U.S.DepartmentofHousingandUrbanDevelopmentOfficeofHealthyHomesandLeadHazardControl

Leading Our Nation to Healthier Homes:

The Healthy Homes Strategic Plan

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Foreword from Shaun Donovan, SecretaryExecutive SummaryI. IntroductionII. Healthy Homes Program BackgroundIII. Strategic Opportunities for Healthy HomesIV. Healthy Homes Program Future Directions References

Appendix A: The Current State of Health and Hazards in Housing Appendix B: HUD Healthy Homes Program Activities and AccomplishmentsAppendix C: Focus Areas of Initial Strategic PlanningAppendix D: Abbreviations Used in this Document

45912141932

40515657

TableofContents

The Strategic Plan is accessible at www.hud.gov/healthyhomes

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Foreword by Shaun Donovan, Secretary, U.S. Department of Housing and Urban Development

As the nation’s housing agency, HUD is committed to promoting decent, affordable housing and addressing housing conditions that threaten the health of residents. Unfortunately, there are still too many homes in the U.S. with hazards that endanger the health and safety of occupants. The cost of housing-related health hazards to the U.S. measures in the tens of billions annually. The time has come for the Department to take action to address these issues by unveiling a Healthy Homes Strategic Plan to guide our efforts.

In 1999, HUD recognized that targeting building deficiencies that contribute to a multitude of health and safety hazards was more cost-effective than implementing interventions on a hazard-by-hazard basis and proposed a healthy homes program, situated in the Office of Healthy Homes and Lead Hazard Control. Today, HUD’s commitment to providing safe and healthy homes for all families and children takes another significant step forward with the publication of the Healthy Homes Strategic Plan.

The Strategic Plan will serve as a road map for the Department and the Office of Healthy Homes and Lead Hazard Control as we strive to protect the health of children and other sensitive populations in a comprehensive and cost-effective manner. The Strategic Plan is the result of years of analysis, and represents a synthesis of programmatic experience, research, and community feedback. The Strategic Plan will help ensure that the Department is focused and effective in achieving program goals and in supporting its mission of increasing access to safe, decent, and affordable housing for all Americans.

I would like to thank all our of public and private sector partners that have been instrumental in helping the Department forge new paths that advance interventions that address multiple housing-related hazards. We look forward to continuing our partnerships on the federal and local levels in pursuit of the ambitious agenda that is presented in this Plan.

Shaun Donovan, July 9, 2009

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ExecutiveSummary

Nearly ten years since the inception of the Healthy Homes program in the Department ofHousing andUrbanDevelopment’s(HUD’s)OfficeofHealthyHomes andLeadHazardControl(OHHLHC), theOffice is in the process ofevaluating progress, distilling lessons learned, andforginganew strategic direction. Thisnewdirectionwill incorporate these lessons, withoutabandoning theOffice’s coremission to ensure that leadpoisoning is eliminated as amajorchildhooddisease. With an established lead hazard control program infrastructure and themostcomprehensivenationalhealthyhomesprogram,HUDisinauniquepositionto continuetopromotenationaleffortstoreducehousing‐relatedhealthhazards.

ProgramBackground

TheOHHLHChasadministeredasuccessfulLeadHazardControlprogramsince1993.Throughrobustgrants,enforcementefforts,research,andoutreach, thisprogramhasbeeninstrumentalinachievingareductionofover70%inchildhoodleadpoisoningcasesfromtheearly1990stotoday.Inadditiontosavinglivesandimprovingthehealthofchildren,thisreductionhassavedthe nation billions of dollars by increasing productivity, decreasing medical and specialeducationcosts, andpotentiallyreducingcriminalactivity. The“healthyhomes”conceptgrewout of the observations of Lead Hazard Control grantees that homes with lead‐based painthazards oftenhadother importanthealth hazardsthat couldbeaddressedat the same time.Thecore ofthis concept is that it is moreefficientand cost‐effective to identify andmitigatemultiplehealthhazardsinhighriskhousing,ratherthanfollow the traditional approachofaddressingindividual hazards through multiple categoricalprograms.

TheHealthyHomes programhasbeenguidedbyastrategicplanproposedbyamultidisciplinarypanelofexpertsconvenedbyHUDin1999,andfundedatapproximately $10million annually since then. InFY 2009, this was increased to $14.6 million. Todate, 101 Healthy Homes Demonstration andHealthyHomesTechnical Studiesgrants havebeenawardedbyHUDforatotalofapproximately$81million.HealthyHomesDemonstrationgrantshavesupportedimplementationofhealthyhomespilotprogramsthroughouttheU.S., createdcapacity throughthedevelopmentofatrainedworkforce, andidentifiedeffectivepractices fornewandexistinghousing. HealthyHomesTechnicalStudiesgrantshavesupportedresearchtoimprovehazardassessmentandcontrolmethodsandtobetterunderstandthedistributionandimportanceofresidentialhazardsandexposures,resultinginmorethan30paperspublishedinscientificandprofessionaljournalstodate.

AccordingtoHUD’s2007AmericanHousingSurvey, sixmillionhouseholdslivewithmoderateor severe physical housing problems. Anyone can suffer from housing‐related illness andinjury;howevercertaingroupssuchaschildren,theelderly,orindividualswithchronicillnessaremoresusceptible.

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Key residential health hazards include asthma and allergytriggers, such as mold, dampness and pests (e.g.,cockroaches, mice), injury hazards, andpoor indoor airquality. The health andeconomic burden of housing‐relatedhazards is substantial. For2007, theNationalHeart, Blood, and Lung Institute estimated the totalcost to the U.S. economy from asthma at $19.7billion (includes $14.7 billion in direct medicalcosts and $5 billion in indirect costs such as lostwork andschool days). Inaddition, researchshows thatabout21%ofasthmacasesintheU.S.arelinkedtodampnessandmold, atanannual costofapproximately$3.5billion. Pestscanalsoplayasignificantroleintriggeringthesymptomsofallergiesandasthma;a recentstudy ofasthma among inner‐citychildrenfoundthat 69%wereallergic tocockroachesand33%torodents.Meanwhile,unintentionalinjuryistheleadingcauseofdeathand disability among children younger than 15 years of age, with over 2,800 child andadolescentdeathsoccurringeachyeardueto injuriesinthehome. Theelderly arealsoatanelevatedrisk forresidentialinjuries;eachyear,35‐40%ofadults65andolderfallatleastonce.It is estimated that falls account for 33% of injury‐related medical expenditures and costAmericansmorethan$38billionannually.

Althoughthehealthrisksassociatedwithhomesaremany andvaried, thehouseholdhazardswhichcancontributetothemtendtobeinterrelated.Excessmoisture,poorindoorairquality,andhigh levels ofcontaminated dustarecommonroot causes for residential healthhazards.Addressing these deficiencies simultaneously, rather than attempting to tackle each hazardindividually, will yield the greatest results in themost efficient, cost‐effective manner. Forexample,dealingwithuncontrolledmoisturecanalleviateconditionsassociatedwithallergiesandasthma (mold and pests), unintentional injuries (structural safety), and poisoning (leadpaintdeterioration).

Thekeyover‐arching healthyhomesprinciples are to keephomes dry, clean, well‐ventilated,pest‐free,freefromcontaminants,safe,andwell‐maintained.

HealthyHomesTrendsandFutureDirectionsfortheOHHLHC

As the healthy homes approach gains momentum and visibility, HUDmust address uniquechallenges and opportunities. The OHHLHC’s lead hazard control funds are restricted bystatute to address lead hazards only, but many lead program grantees are interested inexpanding their focus by also addressing other key residential hazards. The green buildingmovement also provides a key opportunity to assess the potential health benefits of greenpracticesandpromotethe inclusionofhealth‐promotingfeatures into greenconstructionandrehabilitation strategies. Housing professionals, including public housing agencies, arebeginning to recognize thebenefits ofa cost‐effective integratedpest management approachcompared to traditional pest control practices. Smoke‐free housing policies are gainingpopularity among managers of multifamily housing because of increasing demand fromresidents,reducedmaintenancecosts,andacknowledgmentofthepublichealthneedtoreduce

Howhomesaredesigned,

constructed,andmaintained;theirphysicalcharacteristics;andthepresenceorabsenceofsafetydeviceshavemanyeffectsoninjury,illness,

andmentalhealth.

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exposure to environmental tobacco smoke. All of thesetrends represent key componentsofincorporatingthehealthyhomesapproachintoongoingpracticesandprograms.

To develop this Strategic Plan, the OHHLHC reviewed past and current activities andaccomplishments,identifiedchallengesandopportunities,andsolicitedstakeholderreviewandcomments.

AVisionforHealthyHomes

This effort resulted in a roadmap for increasing the Office’s impactandbetter enabling it toachieveitsnewlydefinedvision:

To lead the nation to a futurewhere homes are both affordable and designed, constructed,rehabilitated,andmaintainedinamannerthatsupportsthehealthandsafetyofoccupants.

TheOHHLHCMission

Toaccomplishthisvision,theOffice’smissionwillbe:

Toreducehealthandsafetyhazardsinhousing inacomprehensiveandcost­effectivemanner,withaparticularfocusonprotectingthehealthofchildrenandothersensitivepopulationsinlow­incomehouseholds.

HealthyHomesGoals

TheStrategicPlanfocusesonthefollowingfourkeygoalstoguidetheprogram’sactivities:

1) BuildingaNationalFramework:Fosterpartnerships for implementingahealthyhomesagenda.

2) CreatingHealthyHousing throughKeyResearch: Support strategic, focusedresearchonlinksbetweenhousingandhealthandcost‐effectivemethodstoaddresshazards.

3) Mainstreaming the Healthy Homes Approach: Promote the incorporation of healthyhomesprinciplesintoongoingpracticesandprograms.

4) Enabling Communities to Create and Sustain Healthy Homes: Build sustainable localhealthyhomesprograms.

