Introduction Intervention can Improve Health • • •

•

Patients need information on how to improve the quality of their home indoor air environments Interventions are often simple and inexpensive Avoidance and abatement strategies are easily taught by physicians, physician’s assistants, nurse practitioners, and nurses Primary care clinicians are trusted, influential sources of health promotion information

1

Introduction Indoor Air Pollution Vs. Quality •

•

Indoor air pollution decreases indoor air quality as water pollution decreases water quality

A person may have a choice about whether to drink the water, but have less choice about the air they breath. In addition, such sense of lack of control may color patients’ perception of their symptoms.

2

Introduction Three Basic Strategies • • •

Source Control Ventilation Improvements Air Cleaners

3

Strategies #1 Source Control •

Identifying and treating or eliminating individual sources of indoor air pollution is usually the most effective way to reduce their emissions – Source control is typically the most cost-efficient approach, as increasing ventilation can increase energy costs

4

Strategies #2 Ventilation Improvements •

Increasing the amount of outdoor air coming indoors lowers concentrations of indoor air pollutants – Most home heating and cooling systems don’t mechanically bring outside air into the house – Opening windows and doors and operating window or attic fans, window air conditioning units with vent controls open, and local kitchen and bathroom fans that exhaust outdoors all increase ventilation

5

Strategies #3 Air Cleaners • •

Types, sizes, and costs of air cleaners range widely, from inexpensive table-top models to sophisticated whole-house systems The effectiveness of an air cleaner depends on – How well it collects pollutants from the air (expressed as a percentage efficiency rate) – How much air it draws through the cleaning or filtering element (expressed in cubic feet per minute)

• •

Some are very effective at removing particles from the air, however, air cleaners are generally not designed to remove gaseous pollutants Houseplants – There is currently no evidence that a reasonable number of houseplants remove significant amounts of pollution – In order to control growth of microorganisms, plant soil should not be kept overly damp

•

Source Control is the most effective solution for most indoor air quality problems

6

Introduction Major Types of Indoor Air Pollution • • • • • • •

Environmental Tobacco Smoke (ETS) Biological Contaminants Combustion Products Volatile Organic Compounds (VOCs) Radon Lead Asbestos

•

Part I of this two-part program explores ETS and biological contaminants

•

This, Part II of two, explores combustion products, VOCs, Radon, Lead, and Asbestos

7

Combustion Pollutants • •

Gases or particles from burning materials used to fuel household appliances Some common household combustion pollutants: – – – – –

Carbon monoxide Nitrogen dioxide Particulate matter Unburned hydrocarbons and aldehydes Sulfur dioxide

8

Combustion Pollutants Carbon Monoxide •

Colorless, odorless gas that interferes with the delivery of oxygen throughout the body – Fetuses, infants, elderly people, and people with anemia, heart disease, or respiratory disease may be especially sensitive to exposure

9

Carbon Monoxide Health Effects • • •

Inhibited oxygen delivery Various symptoms Carboxyhemoglobin level can be assessed to monitor exposure and response to treatment

•

When carbon monoxide is inhaled, it combines with the oxygencarrying hemoglobin of the blood to form carboxyhemoglobin, inhibiting the delivery of oxygen throughout the body

•

Symptoms vary widely depending on carbon monoxide concentration, duration of exposure, and age and general health of the patient

•

Patients will typically display mild symptoms at carboxyhemoglobin level of 15%

•

The maximum exposure allowed by the Occupational Safety and Health Administration (OSHA) over an 8 hour period is 35 parts per million (PPM)

•

Symptoms of carbon monoxide include − Flu-like symptoms that clear up when the patient is away from home − Headache, dizziness, confusion, disorientation − Weakness, fatigue − Nausea − Episodes of increased chest pain in people with chronic heart disease − Visual impairment, reduced manual dexterity, difficulty performing complex tasks 10

Carbon Monoxide Sources •

•

Any fuel-burning appliance, vehicle, or tool if not properly installed, maintained, and operated

Examples of potential carbon monoxide-producing devices commonly used in and around homes − Gas appliances, fireplaces, and wood or coal stoves that are not properly vented − Burning charcoal, running gasoline engines in enclosed spaces, unvented kerosene heaters, and environmental tobacco smoke

11

Combustion Pollutants Nitrogen Dioxide • • •

Brownish gas A nitrogen oxide EPA standard - .053 PPM

•

Nitrogen oxides form when fuel is burned at high temperatures

•

The EPA’s health-based national air quality standard for nitrogen dioxide is .053 PPM (measured as an arithmetic mean concentration)

