THE EXPERTS SAY: “For successful long-term asthma management, it is
essential to identify
and reduce
exposures to
relevant allergens and irritants and to control other factors that have been
shown to increase asthma symptoms and/or precipitate asthma exacerbations.
These factors fall into four categories: inhalant allergens, occupational
exposures, nonallergic factors, and other factors.” —NIH National Asthma Education and Prevention Panel,
Expert Panel Report 2 (NAEPP EPR-2), 7/97 and its 2002 update
~~~~~~~~~~
Identifying
and substantially reducing the relevant exposures will result in significantly
reduced inflammation, symptoms, and need for medication. The home environment
and other places the person with asthma spends extended periods of time—school,
day care or work—also are appropriate for exposure reductions.
v INHALANT ALLERGENS (only relevant for individuals who
are sensitive):
§
House-dust mites[1]
(universal in areas of high humidity, which is most of the US)
§
Animal allergens1
(dander, urine, feces, saliva from any warm-blooded pet, rodent, bird)
§
Cockroach
allergens1 (a consideration in inner city and southern part of US)
§
Dust or indoor
fungi (mildew, molds: Aspergillus, Penicilium)
§
Outdoor mold
spores (Alternaria1, Cladosporium; may be seasonal)
§
Outdoor allergens
(pollen from trees, grasses, weeds; seasonal)
v OCCUPATIONAL EXPOSURES:
§ Sensitizing chemicals,
dusts1 can induce [cause] asthma: toluene diisocyanates
(TDI, common in polyurethane paints, varnishes & plastics), latex,
formaldehyde, plant or animal products such as redwood dust, isocyanates,
detergent enzymes, tetracycline, tartrazine, products of heated adhesives
§ Allergen or irritant-induced aggravation of pre-existing asthma: mineral
& inorganic dusts, solvents, pyrolysis products, cleaning materials,
irritant gases, dusts, fumes, physical stimuli (cold, heat, humidity)
v
IRRITANTS:
§
Tobacco smoke
(directly inhaled or second hand/environmental[2])
§
Indoor/outdoor
air pollution and irritants
²
Fumes from
unvented/improperly vented gas, oil or kerosene appliances or heaters [N02;
CO]
²
Use of
wood-burning appliances or fireplaces
²
Pollution levels,
especially respirable particulates (PM2.5), ozone, SO2,
NO2 [CO, a fatal poison, can be a marker of exhaust from
internal combustion engines]
²
Other irritant
fumes or strong odors from paints, pesticides, cleaning agents, sprays,
perfumes
v OTHER FACTORS THAT CAN INFLUENCE ASTHMA SEVERITY:
§
Rhinitis,
sinusitis
§
Gastroesophageal
reflux
§
History of
sensitivity to aspirin, other nonsteroidal anti-inflammatory drugs, or
sulfite-containing foods (a preservative in many prepared salads, processed
potatoes, shrimp, dried fruit, beer, wine)
§
Topical and
systemic beta-blockers, including some eye drops for glaucoma
§
Viral respiratory
infections (colds, influenza, respiratory syncytial
virus [RSV])
B ASTHMA
TRIGGERS: BASIC ENVIRONMENTAL CONTROLS B
|
CATEGORY |
OWNER OPTIONS |
RENTER OPTIONS |
General sanitation [& pest reduction]:
|
2 Must rent units (in California) in clean condition,
without vermin, rodents |
Don’t
leave food or garbage exposed |
|
|
2 Must supply enough covered trash & garbage
disposal bins; routine removal |
Always
keep food & beverages out of bedrooms |
|
|
2 Aim for zero cockroaches, get to ≤10 with integrated pest management [use of poison
bates, traps, boric acid, not more toxic chemical agents] î If chemical agents are used, notify tenants in
advance, ventilate the area well; tenants should not return to the area until
the odor has dissipated |
If
sensitive to a pet, remove the animal from the home [at least keep it
out of the patient’s bedroom, & place dense filtering material over
forced air outlets to trap dander particles] |
Excess moisture [dampness leads to mites, mold growth, &
cockroaches]:
|
2 Keep indoor humidity at 50% or less: î Have no broken windows, leaky roofs or pipes î Have a regular schedule for inspecting roofs,
ceilings, walls, floors & carpets for water & moldy odor î Have washer & dryer hookups, high quality bath
& kitchen fans, & directly vent each to outside î Don’t allow sprinklers to strike buildings |
î Keep indoor humidity between 30- 50% î Avoid high occupancy rates: they cause inadequate
ventilation & higher humidity |
|
|
2 Assure an adequate HVAC system [inadequate systems
trap moisture] |
Set
HVAC at “on” (never “auto”) so fresh air is introduced |
|
|
2 Immediately & thoroughly dry damp building
materials or furnishings [any dampness remaining after 24 hours can grow
molds] |
If
you smell or see mildew or mold: fix it fast and thoroughly. Spores regrow
quickly! |
|
Dust mite reduction: |
2 Remove carpets, especially in bedrooms & on
concrete. Ideal flooring is smooth & easy to clean: wood, vinyl, tile |
î Cover the mattress & pillow with
allergen-impermeable covers î Wash patient’s sheets & blankets weekly at ≥130ºF to kill dust mites î Minimize stuffed toys in children’s beds, &
wash them weekly in hot water î Remove rugs & curtains from bedrooms î Avoid lying or sleeping on upholstered furniture |
|
Reduce fossil fuel emissions: |
2 Provide adequate insulation, an energy- efficient
heating system, and electric appliances |
Keep
room temperatures consistent, above 650F & below 780F |
|
Control irritant fumes: |
2 Have gas, oil or kerosene appliances & heaters
professionally installed & routinely maintained |
|
|
|
2 Reduce particleboard & products, which emits
formaldehyde vapor |
|
|
Reduce outdoor allergens: |
2 Select groundcovers & bushes that reduce
allergens, dust, maintenance, moisture, & chemical dependence |
In
your at-risk pollen season: close windows, stay indoors especially in
afternoon |
|
Design details (general building & decorating): |
2 Avoid dust, maximize wipable surfaces: î use water-based wall paint, not paper or vinyl
covering î use window shades [not drapes or blinds] î provide adequate storage & closets, to decrease
collection of mites, dust & mold |
CHR 11/28/02; 12//03/02 C:\chrword\health ed\asthma
& hsg\expert say.doc © CTS 12/02 |
Companion list with the 2001California Thoracic Society
©
People with Asthma: Appropriate Rental Housing
Accommodations Guide
Ø
Most states
and countries have an implied
warranty of habitability as a basic legal right. These common laws or
statutory codes also prohibit landlord retaliation or eviction when a tenant
pursues these housing rights. State sanctions may be imposed for landlord
delays.