Withintheplan,theOHHLHChasdevelopedshort‐andlong‐termstrategiesforachievingeachof these goals. Short term strategies include: creating amechanism for coordinating federalhealthy homes activities, conductingresearchto characterize the potential indoor air qualitybenefitsofgreenconstruction,collaboratingwithotherHUDofficestopromotehealthyhousingprinciplesinareaswherethereisacriticalpublichealthneed(e.g.,smoke‐freehousing, injury

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prevention, post‐disaster environments), and enhancing lead hazard control programs’capabilitytoaddressbroaderhousingissuesthatimpactoccupanthealth. Inthelongterm,theOHHLHCwillassesstheeffectivenessofhealthyhomestrainingandpublicoutreach/educationefforts,supportthecreationandadoptionofhealth‐protectivehousingcodesandenforcementstrategies,identifyandpursueopportunitiestopromotehealthyhomesconceptstoprivateandpublic sectorentities, andcontinue to act as aconvener ofnational, stateand local partnersthrough national healthy homes conferences and workshops. This work will be done incoordination with the Office’s ongoing efforts in lead poisoning prevention, as the need tocreateandmaintainlead‐safehousingforlowincomefamiliesremainssubstantial;manyareasofthecountrystilllacktheinfrastructureforaneffectiveleadhazardcontrolprogramandthereisaneedforongoingmonitoringandmaintenanceinhomesthathavereceivedtreatments.

The Healthy Homes Strategic Plan will serve as a dynamic roadmap for developing,disseminating, andintegrating the healthyhomes concept. By coordinatingdisparate healthandhousingagendas,supportingkeyresearch, incorporatingthehealthyhomesapproachintoexistingpractices, andprovidingtools to buildsustainablelocal healthyhomes programs, theOHHLHC’s HealthyHomesprogramwill continue to lead inestablishing a framework to helpensureanadequatesupplyofhealthyandaffordablehousing.

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I.Introduction

The mission of the U.S. Department of Housing and Urban Development is to increasehomeownership, support community development and increase access to affordable housingfree from discrimination. The Office ofHealthy Homes and LeadHazardControl (OHHLHC)supports thismissionby assisting Statesand local governments to remedythe unsafe housingconditionsandtheacute shortage ofdecentandsafedwellingsforlow­incomefamilies(HousingAct1937).Noone,ofanyeconomicclass,shouldhavetoworryaboutwhetherhisorherhomeis puttinglovedonesatrisk for illness orinjury. Today’s families arechallengedwithfindingnotonlyaffordablehousingoptions,buthomesthatoffer asafeandhealthyplaceto live. TheOHHLHCdevelopsandpromoteshealthyhousingtoolsandenablescommunitiestocreateandsustainhealthyhomes.

PastandcurrentHealthyHomeprogram activities haveyieldedstrong results. However theOHHLHCrecognizes that itoperatesinadynamic environment andit isnecessary toevaluateactivities toensurethatweareabletobestmeettheneedsofthepopulationsweserve. TheHealthyHomesStrategicPlanpresentsabriefoverviewofsomepastandcurrentactivitiesand

accomplishments to demonstrate the progress that has beenmadeandwheregapsstill exist. Itidentifies challengesand

opportunities by surveying the current political,scientific, and economic trends that impact thesuccess and development of the healthy homes

concept. This analysis results in the proposed strategiesandgoalswhichoutlinethefuturedirectionoftheOHHLHC’sHealthyHomes program, whichwill continue to leadinthedevelopment, dissemination, and integration of thehealthyhomes concepts to improve the availability of decent, safe,and affordable housing. For a guide to the abbreviationsused throughout this plan, please see Appendix D:“AbbreviationsUsedinthisDocument.”

TheDisproportionalBurdenofHousing­RelatedHazards

According to HUD’s 2007 American Housing Survey, nearly 6 million households live withmoderate or severe physical housing problems, including heating, plumbing, and electricaldeficiencies(U.S.Dept.ofHUD,2008b).About24millionhouseholdsfacesignificantlead‐basedpainthazards (Jacobset al.,2002). Anyonecansufferfromhousingrelatedillness andinjury;however certain groups suchas low‐income individuals, children, the elderly, or individualswithchronicillnessaremoresusceptible.

Low‐incomepersonsaremorelikelytolackresourcesforpreventivemeasuresinthehome,anddeferredmaintenancecanleadto thedevelopmentofresidentialhealthhazards. AccordingtotheU.S. Census Bureau, in2007, 37.3millionpeople livedinpoverty (Census Bureau, 2008).Duringthecurrentacuteshortageofaffordablehousing,peopleare forcedto liveinmarginalhousing,ortochoosebetweenaffordabilityandtheirhealthandsafety(JCHS,2005).Theburdenofa homewithphysicalproblems isalso disproportionately heavyonminorities.This is clearly indicated by the 2007 Census poverty rates, withnearly three times asmany

Focusingonpropertiesthatposethegreatesthealthrisks;thatis,thosepropertiesthatare

older,low‐income,orinsubstandardcondition,willyieldthegreatestimprovementin

healthoutcomes.

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blacks (24.5%) andmore than twice as many Hispanics (21.5%) living in poverty as non‐Hispanicwhites(8.2%).ForAmericanIndians(AI)/AlaskanNatives(AN),thisratewas29.4%(CensusBureau,2008). Further,9.8%ofblacks,7.6%ofHispanics,and6.9%ofAI/ANlivewithmoderateorseverephysicalhousingproblems,ascomparedtojust4%ofnon‐Hispanicwhites(Figure1).Housingdataindicatethatlivingconditionsontriballandsaregenerallypoorerthanthe rest of the nation. Almost four percent (3.9%)of Native Americanhousing had severeproblems,asopposedto1.6%forallhousing.

Figure 1: Percent of People in the U.S. Living in Homes with Severe and Moderate Physical Housing Problems (2007)

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5.4

3 2.72.82.2

3.9

1.3

0

1

2

3

4

5

6

7

8

Black Hispanic AmericanIndian/Alaskan

Native

White

Race/Ethnicity

Perc

ent

ModerateSevere

Source:U.S.Dept.ofHUD,2008b

Children are typically more susceptible to biological, chemical, and physical exposures.Possible threats include allergens, asbestos, combustion products, pests, lead‐based paint,mold,organicgases,pesticideresidues, radon, take‐homehazards,andinjuryhazards (KriegerandHiggins,2002). Therapiddevelopmentofachild'sorgansystemsduringembryonic, fetal,and early newborn periods makes children vulnerable when exposed to environmentaltoxicants. Childrenbreathemoreair,drinkmorewater,andeatmorefoodperkilogramofbodyweightthanadults. Aninfant's respiratoryrateismorethantwiceanadult'srate(Snodgrass,1992). Children’s habits (e.g., hand‐to‐mouth contact) also make themmore susceptible toenvironmentalhazardsinthehome, especiallydust. Sincechildrenspendupto80‐90percentof theirtimeindoors, it isparamounttomakeeveryeffort tominimizepossibledangers (U.S.EPA,2002b).

Older adults are also more susceptible to certain housing‐related hazards. Comparedwithyoungadults, older adults havesmaller airways andare thereforemore likely to experiencebronchialhyper‐responsiveness (Yeatts, 2006), whichmakesthemmore vulnerable to indoorair qualityhazards. Theelderly are also at anelevatedrisk forresidential injuries, especiallyfalls (Sleet, 2008). The number of peopleolder than 60 years of age is expected to doublebetween2000and2059,andolderadultstendtoprefertoageinplace, intheirhomes(Yeatts,

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2006;NationalCouncil onAging,2007). Thissubstantialpredictedincreaseintheolderadultpopulation aging at home underscores the importance ofaddressinghazards and identifyinguniqueriskfactorsforhousing‐relatedillnessesandinjuriesinseniors(Selgrade,2006).

Although housing hazards place a particularly significant burden on certain socioeconomic,racial/ethnic, andagegroups, it is important to remember that anyoneof any group can beharmedbyhousing‐relatedillnessorinjury. Advancesinaddressingthesehealthconcernswillbenefitallcategoriesofindividualsandfamilies.

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II.HealthyHomesProgramBackground

Thehealthyhomes conceptbeganto take shape in the1990s asnational attentionand localeffortsgrew.Children’senvironmentalhealthissuesreceivednationalattentionwithPresidentClinton’sExecutiveOrder13045,“Children’sEnvironmentalHealthRisksandSafetyRisks.”IntheFY1999budget,HUDproposed, andtheCongressandPresidentClintonapproved, anewHealthyHomesInitiative(HHI).CongressandPresidentClintonagreedthat“thehealthyhomesapproachappearssuperiortoaddressingproblemsonebyone”andappropriatedfundsfortheInitiative to “develop and implementaprogramof researchand demonstrationprojects thatwould address multiple housing‐related problems affecting the health of children.” Thisprogram was delegated to OHHLHC to build upon the Department’s existing activities andexpertiseinhousing‐relatedhealthandsafetyissues.

CongressdirectedHUDtosubmitapreliminaryplanfor the HHI that would establish focus areas andobjectivesandassessthescientificevidenceforlinksbetweenhousingandhealthhazards. InApril1999,an expert panel convened by HUD prepared the“Healthy Homes Initiative Preliminary Plan.” Theplan identified excess moisture reduction, dustcontrol, improving indoorairquality, andeducationasthekeyfocusareas. ThefiveobjectivesoftheHHIwerethe:

1) Identificationofhomeswhereinterventionswouldbeappropriate;2) Developmentofappropriatelyscaledandefficientinterventionstrategies;3) Selectionofefficientstrategiesforevaluatinginterventioneffectiveness;4) Developmentoflocalcapacitytooperatesustainableprogramstopreventandcontrol

toxicmoldhazardsinresidencesoflowandverylow‐incomefamilies;and5) Determinationofbiomarkerstoaddresshealththresholdlevelsforexposuretomold.

TheOHHLHC’s firstNotices ofFundingAvailability (NOFAs)reflectedthoseobjectiveswith ahousingfocus.Fundswereinitiallymadeavailableforgrantsin:1)MoldandMoistureControl;2)TechnicalStudies(i.e.,research):and3)DemonstrationProjects.

Inkeepingwiththe first threerecommendedobjectives, theHealthyHomesTechnical Studies(HHTS)grantprogramemphasizes researchactivities to developor improvemethods for theidentificationandcontrolofhousing‐relatedhealthhazards. Thepanel’s focusareas, includingmoisture reduction, dust control, and improvements inindoorair qualityprovidedthe initialframework for the scope of HHTS grant projects and framed the interventions, includingeducation,thatareemphasizedintheHealthyHomesDemonstrationgrantprogram.As the OHHLHC identifiedadditional research gaps, it addedother focus areas to theHHTSNOFA. For example, beginning inFY 2002, inrecognitionof theneed to address rodent andcockroach problems in multifamily housing in a more cost‐effective way, the HHTS NOFAsolicitedprojectstoimproveandassessintegratedpestmanagement(IPM)methods.