12

Nitrogen Dioxide Health Effects & Risk Populations • • • •

Shortness of breath from exposure to high concentrations Increased risk of respiratory infection from high concentrations or continued exposure to lower concentrations Repeated exposure may contribute to the development of lung disease (i.e., emphysema) Children and people with asthma and other respiratory diseases are at particular risk

13

Nitrogen Dioxide Sources •

•

Major sources are combustion-associated processes

Major sources of nitrogen dioxide pollution are motor vehicles, power plants, space heating, aircraft, and high temperature combustion processes used in industrial work − Approximately 78% of air is nitrogen and about 21% is oxygen. During high temperature combustion, the nitrogen in the air reacts with oxygen to produce oxides of nitrogen (NOx). Most of the NOx created during this process is nitric oxide. Nitrogen dioxide is formed as nitric oxide combines with oxygen in the air (oxidation).

14

Combustion Pollutants Particulate Matter • •

Particles found in the air Various compositions

•

Particles can be solid or liquid and some are large and dark enough to be seen (i.e. smoke or soot), while others are so small that they can only be seen through an electron microscope

•

Due to the wide variety of sources of particulate matter, physical and chemical compositions also vary widely

15

Particulate Matter Health Effects • • • •

•

Eye, nose, and throat irritation Respiratory infections and bronchitis Lung damage Lung cancer

Cancer-causing pollutants, such as radon, can attach to small particles that are inhaled and carried deep into the lungs

16

Particulate Matter Sources • •

Smaller particles are of particular concern Various sources

•

The EPA focuses particularly on smaller particles (10 micrometers in diameter or less) due to their ability to reach the lower regions of the respiratory tract

•

Airborne particles originate from a variety of sources, including − Burning wood (as in fireplaces and wood stove) − Kerosene heaters − ETS − Agriculture − Unpaved roads

17

Combustion Pollutants Case #1 - The Hargrove Children • •

6 year old boy, Jim; 9 year old girl, Judy Jim’s symptoms began one month prior to visit, Judy’s more recently – – – –

Fatigue, frontal headache, reduced appetite, occasional nausea Symptoms improved by mid-day Physical exams and CBC, UA, glucose normal History: Good health, current immunizations, no prior relevant symptoms – Parents had no symptoms

•

The Hargrove Children have been seen at the clinic for more than 5 years. This visit is due to flu-like symptoms.

•

Jim, age 6, had the symptoms for about a month, but Judy, age 9, more recently began to display symptoms.

•

Jim had fatigue, dull headache, little appetite, and occasional nausea and was complaining about not wanting to go to school. His mother sent him, anyway, thinking he was simply trying to avoid school. The symptoms typically cleared up by lunchtime, until the next morning when the pattern was often, though not consistently, repeated.

•

Mrs. Hargrove became more concerned with the onset of Judy’s symptoms. The two children had remarkably similar symptoms which were present both on school days and weekends.

•

Neither of the children had a history of either avoiding school or manipulative behavior.

•

Immunizations are current.

•

Physical examination, CBC, urinalysis, and glucose, were normal in both children.

•

Neither parent displayed symptoms

18

Case #1 Environmental History •

Description of home

• • •

Recent redecoration? Pets? Recent pesticide use?

• • • • • •

Single-level home City services Gas heat and cooking No recent redecorating No pets No recent pesticide use

•

Given the pattern of symptoms and the children’s health history, an environmental cause was suspected.

•

The left column, above, provides examples of questions you might ask to elicit relevant information about the home environment. The column on the right lists information gathered from Mrs. Hargrove.

•

Mrs. Hargrove was advised to log dates, times, and descriptions of the children’s symptoms and return in two weeks.

19

Case #1 Continued, Three Days Later •

ER Visit – Judy - severe headache, nausea, and vomiting – Jim - stupor

•

Tests – Routine tests normal – Elevated carboxyhemoglobin levels

•

Three days after their clinic visit, the children were seen in the ER. − Judy complained of a severe headache and was nauseated and vomiting. − Jim was hard to awaken and remained in a stupor. − The routine tests ordered by the ER physician were all normal, however, carboxyhemoglobin levels in both children were found to be elevated.

20

Case #1 Disposition •

Diagnosis – Carbon monoxide poisoning

•

Home inspection – Heating system in good condition – Hot water heater flue partially blocked

•

Carboxyhemoglobin, of course, is the important marker of carbon monoxide exposure, and confirmed the diagnosis. − Carbon monoxide poisoning was considered earlier, however, the weather was warm so the gas furnace was rarely on.