Ø
US Fair
Housing Act Amendments (FHAA, 1988)
added disability and strengthened enforcement of the civil rights
discrimination law. Protections apply for both public and private
housing whenever there are 4(+) rental units. Landlord cannot ask or
discriminate in application process; cannot require additional security deposit
or rental charges from tenants with disabilities. Adaptive building design became
effective 3/13/91; reasonable accommodations are required. If the building was
occupied before 3/13/91, renter must be allowed to make modifications at
own expense. FHAA also applies to banks, realtors, appraisers etc when buying
or selling a house. [Greater protection by state and local law can occur].
Enforcement avenues include administrative complaints and private lawsuits.
Remedies include court order to comply with Section 504; attorney fees;
monetary damage awards are possible.
Ø People with disabilities have further protections in public
housing via:
§ Section 504
of the US Rehabilitation Act (1973 and 1978 amendment extending coverage to
federal government itself): applies whenever federal funds are used to build
public housing projects or to use Section 8 vouchers in renting in a “private”
building. The private Section 8 landlord is not required to make modifications,
yet the Public Housing Authority can arrange a transfer to another unit that is
suitable. Unit integration is required. Section 504 implementation is under HUD
regulations. Administrative complaints and private lawsuits can occur, with
remedies including court order to comply with FHAA, attorney’s fees,
compensatory and punitive damages. An Attorney General lawsuit can occur if there
is either a pattern or general public importance: remedies are possible as
noted above, plus a fine to $50,000 for the first violation and to $100,000 for
subsequent violations.
§ Title II of the US Americans with Disabilities Act (ADA, 1990): a person with substantial limitation
from a lung disease such as asthma, who can document substantial limitations
& personal exacerbation, can request & require either
è
A reasonable
accommodation of rules, policies,
practices or services where necessary to allow the person with the disability
the opportunity to use and enjoy a dwelling [Examples: placement in—or
relocation to—an accessible unit away from the prevailing breeze that blows
pesticide spray, heavy pollen, or diesel fumes from the neighborhood; a
designated parking space], and/or
è A reasonable modification that changes the structure at either the landlord’s
or (with Section 8 payment vouchers) the Housing Authority’s expense. [Example:
removing wall-to-wall carpeting can be an asthma related modification].
Ø
If any federal
money is involved, then FHAA, Section 504 and ADA Title II many all apply.
Ø California & other state disability laws parallel
and sometimes exceed federal regulations. They also may apply.
DAY
CARE FACILITIES:
Ø
Section 504 and
Title III of ADA applies (re public accommodations)
§ Religious entities are entirely exempt from Title III
ADA (only)
Ø See Workplace requirements for employees, below
SCHOOLS
(typical classroom has four times as
many occupants as an office):
Ø
Section 504, and
Title III of ADA and other laws are implicated
§
Religious
entities are entirely exempt from Title III ADA (only)
Ø
See Workplace
requirements for employees, below
WORKPLACES
(adults may spend more hours/day here
than in their own dwellings):
ØTitle
I of ADA, if there are 15(+) employees
ØRelevant
California law applies when there are 5(+) employees
Ø California workplaces must have an Injury and Illness
Prevention Program (Title 8,
California Code of Regulations, Section 3203) with a hazard reporting
procedure: report moisture-mold etc. problems to your employer, supervisor,
health and safety officer, union representative or school board.
© CTS 11/01 ctslung@aol.com
CHR
11/9/01; 12/3/02
C:chrword\asthmaHsg\AccomsOther Settings.doc
[1] Studies confirm that sensitization among genetically
susceptible populations (allergy) to these certain allergens is a risk for
developing asthma in children. The importance of inhalant sensitivity as a
cause of asthma declines with advancing age
[2] Exposure to maternal smoking has been shown to be a risk
factor for developing asthma in infancy, although not for
persistence of childhood asthma into adulthood
CHR 11/28/02; 12/3/02