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InconjunctionwiththeHHTSgrants,theHealthyHomesDemonstration(HHD)programgrantrecipients develop, demonstrate, and evaluate cost‐effective, preventivemeasures to correctmultiple residential safety andhealthhazards that produce diseases and injuries in childrenand other sensitive subgroups such as the elderly, with a particular focus on low incomehouseholds. Throughitsemphasisonpromoting thehealthyhomesapproach, theHHDgrantprogramalsoincorporatesaneducationfocus.InFY2008,majorcategoriesofeligibleactivitiesintheHHDprogramNOFA includeddirectremediationactivities, educationandoutreach,andtraining in target communities. In recent years the OHHLHC has increased emphasis ongrantees’evaluationof theeffectivenessoftheirinterventions, includingassessmentofhealthandenvironmentaloutcomes,aswellastheuseofnovelapproaches.

While the majority of the OHHLHC’s healthy homes funding isprovidedviagrants, theOfficealso employs contracts, interagencyagreements,andcollaborationswithHUDprogramofficessuchas theOfficesofPolicyDevelopment andResearch(PD&R),PublicandIndianHousing (PIH), andHousing.WithPD&R,theOfficehasdevelopedguidanceforthesaferehaboffloodedhomesand is currentlysupporting studiesofresidentialmoisturesources andof the costs andbenefits ofgreen buildingpractices.With PIH, the OHHLHC is working to promote adoption ofintegrated pest management and the creation of smoke‐freehousingbypublichousingagencies. WiththeOfficeofHousing,theOHHLHC provided technical assistance in the development of anindoorairqualitymonitoringprotocolfortheirgreenrehabprogramformultifamilyhousingintheirMark‐to‐Marketprogram.

InteragencyagreementshavefundedimportanthealthyhomesactivitiesbytheU.S.CentersforDisease Control, the U.S. Department of Agriculture’s (USDA) Cooperative State Research,Education andExtension Service (CSREES), theU.S. Environmental ProtectionAgency (EPA),theNationalInstituteofEnvironmentalHealthSciences(NIEHS), andtheNationalInstituteofStandardsandTechnology(NIST).

HUD’s partnership with the CDC has been among its most significant collaborations.Recognizingthe importanceoftakingacomprehensiveapproachtoaddressinghealthyhomesissues, in2006, then‐ActingSurgeonGeneral KennethP.Moritsuguannouncedthathis OfficewoulddevelopaCalltoActiontoPromoteHealthyHomes,to:

“help us link the importance of a healthy indoor environment with ourpriorities of prevention, public health preparedness, and the elimination ofhealthdisparities. It will helpinform theAmericanpeopleof thescience, theevidence,andthedatatohelpimproveourhealthliteracyaboutthisissue.AnditwillcalltheAmericanpeopletoactionbaseduponthisscienceevidenceanddata.”Moritsugu,2006.

TheSurgeonGeneral’sfinalCalltoActionwasreleasedatajointHUDandDepartmentofHealthandHuman Services (HHS) press event in June2009. The associated report documents thecurrent state of research on the link between housing and health conditions, which is alsosummarizedinAppendixA:“TheCurrentStateofHealthandHazardsinHousing.”

Whenenforced,housingandbuildingcodeshaveresultedinbetterconstructedandmaintainedbuildingsand

inimprovedhealth.

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III.StrategicOpportunitiesforMainstreamingHealthyHomes

Aspartofstrategicplanning, theOHHLHCexaminednotonlyinternalactivitiesandsuccesses(seeAppendix B: “HUD Healthy Homes Program Activities and Accomplishments”), but alsoconsideredthesocial,political, andeconomicclimate. Somekeytrendsandopportunitiesthatwill impact the implementation of the Healthy Homes Strategic Plan are examined in thissection.

ThePolicyandPoliticalLandscape

1)RegulationsandCodes–Nationalstandards forinformingresidentsabout lead‐basedpainthazards applyto allhousing. However, similar far‐reachingregulations do not exist forotherhousing‐related health hazards. HUD sets physical property standards only for housingreceivingHUD assistance. Multifamily andpublic housingmust complywithHUD’s UniformPhysicalConditionStandards(UPCS;24CFR5, subpartG),whileownershousingfamilieswithHousingChoiceVoucher(formerlyknownasTenant‐BasedSection8Voucher)assistancemustcomplywiththeHousingQualityStandards(HQS;24CFR982.401).Forallotherhousing,stateorlocalhousingandbuildingcodesmaybetheonlyoccupantprotectionsinplace.

Afewlocalitieshaveincorporatedhealthyhomeselementsintotheircommunitiesthroughtheenforcementofspecializedhousingorbuildingcodes. However,most jurisdictions thatadoptand enforce codes use the model codes provided by the International Code Council (ICC).OHHLHC staff participates in code reviews, and by working with non‐profit partners, hasachievedsomesuccessinshiftingattentiontoincludinghealthyhomesincodes.TheOHHLHC’snonprofitpartnersareactivelyworkingtoincludeadditionalresidentialhazardsinthemodelcode and to amendexisting codes to better address healthandsafety issues. Use ofmodelcodes, adaption of existing codes, or the development of new code provisions, especially inrentalhousing,isaviableopportunitytoaddressresidentialhazardsinthefuture.

2)LegislativeClimate–AttentiontohealthyhomesissuesisevidentintheOHHLHC’sprogramfunding levels, and inproposedlegislationaffectingmultipleagencies. For FiscalYear2009,Congressapprovedan appropriationof not less than$14.6millionfor HUD’s HealthyHomesprogram, representinga67%increaseovertheFY2008programbudgetof$8.7million. Thisresulted in a final FY 2009 program budget of $17.5million. InMarch 2008, the HealthyHousing CouncilActwas introduced in theSenatewithbipartisansponsorship. TheHealthyHousing Council Act sought to establish an independent “Council on Healthy Housing” toimprovecoordination amongst federal, state, andlocal governments, aswell as industry andnon‐profitrepresentatives. InOctober2008, the“Research,HazardIntervention,andNationalOutreachforHealthierHomesAct”wasalsointroducedintheSenate.Thebillaimedtoimproveresearch, enhance the capacity of existing federal programs, and expand national outreachefforts. The legislation would have provided statutory authority for the Healthy Homesprogram and authorized additional funding for healthy homes research, hazard reduction,enforcement,andoutreach.Whilethehousingcrisisprecludedthebillsfrombeingbroughttoavoteduring the110th Session, bothareplanned to bere‐introducedduringthe111thSession,andrepresentCongressionalsupportforthehealthyhomesmovement.

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3)FederalPartners –Bolsteredby the successof the healthy homesapproach, other federalprograms have begun to incorporate, or expand on healthy homes concepts. Improvedcoordinationwith these programs will increase the reach and impact of theHealthyHomesprogram. While many agencies have contributed to program accomplishments, there areespecially timelyopportunitiesto developnewinitiativeswithrespecttoHUD, theCenters forDiseaseControlandPrevention(CDC),andtheU.S.DepartmentofEnergy(DOE).

CDC has partnered with HUD in its healthy homes efforts via an interagency agreementprovidingfundsfromtheOHHLHC. CDCcontinuestodemonstrateacommitmenttothehealthyhomesapproachthroughitsagency‐wideGoalActionPlanforHealthyHomesandrecent plansto transition its Lead Poisoning Prevention Branch (LPPB) to a Healthy Homes and LeadPoisoning Prevention Branch. This change will allow CDC to transition Childhood LeadPoisoningPreventionProgram(CLPPP)granteesto thehealthyhomesapproach. Additionally,CDCwill pursue activities related to healthy homes including surveillance to track housinghazardsandrelatedhealthoutcomes,andresearchonhealthyhomesinterventions.Theagencywill leverage its existingprogramsinenvironmental health, injuryprevention, andasthmatodirectlyinformitsnewhealthyhomespriorities. AsCDCexpandsitshealthyhomesefforts,itwillbecriticalforHUDandCDCtocoordinateresearchandprogramagendas.

DOEprogramssupportimprovingtheenergyefficiencyofhomesaswellasotherperformancecharacteristics.TheWeatherizationAssistanceProgramaimsatreducingtheburdenofenergypricesonlow‐incomefamiliesbyincreasingahome’s energy efficiency. As a part of thisprocess, weatherizationwork crewsconductan all‐around safety check in which theyidentifyhazards, including carbonmonoxideleaks andmold. In recent years, DOE hasexpanded i ts program to al lowweatherizationcrewstonotonlyidentifybutmitigate these hazards as well. SeveralHealthy Homes Demonstration programgrantees have teamed with weatherizationprograms in the implementation of theirgrants; thiscoordinationprovidessignificantbenefits to the recipients of the combinedinterventions.

HUD recognizes that improved collaboration among federal and non‐federal partners wouldhelp to optimize valuable timeandresources andachievemoremeaningful andwidespreadresultsinthehealthyhomesarena. Asafirststep, inFebruary2009,HUDhostedameetingoffederal agencies thatare involvedinhealthyhomes‐relatedactivities, includingCDC, DOE, theU.S. Environmental ProtectionAgency (EPA), theNational Institutesof EnvironmentalHealthSciences (NIEHS), the National Institute of Standards and Technology (NIST), and the U.S.DepartmentofAgriculture. Inthefirstmeeting, theagenciesdescribedtheirprogramsrelatedto healthy homes, identified common interests, and initiated a process to increase federalplanningefficiencyonhealthyhomes issues. Thegroupdevelopedseveral subcommittees for

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special issues, andwill meet regularlytodevelopastrategic agendafor allagencies, improveprogrammaticcollaboration,andreduceduplicationofeffort.

TheEconomicLandscape

TheaffordablehousingcrisisintheU.S.addstothecomplexityof creating healthy homes. It is estimated that in the U.S.today, 12million households paymore than50%of theirannualincomesforhousing. Further,afamilywithonefull‐time worker earning the minimumwage cannot afford localfair‐market rent for a two‐bedroom apartment anywhere intheU.S. (U.S. Dept. ofHUD,2008a). For low‐incomefamilies,thelackofaffordablehousingmayforcethemintosubstandardhomes,wheretheyaremore likelyto live inpoorlymaintainedhomeswith health hazards. The high cost of housingmay also prevent them frommeetingotherbasicneeds,suchasnutritionandhealthcare. AttheheartofHUD’smissionisthegoaltoexpandthesupplyofaffordablehousingtolow‐incomefamilies. ThisprovidesanopportunityfortheOHHLHCto coordinatewithHUD’smajorprogramofficestoencouragetheadoptionofhealthyhomesprinciplesintohousingmanagement,construction,andrehabilitation.