•

During an inspection of the household appliances, a technician found a partial blockage of the water heater flue. The water heater was located in the hall adjacent to the children’s bedrooms.

•

Repair of the water heater resulted in immediate cessation of the symptoms.

21

Combustion Pollutants Advising Patients • • •

Annual professional inspections Follow manufacturer instructions and safety warnings Carbon monoxide detectors as back-up

•

Fuel-burning appliances should be professionally inspected annually

•

Household appliances should be used in strict accordance with manufacturer instructions and safety warnings − Have appliances installed properly − Use proper fuels − Keep appliances properly adjusted • A persistent, yellow-tipped flame is a likely indicator of maladjustment and increased emissions − Change filters as frequently as directed − Use appliances in appropriately sized and ventilated areas

•

A carbon monoxide detector should be used as a safety back-up only − The technology is still evolving and detectors are not reliable enough to replace proper appliance use and maintenance

22

Combustion Pollutants Advising Patients, continued • •

•

Choose and use appliances wisely Increase knowledge

Guidelines for making smart combustion appliance choices − Choose vented appliances whenever possible − Only buy combustion products with labels indicating they have been certified to meet safety standards • United Laboratories (UL) and the American Gas Association (AGA) are examples of certifying organizations − Never use a range, oven, or dryer to heat your home − In woodburning stoves and fireplaces • Use seasoned hardwoods (e.g., elm, maple, oak) instead of softwoods (e.g., cedar, fir, pine) • Do not use green or wet wood • Do not use painted or treated wood • Do not burn plastics, charcoal, or colored paper (i.e., comic newspaper pages)

•

Know the symptoms of exposure and take action!

23

Volatile Organic Compounds •

Organic gases, found in many household products, which can be released into the air and inhaled

24

Volatile Organic Compounds Health Effects • •

•

Various symptoms Cancer risk

Symptoms of exposure include − Eye, nose, throat, and respiratory tract irritation − Dyspnea − Headaches, fatigue, dizziness − Visual disorders − Memory impairment − Decline in serum cholinesterase level − Allergic skin reaction

•

Some organic compounds, such as benzene, have been directly linked to human cancer. Others, like formaldehyde and perchloroethylene, are suspected carcinogens

25

Volatile Organic Compounds Sources •

•

Various chemical sources commonly used in homes

Common household sources include − Paints, varnishes, and wood preservers − Paint strippers and other solvents − Cleaning, disinfecting, and degreasing products − Insect repellents − Air fresheners − Aerosol sprays − Hobby supplies − Fuels − Dry-cleaned clothing

26

Volatile Organic Compounds Formaldehyde • • • •

•

The chemical formaldehyde (HCHO) is a preservative and disinfectant with a wide variety of uses Exists in every home, to some degree Colorless, pungent-smelling gas One of the most hazardous compounds to ecosystems and human health

Common uses of formaldehyde include − Manufacturing of building materials and household products − Manufacturing fabric. Formaldehyde is used to bind pigments, as a fire-retardant, to create stiffness, and to add wrinkle resistance and water-repelling qualities − Producing paper products, such as grocery bags, paper cups and plates, waxed paper, facial tissues, napkins, paper towels, and sanitary napkins, due to its water-repelling qualities

27

Formaldehyde Health Effects • •

•

Most adults react to airborne concentrations of 0.5 to 1.5 PPM Symptoms vary among individuals

Most adults exhibit symptoms in response to a concentration of 0.5 to 1.5 PPM − Infants, the elderly, people with specific allergic reactions, and people with respiratory problems may react to lower levels

•

Symptoms of exposure include − Eye irritation or watery eyes − Burning sensation in eyes and throat − Nausea, vomiting, abdominal pain, or diarrhea − Dizziness − Fatigue − Lethargy − Headaches − Skin rashes − Difficulty Breathing − Upper respiratory tract irritation − May trigger asthma attacks − Some may develop sensitivity to formaldehyde − At high levels, a probable human carcinagen

28

Formaldehyde Sources •

Home building, decorating, and furnishing materials – – – –

• • • •

Pressed wood products Insulation (especially foam) Adhesives Paints and other coatings

Tobacco Smoke Household products Unvented, fuel-burning appliances Clothing and drapery

29

Formaldehyde Case #2 - Mrs. Kingsley • • • •

Female, 46 years old For 10 days - eye irritation, sore throat, runny nose, non-productive cough Children and mother-in-law have similar symptoms Husband has no symptoms

•

Mrs. Kinsley, age 46, came to the clinic complaining of eye irritation, sore throat, runny nose, and a non-productive cough, symptoms she had had for 10 days.

