory allergy. Asthma severity measured by self-reported lost school/work days, disturbed sleep, and symptoms improved significantly, as did sadness, nervousness, restlessness, and child behavior. Medicaid data in this exploratory study were inconclusive and inconsistent with self-reported health outcomes and visual assessment data on housing quality but hold promise for future investigation. Possible sources of bias in the Medicaid data include older age in the study group, changes in Medicaid eligibility over time, controlling for Medicaid costs in an urban area, and the increased stress associated with moving, even if the move is into better housing. CONCLUSION: The mixed method approach employed here describes the complex relationships among self-reported health, housing conditions, environmental measures, and clinical data. Housing conditions and self-reported physical and mental health improved in green healthy housing. Health care cost savings in Medicaid due to improved housing could not be quantified here but hold promise for future investigations with larger cohorts over a longer follow-up period.

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.

Effect of weatherization combined with community health worker in-home education on asthma control.

OBJECTIVES: We assessed the benefits of adding weatherization-plus-health interventions to an in-home, community health worker (CHW) education program on asthma control. METHODS: We used a quasi-experimental design to compare study group homes (n = 34) receiving CHW education and weatherization-plus-health structural interventions with historical comparison group homes (n = 68) receiving only education. Data were collected in King County, Washington, from October 2009 to September 2010. RESULTS: Over the 1-year study period, the percentage of study group children with not-well-controlled or very poorly controlled asthma decreased more than the comparison group percentage (100% to 28.8% vs 100% to 51.6%; P = .04). Study group caregiver quality-of-life improvements exceeded comparison group improvements (P = .002) by 0.7 units, a clinically important difference. The decrease in study home asthma triggers (evidence of mold, water damage, pests, smoking) was marginally greater than the comparison group decrease (P = .089). Except for mouse allergen, the percentage of study group allergen floor dust samples at or above the detection limit decreased, although most reductions were not statistically significant. CONCLUSIONS: Combining weatherization and healthy home interventions (e.g., improved ventilation, moisture and mold reduction, carpet replacement, and plumbing repairs) with CHW asthma education significantly improves childhood asthma control.

Health outcomes and green renovation of affordable housing.

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.

Nurse case management and housing interventions reduce allergen exposures: the Milwaukee randomized controlled trial.

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 postintervention (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.

Selecting a lead hazard control strategy based on dust lead loading and housing condition: I. Methods and results.

A methodology was developed to classify housing conditions and interior dust lead loadings, using them to predict the relative effectiveness of different lead-based paint hazard control interventions. A companion article in this issue describes how the methodology can be applied. Data from the National Evaluation of the HUD Lead Hazard Control Grant Program, which covered more than 2800 homes in 11 U.S. states, were used. Half these homes (1417) met the study's inclusion criteria. Interior interventions ranged from professional cleaning with spot painting to lead abatement on windows, and enclosure, encapsulation, or removal of other leaded building components. Modeling was used to develop a visual Housing Assessment Tool (HAT), which was then used to predict relative intervention effectiveness for a range of intervention intensities and baseline floor and windowsill dust lead loadings in occupied dwellings. More than 117,000 potential HATs were considered. To be deemed successful, potential HATs were required to meet these criteria: (1) the effect of interior strategy had to differ for HAT ratings of good vs. poor building condition and/or baseline dust lead loadings; (2) the HAT rating had to be a predictor of one year post-intervention loadings; (3) interior intervention strategy had to be a predictor of one-year loadings; (4) higher baseline loadings could not be associated with lower one-year loadings; and (5) neither exterior work nor site/soil work could result in higher predicted one-year loadings for either HAT rating. Of the 1299 HATs that met these criteria, one was selected because it had the most significant differences between strategy intensities when floors and sills were considered together. For the selected HAT, site/soil work was a predictor of one-year loadings for floors (p = 0.009) but not for sills (p = 0.424). Hazard control work on the building exterior was a predictor of both sill and floor one-year loadings (p = 0.004 and p < 0.001, respectively). Regardless of the type of interior intervention strategy, interior work was a predictor of both floor and sill one-year loadings (each p < or = 0.001).

Selecting a lead hazard control strategy based on dust lead loading and housing condition: II. Application of Housing Assessment Tool (HAT) modeling results.