CurrentTrendsAmongHousingPrograms/Professionals

Housing professionals include those who work in public sector federal and local housingprograms,aswellasprivatesectorpersonnelsuchaspropertyownersandthosewhowork inhousing rehabilitation, construction and maintenance. Other relevant professionals includepublic health nurses, social service providers, energy auditors, architects, inspectors, pestmanagement professionals, weatherization experts, and others who visit homes to provideservices or perform other work. Several current movements among housing and relatedprofessionals present theopportunity to incorporateaspects of thehealthy homes approachintoongoingpracticesandprograms.

1) IntegratedPest Management (IPM)–There is increasing recognitionthat traditional pestcontrol practices, especially the broadcast application of pesticides, canbe hazardous toresidents and ineffective for sustained pest control. There is evidence that IPM is moreeffectivethantraditionalpracticesat similarorreduced(long‐term)costs. IPMminimizesthe use of toxic pesticides and instead emphasizes environmental controls such aseliminationofharboragesandremovalofaccess tofoodandwater. BroadadoptionofIPMprinciples by public housing agencies andother property owners andmanagers has thepotential to improve the health of residents by reducing exposure to pests, pest‐relatedallergens,andpesticides.

2) Energy Conservation, Green Building, and Health – The housing sector accounts forapproximately one‐fifth of all energy consumption in the U.S. As energy costs haveincreased, HUD has taken aggressive steps to promote energy efficiency in homes. TheDepartment’sEnergy Task Force, consistingofrepresentatives from HUDprogram officesandRegionalEnergyCoordinators,developedandareimplementinganEnergyActionPlan.The OHHLHC regularly participates in Energy Task Force activities, as this is a key

Withoutanadequatesupplyofaffordablehomes,healthyhomescannotbeachieved.

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opportunityto incorporatehealthyhousingprinciples. Ashomesbecomemoreairtight inanefforttoconserveenergy,properventilationbecomesincreasinglyimportant. TheOfficewill work to promote attention to the need of ensuring adequate indoor air quality inconjunctionwithresidentialenergyconservation.

As apart oftheeffortto reduceournation’senergyconsumption, thelargerconceptofgreenbuilding has also gainedmomentum. Althoughthere isno universallyaccepteddefinitionof“greenbuilding,”theEPAdescribesitgenerallyas“thepracticeofcreatingandusinghealthierandmore resource‐efficient models of construction, renovation, operation, maintenance anddemolition”(U.S.EPA,2008c). Traditionally, thefocusofgreenconstructionprogramshasbeenonmaximizingenergyandwaterefficiency, selectingenvironmentallypreferableproductsandmaterials, and minimizing the effects of development on the outdoor environment. Manyproponentsoftheconcepthavealsoemphasizedthepotentialofgreenconstructiontoimproveindoorenvironmentalquality(IEQ)withthepotential forresultingbenefitstooccupanthealth.The momentum of the green building effort is a strategic opportunity for the OHHLHC tounderscore that IEQ and occupant health is as important as a reduction in environmentalimpact.

To betterunderstandthepotential forgreenhousingto improveoccupanthealth, inFY2009,theOfficeisintroducinganewNoticeofFundingAvailability(NOFA)tosupportresearchonthepotential environmental and health benefits of green building methods. TheOffice is alsocoordinating with CDC andHUD’s Office of Affordable Housing Preservation on research toassess thepotential environmental andhealthbenefitsoflow incomehousingunitsthathaveundergonegreenrehabilitation.

CriticalPublicHealthNeeds

ItisimportanttoacknowledgeemergingpublichealthneedsandtheirrelationshiptotheworkoftheOHHLHC.

1) Smoke‐FreeHousing–Asthedangersofexposuretosecondhandsmokeandthebenefitsofsmoke‐freeenvironments have becomebetterunderstood, so has the demandfor smoke‐free housing. As ofNovember 2008, over 100 local Housing Authorities nationwide hadadoptedsmoke‐freepoliciesforsomeoralloftheirapartmentbuildings,27ofwhichwereadoptedsinceJanuary2008(TCSG,2008). LettersfrommultipleHUDfieldoffices,includingonefromtheChiefCounselinHUD’sDetroitfieldoffice,havestatedthathousingauthoritiesandHUD‐subsidized ownersmay adopt smoke‐free “house rules”without approval fromHUD.HUDanditsfederalpartnershavetheopportunitytofacilitatetheadoptionofsmoke‐freehousinginthe immediatefuture. TheOHHLHCwill continueto support theseeffortswithin assisted housing by collaborating with the program offices to encourage furtheradoptionofsmokefreepolicies.

2) Unintentional Injuries – Preventing unintentional injuries has been part of the HealthyHomes program’smission since thebeginning. TheOHHLHC is amemberof thePublic/Private Fire Safety Council (FireSafety.gov), and has sponsored research, demonstrationprojects, and outreach efforts focusing on reducing unintentional residential injuries,

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especially forchildren. Recognizingthemajorhealthtollandeconomic burden posedby unintentional injuries, there is acontinuedneedtoaddressthecost‐effectiveidentificationandcontrolofresidentialinjuryhazards,especiallyintheelderly.Notingthestatisticsregardingtheincreasedpopulationthatisaginginplace(intheirhomes), partnerships inthisareawillbecritical.

3) Natural Disasters – Recent natural disasters, includingHurricaneKatrina,wildfires inCalifornia, andfloodingintheMidwest, havedemonstratedtheconnectionbetweenhomes,health, andextremeweatherevents. Disasterssuchas thesecancontaminatewatersupplies andcausedamage to homesthat could result in occupant illness or injury (e.g., waterdamage resulting in extensive growth of mold and otherbiological agents). In light of this, OHHLHC has begun todevelop educational material for home owners and othersinvolvedin the rehabilitationof homes inanareaaffectedby anextremeweather event.Thusfar,guidancedocumentshaveaddressedproperproceduresforhurricaneandfloodingcleanupand rebuilding. In preparationfor future events, OHHLHCwill continue toworkwith federal and state partners and HUD program offices to develop outreach andeducational materials which address additional natural disaster‐related hazards and toexpanddistributionofthesematerialstovictims. OHHLHC is also interested inpromotinghousingdesign thatminimizes potential healthhazards commonly resulting fromnaturaldisasters.

ExpandingtheFocusofLeadHazardControlPrograms

HUDLeadHazardControlgranteeswereamongthefirsttoobservethathomeswithlead‐basedpaint hazards often had other important health hazards that could be addressed in a cost‐effectivemanner. Indeed,somecommonleadhazardcontrolinterventions, suchaspreventingwater intrusion andreducing dust loadingwould also likely reduce levels ofcertain asthmatriggersindustandair(e.g.,mold,dustmites).Asthecomprehensivehealthyhomesapproachgainsmomentumandchildhoodleadpoisoningiseliminatedasamajorchildhooddisease,leadhazardcontrolgranteeswillcontinuetoplayaninvaluableroleinthehealthyhomesmovementbyexpandingtheirfocustoaddressotherresidentialhealthhazards.TheOHHLHCwillworktohighlight best practices andencourage adoption by otherprograms andcontinue to exploregreater flexibility intheuseof LeadHazardControl funds, whichare currently restricted bystatuteforuseinaddressingleadpainthazardsonly.

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IV.HealthyHomesProgramFutureDirections

Duringthestrategicplanningprocess,OHHLHCstaffbroadlyexaminedhealthyhomes trends,reflected on the Office’s accomplishments andmissionwithin HUD to date, and consideredresponsestoasetofpotential focusareas. ThisresultedinatargetedHealthyHomesStrategicPlan that is current, but also incorporates the OHHLHC’s continued commitment to ensuringthatchildhoodleadpoisoningiseliminatedasamajorchildhooddiseaseby2010. After2010,theOHHLHCwillcontinuetoprovidefundingandservicesforthosecommunitiesthatstillhaveasignificantamountofhighriskhousing.

ThePlanningProcess

Todevelopthisplan, theOHHLHCdraftedalistofrevisedfocusareas(seeAppendixC: “FocusAreasofInitialStrategicPlanning”),andsolicitedfeedbackfromselectedinternalOHHLHCstaffandexternalpartners. Amongthefederalpartners,non‐profitpartners,andOHHLHCstaffwhoprovidedfeedback,thesevenhighestpriorityfocusareaswere1:

o Develop standard, evidence‐based healthy homes assessment tools and interventionprotocols;

o Support the development of objective standards for what is considered a “healthy”residentialenvironment;

o IncreasecollaborationinternallyatHUDandwithotherfederalhousingprograms;o Improveoveralldisseminationofhealthyhomesinformation, includingbestpractices,to

partners,grantees,andthepublic;o Conductcost‐benefitanalysesontheeffectivenessofahealthyhomesapproachthrough

theanalysisofhealthandfinancialoutcomes;o Promote the inclusion of health considerations into green and energy efficient

construction;ando Increasetheemphasisonidentifyingkeyresearchquestionsandsupportinglarger,more

definitivestudies.

While most respondents were enthusiastic about the breadth of topics covered under thepotential focus areas, a few points weremade about additional focus areas to consider. Ofparticularnotewererecommendationsabouttrainingopportunitiesandbuildinglocalcapacity,enforcement and regulatory options (e.g., housing andbuilding codes), collecting healthandhousing data, and ensuring that lead hazard control is not neglected as the healthy homesapproachmoves forward. Theseelementswereincorporatedinto thespecific long termandshort term goals, and supported the development of the Healthy Homes Office’s Vision andMission:

✦ HealthyHomesVision

To lead the nation to a futurewhere homes are both affordable and designed, constructed,rehabilitated,andmaintainedinamannerthatsupportsthehealthandsafetyofoccupants.

1Highestpriorityfocusareasaredefinedasthosethatwerelistedaseitherfirstorsecondprioritybyatleasthalfofallrespondents.

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✦ HealthyHomesMission

Toreducehealthandsafetyhazardsinhousing inacomprehensiveandcost­effectivemanner,withaparticularfocusonprotectingthehealthofchildrenandothersensitivepopulationsinlow­incomehouseholds.