•

She reported that her three children and her mother-in-law, who lives with them, all had similar symptoms. Her husband had no symptoms.

30

Case #2 Findings • • •

•

Mild conjunctivitis Nasal and oropharynx injection without exudate Occasional expiratory wheezes in bases bilaterally

On examination, Mrs. Kingsley was found to have mild conjunctivitis, nasal and oropharynx injection without exudate, and occasional expiratory wheezes in bases bilaterally.

31

Case #2 Environmental History •

Description of home

•

Recent redecoration?

• •

Pets? Moisture problems?

•

Do any family members have allergies?

• • • • • • •

20 years old Four bedrooms New bath added Kitchen updated No pets No moisture problems evident No allergies

•

The Kingsleys had recently been upgrading the house by adding a bathroom and modernizing the kitchen.

•

Mr. Kingsley did much of the work himself. He purchased unpainted, veneered, newly fabricated particleboard cabinets from a home improvement store.

•

Mrs. Kingsley was unable to decide on the color for the cabinets before their installation so they were put in place without varnish or paint.

•

There was a strong odor, particularly in the kitchen, accompanied by burning eyes and coughing.

•

There was no evidence of moisture problems in the home, which could result in the growth of biological pollutants.

•

No family members have known allergies and the family has no pets.

32

Case #2 Impression & Plan •

Impression

•

Plan

– Formaldehyde exposure with irritation – Ventilate the home – Seal the new cabinets

•

Based on the environmental history and the symptoms displayed by Mrs. Kingsley and her family, the clinical impression was formaldehyde exposure with irritation, due to off-gassing from the unfinished particleboard of the new cabinets.

•

Mrs. Kinglsey was advised to increase outside air ventilation, particularly in the two rooms where the new cabinets were installed. − Windows should be opened and the air handling system should be turned on to dilute the formaldehyde concentration in the air.

•

The cabinets should be sealed with paint or varnish that does not, itself, contain formaldehyde.

33

Formaldehyde Advising Patients • • • • • • • • •

Ask questions Use exterior-grade products Coat pressed wood products Use dehumidifiers and air conditioning Wash bedding and clothing before use Store chemicals safely Be wary of dry-cleaned clothing Use pesticides as directed Take precautions when purchasing new carpet EPA Toxic Substance Control Act (TSCA) Assistance Line 202.554.1404 Carpet and Rug Institute Guidelines for carpet installation: WWW.carpet-rug.com/techinfo/technicaliaq.htm

•

Ask about the formaldehyde content of pressed wood products (building materials, cabinetry, furniture) before purchasing them

•

Exterior-grade products contain phenol resins, rather than urea resins, so they emit less formaldehyde

•

Coat pressed wood products thoroughly with polyurethane, paint, or other sealants to reduce emissions − Allow appropriate ventilation and follow manufacturer instructions when applying coating − Avoid using coating products that contain formaldehyde

•

Use dehumidifiers and air conditioning to maintain moderate temperature and humidity as formaldehyde release is accelerated by heat and may also depend somewhat on humidity level

•

When storing chemicals − Store chemicals in sealed containers, outdoors − Store as little as possible

• •

Do not accept dry-cleaned clothing that is not fully dry or that emits strong odors When purchasing new carpet − Choose low-emitting carpet, padding, and adhesives − Ask the retailer to unroll and air out carpet prior to installation 34

Radon • •

Colorless, odorless, cancer-causing, radioactive gas The second leading cause of lung cancer in the United States, according to the Surgeon General

35

Radon Health Effects & Risk Populations • •

No immediate symptoms Smokers are at particularly high risk for radoninduced lung cancer

36

Radon Sources •

Product of radioactive decay of radium

•

Naturally occurring and found in low concentrations almost everywhere on earth

•

Colorless, odorless, and chemically inert like helium, neon, and the other so-called "noble" gases

•

Radon comes from the natural radioactive decay of the element radium. It is midway in a chain of radioactive transformations originating with uranium (which has such a long "half-life" that half of the earth's original compliment remains) in soil, rock, and water

•

Radon can be found almost everywhere and can get into any type of building but is of most concern in the home as people spend most of their time in their homes

37

Radon Advising Patients •

Test your home (level should be below 4 pCi/L)

National Radon Information Hotline 800.SOS.Radon The Radon Fix-It Program 800.644.6999

•

Testing is the only way to determine if radon levels are high − Testing is easy and inexpensive (a test kit costs about $20) − All homes below the 3rd floor should be tested − Homes with radon levels of 4 pico Curies per liter (pCi/L) or higher should be fixed • The EPA estimates that living with 10 pCi/L in the air is equivalent to smoking a pack of cigarettes each day