In Part I in this issue, modeling was used to identify a Housing Assessment Tool (HAT) that can be used to predict relative intervention effectiveness for a range of intervention intensities and baseline dust lead loadings in occupied dwellings. The HAT predicts one year post-intervention floor and windowsill loadings and the probability that these loadings will exceed current federal lead hazard standards. This article illustrates the field application of the HAT, helping practitioners determine the minimum intervention intensity needed to reach "acceptable" one year post-intervention levels, with acceptability defined based on specific project needs, local needs, regulations, and resource constraints. The HAT is used to classify a dwelling's baseline condition as good or poor. If the average number of interior non-intact painted surfaces per room is >/=2, then the dwelling is rated as poor. If exterior windows/doors are deteriorated and the average number of exterior non-intact painted surfaces per building side is >/=5, then the dwelling is rated as poor. If neither of these conditions is true, then the dwelling's HAT rating is good. The HAT rating is then combined with baseline average floor loading to help select the treatment intensity. For example, if the baseline floor loading is 100 mug/ft(2) (1,075 mug/m(2) and the HAT rating is poor, the probability that the one-year floor loading exceeds the federal standard of 40 mug/ft(2) (430 mug/m(2) is 27% for a high-intensity strategy (i.e., window lead abatement with other treatments) but is 54% for a lower-intensity strategy (i.e., cleaning and spot painting). If the HAT rating is good, the probability that the one-year floor loading exceeds 40 mug/ft(2) is approximately the same for low- and high-intensity strategies (18% for window lead abatement with other treatments compared with 16% for cleaning and spot painting). Lead hazard control practitioners can use this information to make empirically based judgments about the treatment intensity needed to ensure that one year post-intervention loadings remain below federal standards.

Immediate and one-year post-intervention effectiveness of Maryland's lead law treatments.

A 1994 Maryland law prescribes a lead-based paint risk reduction standard for pre-1950, privately owned rental housing. This standard, applied at each tenancy change, can be met by sampling to verify that dust lead loadings are within acceptable limits or by performing specific lead hazard reduction treatments, followed by an independent visual inspection without dust sampling. We evaluated the ability of visual inspection to predict treatment completion and dust lead loadings. Fifty-two Baltimore housing units were enrolled and received the law-specified treatments. Before treatment, study risk assessors conducted visual assessments and dust lead wipe sampling in each unit. After treatment, Maryland-certified visual inspectors conducted the law's required visual inspection, followed by the study risk assessors, who performed a separate visual assessment and collected dust wipe samples. One year later, study risk assessors performed another visual assessment and dust wipe sampling (n=34). Dust lead loadings declined significantly immediately after prescribed lead treatments were implemented. Fifty-three percent, 20%, and 47% of units had at least one sample that exceeded 1995 EPA/HUD floor, window sill and window trough clearance guidance of 100, 500 and 800 microg/ft2, respectively. Overall, 73% of units had one or more immediate post-intervention single surface sample results exceeding the 1995 clearance values that were in effect at the time of the study. One-year post-intervention loadings remained significantly below pre-intervention levels for floors but not window sills or troughs. Visual assessments alone, without dust lead testing, did not ensure that prescribed treatments were completed or that dust lead loadings were below clearance values.

National evaluation of the US Department of Housing and Urban Development Lead-Based Paint Hazard Control Grant Program: study methods.

The US Department of Housing and Urban Development (HUD) undertook an evaluation of its Lead Hazard Control Grant Program between 1994 and 1999. The Evaluation is the largest study ever done on the effectiveness of lead hazard controls implemented in residential dwellings. The Evaluation had several major objectives: determining the effectiveness of various lead hazard controls in reducing residential dust lead levels and children's blood lead levels, establishing the costs of doing lead hazard control work and factors that influence those costs, determining the rate of clearance testing failures and their causes, and identifying possible negative effects of lead hazard control work on children's blood lead levels. This paper reports the overall research design and data collection methods of the Evaluation. The large number of dwelling units enrolled in the Evaluation was possible only by the innovative partnership among HUD, the Evaluators, and the grantees. HUD and the Evaluators relied on the grantees for essentially all of the data collection. The 14 participating HUD Lead Hazard Control Grantees were responsible for implementing the lead hazard control programs in their communities and collecting the study data. This paper describes the methods for recruiting and enrolling dwellings and families, collecting environmental and housing data, interviewing participating families, and collecting data on lead hazard control work performed and its costs. The paper also describes the basic quality control and quality assurance procedures used. The principal outcome measures were lead in dust collected using wipes from floors, window sills, and window troughs and lead in blood collected from children who were 6 years old or younger at enrollment. Data collection was conducted before intervention, immediately postintervention, and 6 and 12 months postintervention. For a subset of dwellings undergoing an extended follow-up data were also collected at 24 and 36 months postintervention. This paper provides the context for subsequent reports that will describe such findings as the influence of lead hazard control work on serial dust lead levels, the influence of lead hazard control work on serial blood lead levels in children, the nature and costs of the lead hazard control work done at the dwellings, and the experience of the grantees in meeting clearance testing requirements.