HealthyHomesGoalsandStrategies

Toaccomplishthismission,theOHHLHCidentifiedthefollowingkeygoals:

1) Building a National Framework: Foster partnerships for implementing a healthyhomesagenda.

2) CreatingHealthyHousingthroughKeyResearch:Supportstrategic, focusedresearchonlinksbetweenhousingandhealthandcost‐effectivemethodstoaddresshazards.

3) Mainstreaming theHealthyHomesApproach:Promote theincorporation of healthy homes principles into ongoingpracticesandprograms.

4) Enabling Communities to Create and SustainHealthy Homes: Build sustainable local healthyhomesprograms.

The following is a description of the goals as well asshort‐ and long‐term strategies to achieve them.Milestones and outcome measures to track progress inachievingeachgoalarealsoidentified.

Goal 1: Foster partnerships for implementing a healthy homes agenda (Building aNationalFramework).

TheOHHLHC’sHealthyHomesprogramhasastrongtrack recordofworkingwithotherHUDprogram offices andfederal partners to accomplishresults, andvalues theuniqueresources,expertise, andperspective that eachpartnerbrings to the table. Becauseofthemulti‐facetednatureof thehealthyhomes concept, HUDmust createandsustainboth formaland informalcollaborationswithitsfederalpartnerstohelpensurethattheprogram’smissionisachievedasefficiently as possible. Through interagency agreements, HUD can leverage professionalexpertise in areas such as epidemiology and health education at CDC, and tap into existingnetworks such as USDA’s Cooperative State Research, Education, and Extension Service(CSREES).

It is also important to developandmaintain less formal relationships withfederal programsthatareactiveinareasthatcaninfluenceprogresstowardthehealthyhomesgoal.Forexample,

Actionsgovernmentcantakeinclude…work(ing)togetheracrossagenciesand

sectorstoprovideguidanceandtechnicalassistancetosupportsafe,healthy,andenvironmentallyfriendly

housingoptions.

TheSurgeonGeneral

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anongoingsystemofcoordinationwouldhelp facilitateandsolidifyroutes ofcommunicationbetweentheOHHLHCanditsfederalpartners.Suchasystemwouldhelpinnecessaryeffortstounderstandprogramrolesandresponsibilities,identifyknowledgegapsandresearchpriorities,andshareeffectivehealthyhomespractices. Collaborationwithprivatesectorentitiesinvolvedinhousingandhealth, includingnon‐profit organizations andindustry, will also be critical tocoordinatingandimplementinganationalhealthyhomesagenda.

ShortTermStrategies

o DevelopNewFederalPartnerships:Identifyprogramgoalsthatcanbebestaccomplishedthrough the formation of formal partnerships with federal partners anddevelopnewpartnerships, as needed. The OHHLHC will continue to work with current federalpartners, includingCDC,EPA,andUSDA,butmayalsopursuenewpartnershipswiththeDepartment of Energy, organizations within the Department of Health and HumanServices, and the Federal Emergency Management Agency. Potential topic areas forcollaboration include, but are not limited to: research on the relationship betweenventilation and indoor air quality, incorporating healthy homes concepts intoweatherization and energy assistance programs, cost‐effective injury preventionstrategiesforchildrenandseniors,andstrategiesforworkforcetraining.

o Create a Mechanism for Coordinating Federal Healthy Homes Activities: This couldinclude,forexample,regular(e.g.,quarterly)meetingsofacoordinatingcommitteewithin‐personmeetingsasneeded.Representativesfromstateandlocalgovernmentsaswellas private organizations could be invited to participate in meetings to inform thecommitteeoneffectivestrategies,opportunitiesforcollaboration,etc.

o IdentifyandDevelop KeyPrivate SectorPartnerships: Reaching out to relevant privatesectorentities, includingbothnon‐profitorganizationsandindustry, iskeyto achievingthe healthy homes mission. Key partners include builders, renovators, insurers,appraisers, financial institutions, multifamilypropertyowners, andhealthandhousingadvocacygroups.

LongTermStrategies

o ServeasaConvenerofNational,State,andLocalPartners:Supportcollaborationandthedisseminationofinformationwithinthehealthyhomescommunitybybringingtogetherpolicy‐makers,practitioners,andthepublic. ANationalHealthyHomesConferencewillbeorganizedandheldonaregularbasis(e.g.,onceevery2‐3years).Ateachconference,thefocusareaswouldchangetoreflecttheevolutionofthehealthyhomesconceptandto address timely issues. At the first conference, held in 2008, planners convenedabroadcommunityofexperts, andincludedbothpublic andprivatestakeholders intheplanningandimplementation.

o SponsorWorkshopsonSpecificHealthy­HomesIssues:Workshopswouldfocusonspecifichealthyhousingtopics suchasparticular scientificor policy issues (e.g., dust samplingandpreparationforallergens,modificationofhousingcodes,andadoptionofsmoke‐freehousing)or the discussionof the most effective outreach strategies. The goal of the

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workshopswouldbeto advancethehealthyhomesconceptinspecificareasbyhelpingto identify best practices, identify key knowledge gaps, and foster mainstreaming ofhealthyhomesintohousingpolicyandpracticewithinHUDandthroughoutthenation’shousingconstruction,rehabilitation,andmanagementprograms.

o ExpandOutreach totheMainstreamHousingIndustry:Identifyandpursueopportunitiesto form partnerships withmainstream housing and construction entities in order toexpandthebaseofpractitioners.

o Federal Policy Agenda: Coordinate the development of a cohesive federal policy thatreflectsthemissionsandstatutoryauthoritiesoftheparticipatingagenciesandprovidesthebasisforagenciestodevelopandimplementprogram,policyandregulatorychanges,andidentifypotentiallegislativeimprovementsforconsiderationbyCongress.

MilestonesandOutcomeMeasures

Milestone1.Establishaninteragencyworkinggrouptocoordinatehealthyhomesactivities.

Outcomes:a)thedevelopmentofworkinggroupgoalsandobjectives;b)participationofpartners in regular meetings; c) establishment of new areas of coordination amongfederal and non‐federal partners; and d) demonstrated progress towards meetingestablishedworkgroupgoals

Milestone2.Creationofnewfederalpartnerships.

Outcomes:a)thecreationofnewformalfederalpartnershipsthroughtheestablishmentofinteragencyagreements; andb)thecreationofnew informalfederalpartnershipsasevidencedbytheregularexchangeofinformationonhealthyhomesissues.

Milestone3.Createnewprivatesectorpartnerships.

Outcomes: a)thecreationofnewformalprivatesectorpartnershipsthroughgrantsandcontracts;andb)creationofnewinformalprivatesector partnerships as evidencedbytheregularexchangeofinformationonhealthyhomesissues.

Milestone4.Planandimplementregularnationalhealthyhomesconferencesandtopic‐specificworkshops.

Outcomes:a)nationalconferencesheldat2‐3yearintervalswithsuccessdeterminedbythenumberofpublic andprivatesector partners involvedinplanning andconferenceimplementation, the number of attendees, and feedback from attendees; and b) theorganizing and holdingof topic specific workshops on key healthy homes issues withsuccessbasedonfeedbackfromattendees.

Goal 2: Support strategic, focused research on linksbetween housing and health andcost­effective methods to prevent and address hazards (Creating Healthy HousingthroughKeyResearch).

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The OHHLHC’s Healthy Homes program has supported research through the funding ofTechnical StudiesandDemonstrationprogramgrants, contracts, and interagency agreements.Whilemostprojects have beenfundedatmodest levels (e.g., $400,000 ‐ $900,000), themostsignificantfindingshavebeenproducedbylarger,morecostlystudies, suchasthecollectionofallergendatafromanationallyrepresentativesampleofhomesthroughtheNationalSurveyofLeadandAllergensinHousing(NSLAH)(cooperativeresearchwiththeNIEHS),andaClevelandstudy that assessed the impact of mold/moisture interventions in the homes of asthmaticchildren. Another importanttool for settingtheresearchagenda is thereport from theCDC‐NCHH Healthy Homes expert panel reviews, released in January (NCHH, 2009). Movingforward, theHealthyHomesprogramwill coordinatearesearchagendawithkey partners toproducedefinitiveandnovelresearchintwokeyareas:

Developing cost­effective methods and protocols – Healthy homes experts agree that whileconsensus is building on effective protocols to assess,prevent, and control housing‐relatedhealth andsafety hazards, knowledge gaps persist.Evidence‐based,practical,andwidelyaccessiblemethods are needed to both identify hazards andconduct follow‐up interventions. This ischallengingbecause of the wide range of both hazards andhousingtypesthatareencountered. Furthermore, itis important to support the development ofinterventions and preventative practices that targetthe highest priority hazards and are cost‐effective. Assessment tools must be reliable (i.e.,results are reproducibleamongdifferent users), easily administered, andbasedonvalidatedmethods thataccurately identify hazards. Interventionprotocols shouldhavethe backingofresearchthatdemonstratestheireffectiveness ineliminatingorreducinghazardousconditionswithresultingimprovementsinhealthoutcomes(e.g., reducedincidenceofaparticularinjury,improvedasthma control) ordecreases in the risk of illness or injury. Cost‐benefit analysesshouldbe conductedinorder to identify themorecost‐effective interventionsandclarify netcosts.

Linkinghousingandhealth–Whilemuchisalreadyknown,moreresearchisneededinordertoimprove our understanding of residential exposures and conditions. The Healthy Homesprogramwillcontinuetopursueresearchonlinksbetweenhousingandhealthincooperationwithfederalpartnerswithhealthexpertise,suchasCDCandNIEHS.

ShortTermStrategies

DevelopingMethodsandProtocols

o Complete researchon protocols for processing dust for allergen analysis and developandfacilitatetheadoptionofastandardprotocol.

o Conductinitialplanningforapotentialmulti‐siteasthmainterventionstudy.

Governmentagencies,otherresearchorganizations,andscientistsshoulddevelopandsupportaportfolioofrigoroushealthyhomesresearch.

TheSurgeonGeneral

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o Conduct periodic literature reviews for healthy homes issueareas, including availableevidenceabouttheeffectivenessofresidentialinterventions.