38

Lead • •

•

A heavy metal, basic chemical element that is combined with many other substances to form numerous compounds Can harm virtually every system in the human body (including the central nervous system, kidneys, and blood cells), often with no visible symptoms Exposure usually occurs through inhalation or ingestion, as inorganic lead is not absorbed through skin

39

Lead Health Effects •

Adults – – – – –

•

Infants and small children – – – – –

•

Gastrointestinal discomfort/constipation/nausea Personality changes Fatigue/weakness Hearing loss Tremors/lack of coordination Irritability Abdominal pain Ataxia Seizures/loss of consciousness Chronic learning deficits/hyperactivity/reduced attention span

Inhibited heme synthesis – Standard screening method is investigation of blood lead (PbB) levels which reveal recent exposure to lead

•

Lead inhibits heme synthesis. Since interruption of that process produces protoporphyrin accumulation at the cellular level, the standard screening method is investigation of blood lead (PbB) levels which reveal recent exposure to lead. Acute symptomology in adults is often associated with PbB at levels of 40 µg/dl or higher

40

Lead Sources • • • •

Melting pure lead, molding, soldering, removal or encapsulation of lead (including the alteration, repair, or removal of structures that contain lead) Can be inhaled and absorbed through the lungs and respiratory tract when lead takes the form of a dust fume or mist Contaminated soil Contaminated drinking water

41

Lead Advising Patients • • • • • • •

Department of Health 212.Ban.Lead National Lead Information Center 800.Lead.FYI CDC Lead Poisoning Prevention Branch 800.488.7330

The most common treatment for lead poisoning is to reduce exposure Wet-mop and wipe furniture frequently to control lead dust Paint that may be lead-based should not be disturbed Lead-based paint should be removed only by professionals Do not burn painted or treated wood A healthy diet rich in calcium and iron will help reduce the amount of lead absorbed by the body At least once a year, children under 6 should be tested

42

Asbestos •

A mineral fiber – Naturally occurring – Extremely aerodynamic – Harmful if ingested at high concentrations over extended time – Dangerous if airborne – Greater the dose, higher the risk

•

Asbestos fibers occur naturally and are extremely aerodynamic so virtually everyone is exposed

•

To be of significant concern, fibers must be ingested at high concentrations over an extended period, causing them to accumulate in the lungs

•

Asbestos is only dangerous if it becomes airborne so as long as asbestos-containing materials are not disturbed, they pose no threat Concern about asbestos: the greater the dose, the higher the risk of disease

•

43

Asbestos Health Effects • •

No immediate symptoms Lung cancer – Smokers at extreme risk

• •

Mesothelioma Asbestosis

•

Fibers, too small to be visible, are inhaled and accumulate, over time, in the lungs. Thus, symptoms do not appear until many years after exposure begins

•

Lung cancer is a malignant tumor of the bronchi covering that grows through surrounding tissue, invading and often obstructing air flow − Time between exposure and cancer occurrence is 10 to 50 years − There is a synergistic effect between smoking and asbestos exposure which creates extreme susceptibility

•

Mesothelioma is cancer of the pleural lining − Considered to be exclusively asbestos-related − Almost always fatal by time of diagnosis − Latency period is 30 to 40 years - May start as soon as 10 years after 1st exposure

•

Asbestosis is scarring of the lung tissue that impairs the elasticity of the lung, interfering with its ability to exchange gases and leading to inadequate oxygen delivery to the blood − Slowly progressive − Latency period is 10 to 30 years

44

Asbestos Sources •

Building materials (such as pipe and furnace insulation materials, fire retardant, textured paint and other coating materials, acoustical materials, and floor tiles) – Several asbestos products have been banned and manufactures have also voluntarily limited use of asbestos so it is most frequently found in older homes

45

Asbestos Advising Patients •

Leave asbestos material alone if it is in good condition – There is no danger unless fibers become airborne

•

When there is a need to remove asbestos materials, use a professional contractor

EPA’s TSCA Assistance Line 202.554.1404

46

Conclusion •

When exposure to indoor air pollution is suspected, assess your patient’s environment by asking about – – – –

•

The patient’s home (number of levels, types of utilities, etc.) Recent redecorating Pets Recent pesticide use

In summary, the three basic strategies for controlling indoor air pollution are – Source control (typically the most practical and effective) – Ventilation improvements – Air cleaners

•

Help your patients learn to recognize risk and know where to look for information

47