LinkingHousingandHealth

o AnalyzedatafromNationalSurveyofLeadandAllergensinHousingandtheAmericanHealthyHomesStudyto identifyrisk factorsthatpredictmultiplehazards(e.g. elevatedallergenburdenandlead‐basedpaint hazards). Resultswouldbeexpectedto improvetargetingandhomeassessmenttools.

o Conduct research to characterize the potential indoor air quality benefits of greenconstruction compared to traditionally built units. Examples include continuedcollaborationwithHUD’sOfficesofAffordableHousingPreservation(OAHP)andPolicyDevelopment and Research (PD&R), and CDC to document the effects of greenrehabilitationeffortsonindoorairqualityandhealth.

LongTermStrategies

DevelopingMethodsandProtocols

o Conduct a multi‐site study of asthma interventions focusing on multifacetedinterventionsthatincludemold/moisturecontrolindifferentclimaticregionsoftheU.S.(followuptoClevelandasthmastudy).

o Support research to improve knowledge regarding the health outcomes of IPMinterventions, particularly in urban multifamily housing. Also support research toimprovemethodsforpreventingandcombatingbedbuginfestations.

o Assess effectiveness of healthy housing professional training and public outreach/education efforts (e.g., knowledge of healthy housing principles, behavior change byhealthandhousingprofessionals,homeowners,andtenants).

o Conduct research to refine a comprehensive healthy housing assessment tool thatminimizestheburdentotheuserandmaximizesthepredictivepowerofthetool.

o Conduct researchon the efficacy of residential interventions to prevent unintentionalinjuries.

o Conduct cost‐benefit analyses to assess the effectiveness of standard healthy homesassessment and intervention protocols and possibly more specialized protocols (e.g.,mold/moisture intervention focus, and analysis of IPM vs. traditional pest controlmethods). Such analyses will help to identify the most cost‐effective protocols andsupporttheneedtowidelyimplementthesemeasures.

o Improve understanding of the relationship betweenresidential indoorair quality andventilationcharacteristicsofhomes.

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o Support research necessary to clarify and strengthen existing evidence for specificchangestothebuildingorpropertymaintenancecodes.

o Support thedevelopmentandadoptionofa coreset ofobjectivemeasures forwhat isconsidered a healthy residential environment that can be used to influence housingprofessionals and policy makers as well as self‐protective actions by homebuyers,owners,andtenants.

LinkingHousingandHealth

o Support research on the potential health benefits ofgreen constructionand rehabilitation(e.g., useof lowemission materials), and on green constructionincorporating additional healthy housing factors (e.g.,improved ventilation, smooth and cleanable floorsurfaces) (Note: a recent Healthy HomesDemonstration grant in Seattle showed significantimprovements in children’s asthma symptoms innewly‐builtunits).

o Work with federal partners to develop a nationalsurveillance system to track residential hazards andrelatedhealthoutcomes.

MilestonesandOutcomeMeasures

Milestone1. Completethedevelopmentoftoolstofacilitatetheadoptionofstandardized

healthyhomesassessmentmethods.

Outcomes: a) development of a core set of validated home assessment measures; b)development of a set of evidence‐basedhealthy homes interventionprotocols; and c)creationofstandardizedproceduresfordustsamplinganddustpreparationforallergenanalyses.

Milestone2.Createaregularlyupdatedhealthyhousingresearchagenda,informedbypublicandprivatepartners.

Milestone3.Initiateandcompleteresearchonkeyhealthyhomestopics.

Outcomes: a) complete a multi‐site study to assess the benefits of mold/moisture‐focusedinterventionsonasthmatic childrenina varietyofclimatic zones;b)completeresearchontheenvironmentalandhealthbenefitsofgreenconstruction(rehabandnewconstruction);andc)completeresearchontherelationshipbetweenventilationandIAQinenergyefficienthomes.

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Milestone4.Initiateandcompletecost‐benefitresearchonhealthyhomesinterventions.

Outcomes: a)complete cost‐benefit researchon astandardpackageof healthyhomesinterventions; andb) completecost‐benefit researchonspecific HH interventions andmeasures (e.g., IPM, smoke‐free housing, green construction), includingtheirusewithspecificpopulations(e.g.,asthmaticchildren).

Goal3:Promotetheincorporationofhealthyhomesprinciplesthroughongoingpracticesandprograms(MainstreamingtheHealthyHomesApproach).

Reducing housing‐relatedhealth and safety hazards in the maximum number of U.S. homesultimately depends on the extent to which healthy homes principles can be successfullyincorporatedinto ongoingpublicandprivatesectorhousingpractices,programs, anddeliverysystems. Over the short term, collaboration with public sector housing professionals andprograms will be critical. Target housing audiences can be reached by the Healthy Homesprogram’s promotion of: 1) cost‐effective aspects of healthy homes assessments andinterventions; 2) the incorporation of healthy homes principles into related housing andenvironmentalmovements;and3)promotingtheuseofhealthyhomesprinciplesinissueareaswherethereisacriticalpublichealthneed. Overthelongterm,asthehealthyhomesapproachisproventobecost‐effectiveandmethodsarevalidated, itwillbenecessary tocontinueworkwith federal and state housing programs, support health‐protective codes and enforcementstrategies,andsecureprivatesectorinput.

ShortTermStrategies

Promote theIncorporationofHealthyHomesPrinciplesintoNationalandLocalPlanningEffortsandCurrentHousingTrends

o IntegratedPestManagement:ContinuecooperativeworkwithinHUD’sOfficeofHousingandPIH, USDA, andEPA, to encouragethe adoptionof IPMbypublic housingagencies(and other low‐income housing providers including owners of subsidized housing)throughatrainingprogramthatreachesmanagement,staff,andresidentsofmultifamilyhousingthroughout thecountry. Work towardexpandingeffortto otherHUDprogramoffices, suchas theOfficeofNative American Programs, and reachout to local healthdepartmentstoencouragetheir involvementinconductingoutreachandpromotingtheuseofIPMintheircommunities.

o Incorporating Healthy Housing Principles in HUD­Supported Rehabilitation Programs:Identify key healthy housing components that can be incorporated into the rehab ofaffordable housing and work with HUD program offices to identify opportunities topromotetheinclusionofthesecomponentsbylocalprograms.

o EnergyConservation:Withenergyconservationattheforefrontofnationalattention,andtheOHHLHC’scommitment totheHUDEnergyTaskForce,theHealthyHomesprogramwill encourage an integrated approach to home interventions by facilitating the

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incorporation of healthy homes assessments and interventions into weatherizationprograms. The OHHLHC will support the development and field testing of acomputerizedhealthyhomesassessmentmoduleforusebyweatherizationprogramstoexpand the identification and control of additional health and safety hazards andimproveindoorairqualitymodeling.

o Green Building: Green housing must include elements that improve indoorenvironmental quality and the health of residents. Through a new Sustainable andHealthy Housing Initiative, the OHHLHC will actively promote the inclusion of healthconsiderations into green housing construction, rehabilitation, and maintenance andsponsorresearchtoassessresultinghealthandenvironmentalbenefits.

Promote the Use of HealthyHomes Principles in Issue AreasWhere There is a Critical PublicHealthNeed

o Smoke­Free Housing: As smoke‐free housing policiesgainmomentum among public housingagencies andinlocaljurisdictions,theHealthyHomesprogramwillworkwithHUDprogramofficestoencouragesmoke‐freehousinginpublicandassistedhousing,includingtribes and tribally‐designated housing entities, andrelevant federal partners likeCDCandEPAonpublichealth messaging related to eliminatingenvironmentaltobaccosmokeexposure.

o Unintentional Injury Prevention: The OHHLHC willinitiatecollaborationwithHUDprogramoffices thatcoordinatesupportivehousingfortheelderly(Section202 of the Housing Act of 1959) and the disabled(Section811oftheNationalAffordableHousingActof1990), as well as with key federal partners like theCDC.

o Radon Risk Reduction: The Office will initiatecollaborationwithHUDprogramofficesthat overseehousingassistanceandmortgageprograms, and with EPA coordination, promote testing for radon and sub‐slabdepressurizationsystemsinpropertieswithhighlevelsofradon.

LongTermStrategies

o Continue to Facilitate the Adoption ofHealthyHomesPractices byExisting Housing andMortgage Programs: The Healthy Homes program will continue to work with HUDprogramofficesthatadministerHUD‐assistedhousinginanefforttoincorporatehealthyhomes practices. Practices to emphasize will include: adoption of IPM practices;creationofsmoke‐freehousingdevelopments; adoption ofspecifications for “moisture

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resistance” by publicly funded housing rehabilitation programs; and radon riskreductionwhereradonlevelsarehigh.

o Support the Creation andAdoption ofHealth­ProtectiveHousing CodesandEnforcementStrategies:Intheabsenceoffederalregulationsgoverninghealthyhomesissuesbeyondlead‐basedpaint,stateandlocalpolicieswillcontinuetobekeymechanismsforchange.TheHealthyHomes programwillsupport researchnecessarytoclarify andstrengthenexisting evidence for specific changes to the building or propertymaintenance codes,and facilitate the adoptionofeffective health protectivepractices into existing codes.HUD’s continuedmembershipon the International Code Council will provideaprimemedium for OHHLHC staff to review model property maintenance and energyconservation codes, as well as codes for new construction, existing buildings, andresidences,toensurethattheyreflecthealthyhomesprinciples.

o GatherCriticalPrivateSectorInput: Ultimately,privatesectorhousingprofessionalswillneed to feel confident about the healthyhomes approachandits cost effectiveness inorder for it to become fully incorporated into standard building and rehabilitationpractices. The Healthy Homes program will solicit input from private sectorstakeholders in an effort to identify and address their key needs and barriers toadoption.

o QualifiedAllocationPlansandConsolidatedPlans:TheHealthyHomesprogramwillbuildon theexperienceoftheLead‐SafeHousingRuleandprovideevidence‐basedguidanceregarding how state and local housing agencies can optimally factor healthy homesconsiderations into plans for publicly supported rehab, construction, and ongoingmaintenance.

MilestonesandOutcomeMeasures

Milestone1. AmajorityoffederallyassistedmultifamilyhousingprogramshaveadoptedIPMandsmoke‐freehousingpoliciesinatleastsomedevelopments

Outcomes: the number of public housing agencies adopting IPM practices andestablishingsmoke‐freehousingdevelopments.

Milestone2.Theadoptionofbroaderhealthyhomesassessmentsandinterventionsbyweatherizationprograms.

Outcomes: thenumberofweatherizationprograms adopting expandedhealthyhomesassessmentsandinterventions.

Milestone3.Strengtheningofthehealthprotectiveprovisionsofexistinghousingandbuildingcodesanddevelopmentofnewcodes:

Outcomes:a)theadoptionofmodifiedcodes;b)thedevelopment andadoptionofnewcodes;andc)increaseinthenumberofjurisdictionsadoptinghealth‐protectivecodes.

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Milestone4.Anincreaseinthenumberofjurisdictionsadoptinghealthyhomesprovisionsinqualifiedactionplansandconsolidatedplans.

Goal4:Buildsustainablelocalhealthyhomesprograms(EnablingCommunitiestoCreateandSustainHealthyHomes).

TheOHHLHChasprovidedfinancialandtechnicalsupportforlocalprogramsforovertenyears.Inorder fortheseprograms to succeedbeyond thefederal fundingperiod, acombinationofOHHLHC‐provided tools, innovative private sectorpartnerships, and public awareness will beessential. The OHHLHC plans to provide theresourcesandeducationtoolsnecessarytosetlocalcommunities on the path towards creating andsustaining healthy homes. Inthe short term, thisincludes gathering input from local programs,providing continued support for lead and healthyhomes grantees, and initiating broader marketingefforts to engage the public in healthy homesawareness. Over the long term, theOHHLHCwillalso need to pursue privatesector commitment tothehealthyhomesmissionintheformofimplementationsupportandfavorablefinancing.

ShortTermStrategies

o Provide Effective Training to a Variety of Audiences: The National Healthy HomesTraining Center, funded throughtheOHHLHCvia an interagency agreementwithCDC,will continueto train the variety ofhousingandhealthpersonnel who visit homes toprovideservicesorperformotherwork(suchasinspectors,publichealthnurses,energyauditors,andsocialserviceproviders)topromotehealthierhousing.

o Enhance Lead Hazard Control Programs’ Capability to AddressBroader HealthyHomesIssues: The OHHLHC will work to enable grantees to combine funds to addresscategorical hazards (such as lead paint) with otherhousing hazards, andcontinue toseek flexibility inappropriatedfunds.TheOfficepromotescooperationbetweenhealthandhousingagenciestoconductassessmentsandinterventionsforlead‐basedpaint(aswell as other housing‐related hazards) and pursue code enactment/enforcement andeducationalstrategies.TheOHHLHCwillalsoprovidecommunicationchannelsforLeadHazardControlgranteestolearnfromHealthyHomesgrantees’experiences.

o Facilitate Exchange ofBest Practices: Work withlocal programs to better understandsuccesses, challenges, and remaining needs. Compile and disseminate guidance thatidentifies “best practices” in key healthy housing program areas such as participantrecruitment,homeassessment,andinterventionstoeliminatehazards. Developaweb‐

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basedsystemto facilitate theexchangeofinformationbetweengrantees(similartotheformer “Healthy Homes grantee exchange”). Develop and implement a system forsummarizing thekeyfindingsofOffice‐fundedprojects (e.g., creatingandposting finalprojectsummariesandresearchresultsontheweb).

o Support thedevelopment ofanelectronic interactive version of the “Healthy HousingInspectionManual”thatwasdevelopedthroughHUD’sinteragencyagreementwithCDC,obtainfeedbackfromusersofthetool,andrevisetheinstrumentifandasnecessary.

o Enhancement of the OHHLHC Communications and Outreach Program: Activities willcontinue to address lead poisoning and healthy homes issues, through a variety ofchannels involving grantees, stakeholders, and low‐income families. Externalinformationdisseminationwillalsoproactivelyexpandintogrowingaudiencesegments(e.g., seniors) and address emerging trends (e.g., green building). The enhancedcommunications and outreach efforts will incorporate new media and tools foreducation and explore, select and implement innovative resources and outreachtechniques.

o NationalLead andHealthyHomesMarketingPlan: TheOHHLHCwill research, develop,andimplementathree‐yearNationalLeadandHealthyHomesMarketingPlan,whichwillsupportacomprehensivestrategyto link traditionalwithnewoutreachactivities. Thisdocument will be updated annually and will be developed with input from federalpartners and other stakeholders. Components of thePlan will include primary andsecondary research; tailoringmessage andmediato key target audiences; testingandpackagingofmessaging; finding opportunities to leveragecurrent resources; selectingappropriatevehicles fordissemination;tactics(specificcampaigns);andevaluationandrefinement.

LongTermStrategies

o Evaluate and Improve Training: Evaluate the effectiveness of OHHLHC‐sponsoredhealthyhomestrainingandusetheresultstoimproveandstandardizeavailabletraining.

o Expand Training to Build Professional Workforce: Expand training concepts and adaptcurriculum for trade schools, communitycolleges, four‐year universities, andgraduateprograms to increase the professional workforce engaged in designing, creating, andmaintaininghealthyhomes.

o EvaluatetheNationalHealthyHomesMarketingCampaign: Evaluatetheeffectivenessofspecificaspectsofthehealthyhousingmarketingcampaigntoadvanceimprovementandviablealternativestrategies.

o Identify and Pursue Opportunities to Promote Healthy Homes Concepts to Private andPublic Sector Entities: Demonstrating the cost‐effectiveness of the healthy homesapproach should encourage meaningful private and public sector involvement. Forexample, educators (e.g., the American Council for Construction Education, AmericanAssociation of Community Colleges), housing developers, rehabilitation programs,

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builders,financialinstitutions,componentmanufacturers,architects,realtors,andhealthinsurershavecriticalrolestoplayinensuringthathomesarehealthyandsafe.

MilestonesandOutcomeMeasures

Milestone1.Developa“HealthyHomesGuidanceManual”forhealthandhousingprogramslooking to incorporate healthy homes provisions in programs or to improveexistingprograms.

Outcomes:thedocumentiscompletedandupdatedasneeded.

Milestone2.Completionandimplementationofahealthyhousingmarketingplan.

Outcomes:a)anationalmarketingplanisdevelopedwithinputfromHUD’sfederalpartners;andb)anevaluationofeducation/outreacheffortsiscompleted.

Milestone3.Developaweb‐basedcommunicationexchangeforhealthyhomesprofessionals.

Milestone4.HealthyhousingtrainingcentersareestablishedthroughouttheU.S.andaninfrastructure of professionals trained in healthy housing principles has beencreated.

Outcomes:a)healthyhousingtrainingcentersofferingrecognizedcoursesareestablishedthroughouttheU.S.;b)aworkforceoftrainedandcredentialedhealthyhousingprofessionalsisestablishedthroughouttheU.S.;c)theeffectivenessofthetrainingisformallyevaluatedandthetrainingismodifiedbasedonthefindings.

Milestone5.Amajorityofhealthandhousingprogramsinmajormetropolitanareashavedeveloped healthy homes programs or incorporated key healthy homescomponentsintoexistinghomevisitationprograms.

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AppendixA:TheCurrentStateofHealthandHazardsinHousing

TheHealthyHomes programhas evolved to addressmultiplehousinghazards thathave thepotential to impact residents’ lives in a cost‐effective manner. Research has shown, andcontinuesto clarify,therelationshipofhousingconditionsandhowresidents’actionscanleadtopotentialillnessorinjury. Currentresearchhas identifiedarelationshipbetweenthehomeenvironment and the following health conditions: allergies, asthma, unintentional injuries,poisoning,cancer,andheartdisease. Mold,moisture, contaminateddust, andpoorindoorairquality are common housing conditions that pose a hazard to residents’ health. There arecertainhazardsforwhichresearchismoreconclusive. Forexample, therelationshipbetweenleadexposure, leadpoisoning andthe benefitsof leadhazardcontrol iswell understood. Inotherareas, suchastherelationshipbetweenmoldexposureandthedevelopment ofasthma,furtherstudyisneededtodeviseeffectivepreventionandinterventiontechniques.Thissectionis organizedby the health condition, and provides a summary of its impact andcost burden(“HealthandCost Burden”), andtheevidencethat links it tohousing,withthe recommendedintervention(“HomeConnection.”)

AsthmaandAllergies

TheHealthandCost Burden – Asthma and allergies take a heavy toll on quality of life andcontributesignificantly to healthcarecosts. Asthma, which ismore common inpeoplewithknownallergies (i.e., atopic), impacts over20million Americans, creating a financial burdenanddecreasedqualityoflife(CDC,2008d). Asthmaisrecognizedas aleadingcauseofschoolandworkabsences, emergency roomvisits, andhospitalizations. Directhealthcare costs forasthma in the United States total more than $14.7 billion annually; indirect costs (lostproductivity)addanother$5billionforatotalof$19.7billion(Figure 2). Childrenundertheageof 18makeupabout a third, or almost 7million, of thosediagnosedwithasthma (CDC,2008d). This leads to 12.8millionmissed school days andnearly fourmillionchildrenwhohavehadanasthmaattackinthepreviousyear(CDC,2006a). TheCDCestimatesthat, in2005,therewere3,884asthmadeaths(CDC,2008a).

Research indicates that allergies affect over 50 millionAmericans, and a recent nationwidesurvey found thatmore than half of the population tests positive to one or more allergens(Gergenetal.,1987;Arbesetal.,2005). AllergicdiseasecostsAmericans$7.9billionannually,with$4.5billionspentondirectmedicalcare(Stempel,1997).

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Source:NIH,2007

Asthmadisproportionatelyaffectschildrenfromlower‐incomefamiliesandfromspecificracialandethnic groups. In 2005, 13percent of black children were reported to have asthma ascomparedwith9percentofbothHispanicandwhitechildren(Figure3).Whileepidemiologicaldataislimited,TribalHealthOfficialsreportthatasthmaisincreasinginAmericanIndian(AI)/Alaskan Native (AN) children. Asthma rates are also higher in AI/AN children than in thegeneralpopulation,estimatedat13%comparedto8.9%in2008(Brim,2008).Inthereportofthe “Great Plains Asthma Education Conference” in 2006, health officials cited exposure tomainstreamandsidestreamtobaccosmoke,theuseofwood‐burningstoves,ahighincidenceofattacks of respiratory viruses in infants, and co‐morbidity of asthma withobesity as majorfactorsintheprevalence.Whileindoorsmokingandventilationarehousing‐relatedcauses,therelationshipofasthmatotribalhousingconditionsisanareawheremoreresearchisneeded.Whilechildrenarethepopulationmostatriskfordevelopingasthma,thereisagrowingneedtoaddress the onsetof new cases inolder adults, and to examine how their risk factorsmightdifferfromthoseofchildren(Selgradeetal.,2006).

Figure 2: Distribution of Asthma Cost in the U.S. (2007): $19.7 Billion in Total Costs

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Source:CDC,2008d

TheHomeConnection–Bothgeneticandenvironmentalfactorsplayanimportantrole inthedevelopment ofallergies andasthma. Allergens not only triggerasthmasymptoms, they areconsideredto beamajor causeofthediseaseaswell (NIH, 2008). More thanhalfof the20millionAmericansdiagnosedwithasthmaareconsideredtobeallergicasthmatics(Arbesetal.,2007). In thesecases, airborne particles, or allergens, triggerallergic responses that leadtoasthmaattacks. Inadditiontoactingastriggers,researchindicatesthatresidentialexposureatayoungagetosomeallergensandirritantscanleadto thedevelopmentofasthma(Selgradeetal.,2006).Importantresidentialallergensareassociatedwithdustmites,cockroaches,rodents,mold,pollen,andanimaldander,whileimportantnonallergenasthmatriggersincludechemicalresidues in dust, combustion products (e.g., nitrogen dioxide), and environmental tobaccosmoke.

ThepresenceofsignificantlevelsofallergensinhousedustisrelativelycommoninU.S.homes.ResultsfromtheNationalSurveyofLeadandAllergiesinHousing(NSLAH), conductedbyHUDandtheNIEHSin2000,indicatethatapproximately46%ofsurveyedhomeshadelevatedlevelsof at least threeallergens (Salo et al., 2008). Cockroach levelshighenoughto trigger asthmasymptomswerefoundindustfromapproximately10%ofkitchens(Cohnatal.,2005).

Residential exposures to allergen and non‐allergen triggers have been attributed toapproximately 39%ofnew asthmacases inchildren less than6years, and to approximately44%ofnewandexistingasthmacasesinchildren6‐16years(Lanphear,2001a; 2001b). Inastudythatprimarilyinvolvedminoritychildrenfromlowincomehouseholds,69%ofinnercitychildrendiagnosedwithallergicasthmaweresensitivetocockroaches,62%todustmites,50%tomold,and33%torodents(Morganetal., 2004;Gruchallaetal., 2005). Allergens inrodenturinecanalsocontributetoasthmaseverity(Erwinetal.,2003).

Environmental interventions often focus on eliminating allergen sources, such as pests andmold,andcontrollingdust,whichisareservoirforallergens.Suchinterventionshaveprovento

Figure 3: Current Asthma

Prevalence in the U.S. (2006 )

9 6

8

1 3 9 9

0

5

1 0

1 5

Black Hispan i c Whi te Race/Ethnicity

P er c

e nt

To ta l Children

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beeffectiveascomponentsofmultifacetedinterventionsthatalsoincludehealtheducationandoptimizationofmedical care. Commonenvironmentalinterventionsincludetheinstallationofimpervious pillow and mattress covers, use of HEPA vacuums and air filters, specializedcleaning, and IPM (NCHH, 2009). Interventions to reduce non‐allergenic triggers includeeliminating secondhand smoke from the home and ensuring proper ventilation andmaintenanceofheatingsystemsandcookingappliancesthatproducecombustionproducts.

Excessmoisturecanamplify levelsofallergenssuchasdustmitesandmold,andcansupportpestpopulations.Dampindoorenvironmentsarethemselvesassociatedwithincreasedasthmaandotherrespiratorysymptoms(IOM,2004). Excessindoormoisturecanbeduetoinsufficientventilationorwaterintrusion, relatedtobothresidents’lifestylehabits andahome’sphysicalcondition.Itisestimatedthat21percentofasthmacasesintheU.S.arelinkedtodampnessandmold, at an annual cost of $3.5 billion (Mudarri and Fisk, 2007). Mold and moistureintervention work (e.g., dehumidification, elimination of water intrusion, removal of mold,ventilationimprovements)hashadpromisingresults incontrollingasthmasymptoms, butitswidespread implementation still requires additional field testing (Kercsmar et al., 2006). InHUD’sMold and Moisture Problems in Native American Housing on Tribal Lands: A Report toCongress, mold was present in 15% of homes surveyed. Indian housing is likely moresusceptibletomoldandmoistureproblemsduetoincreasedovercrowding,insufficientthermalinsulation, physical deterioration, poor site conditions and depressed socioeconomicconditions.

UnintentionalInjuriesandPoisoning

TheHealthandCostBurden–Injuriescauseemotional,physical,andeconomicstress.Injuriesand deaths from falls, fire, drowning, poisoning, suffocation, and choking all occur in andaroundthehome;theCDCestimatesthatapproximatelyhalfofallinjuriesoccurinandaroundthehome(CDC,2008b). Injuriescanleadtochronicpain,lossofincome, stress, andchangeinlifestyles,impactingtheinjuredandtheirfamilyandfriends.

Unintentional injury is now the leading causeofdeathanddisabilityamongchildrenyoungerthan 15 years of age. A recent HUD‐supported study of deaths among U.S. children andadolescents from1985to 1997foundthatanaverageof2,822unintentionaldeathsoccurredannually from residential injuries (Nagaraja et al., 2005). The highest death rates wereattributabletofires, submersionorsuffocation, andpoisoning. Blackchildrenweretwotimesas likely to die from residential injuries aswerewhite children (Figure 4). Injury inAI/ANchildren is also of special concern. A report from theGreat Lakes Inter‐Tribal EpidemiologyCenter(servingtribesinMinnesota,Wisconsin,andMichigan)indicatedthattheunintentionalinjuryage‐adjustedmortality rateswere70per100,000forAI/AN, vs. approximately40per100,000forallracesinthethree‐stateregionbetween2002and2006.

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Source:Nagarajaetal.,2005

Theelderlyarealso at an elevatedrisk for residential injuries (Figure 5). Unintentional fallrates amongelderlyAmericanshavebeenincreasinginrecentyears. Whiletheexactcauseofthe increase isnot well understood, oneexplanationis that Americans are living longer andchoosing to age inplace in their homes. The fact remains that falls are the leadingcauseofinjurydeathforAmericans65yearsandolder. Eachyear, about35%to40%ofadults65andolderfallatleastonce(CDC,2007b).Itisestimatedthatfallsaccountfor33%ofinjury‐relatedmedicalexpendituresandcostAmericansmorethan$38billionannually(CDC,2004).

Figure 5: Unintentional Fatal Fall Rates among U.S. Men

and Women Aged 65 Years and Older (1994-2003)

Source:CDC,2006c

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Althoughpoisoningisconsideredanunintentionalinjury,thesubstantialhealthhazarditaloneposes warrants further exploration. Household poisoning results in millions of injuries(includingdeath)andbillionsofdollarsspentintheU.S.eachyear.TheAmericanAssociationofPoisonControlCenters(AAPCC)reportedthatin2005nearly2.5millionpeoplewereinvolvedinpoisonexposureincidents(Lai etal., 2006). Inthatsameyear, 828,899injuriesand32,691deathswereattributedtopoisoning;74%ofthesewereunintentional(CDC, 2008e). In2000alone, itisestimatedthatpoisonings ledto $26billioninmedicalexpenses (Finkelsteinetal.,2006). Morethan90%ofall casesofexposureoccurinthehome, andwelloverhalfofthesevictims are children (Lai et al., 2006). Children are at greater risk forhouseholdpoisoning,because they are bothmore likely to be exposed and more susceptible to adverse effects.Common sources of household poisonings include lead, combustion products, pesticides,volatile organic compounds (VOCs), cleaning supplies, automotive products, andpharmaceuticals.

The Home Connection – Unintentional injuries can be prevented by modifying the homeenvironment and educating residents about risks. Some adjustments to the home, such asinstalling smoke alarms, fencing around pools, and water heaters with pre‐set safetemperaturesareeffectiveinjurypreventioninterventions. Othermodifications(e.g.,handrails,grabbars,lightingimprovements,andwindowguards)havealsohadpromisingresultsbutwillrequire more field testing. Implementation of injury prevention‐related safety education,buildingcodes,andcommunitybasedinitiativesalsoneedfurtherresearch(NCHH,2009).

Poisonoussubstancessuchascleaningproducts,pesticides,cosmeticsandmedicationsshouldbe stored high in a locked cabinet, out of the reach of children. Households can also beencouraged to replacetoxic substances (e.g., cleaning products, pesticides)withnon‐toxic orlesstoxicalternatives.

ImportantResidentialContaminants

Lead

TheHealthandCost Burden– Although national blood lead levels have fallen over the lastseveral decades (Figure 6), lead poisoning continues to pose a threat to many children.Reported cases of childhood lead poisoning have declined significantly over the past twodecades; however, the most recently published federal estimate, for 1999‐2002, was that310,000U.S. childrenstill haveelevatedbloodlead levels (i.e., ≥10microgramsperdeciliter)(CDC,2005).

Leadpoisoningmaycausearangeofhealthproblems,including:damagetothebrainandothervital organs, behavioral problems, learningdisabilities, seizures, and in extreme cases, death.Recent research indicates that even relatively low blood lead concentrations inchildrenandadolescentsmaybeassociatedwithdeficits incognitiveandacademic skills (Lanphearetal.,2000;Canfieldetal., 2003). Thus,despiteprogressinthis area, it is clear that leadpoisoningcontinues to be a substantial health risk for young children. Themonetarycosts associatedwithleadpoisoningarealsoquitelarge;a2002studyestimatesthatchildhoodleadpoisoningcostsAmericansapproximately$43.4billionannually(Landigran, etal.2002)primarilyinlostwagesandlifetimeearningpower. Althoughleadpoisoningcanaffectchildrenfromallsocial

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andeconomic levels, those living at or below thepoverty line inolder (especially pre‐1940)housingareat thegreatestrisk. Adisparity also existsamongracialgroups; themost recentpublished estimates show 3%ofblack childrenand2%ofMexican Americanchildrenhaveelevatedbloodlead levels, as compared to only1.3%ofwhite children(Schwembergeretal.,2005).

Source:CDC,2005(frommultipleNationalHealthandNutritionExaminationSurveys)

TheHomeConnection–Alargereservoirofleadremainsinandaroundhousing,butcorrectivemeasureshaveproventobesuccessful. HUD’s2000NSLAHfoundthat, overall, approximately40%ofU.S.housingunitscontainlead‐basedpaint,and25%haveoneormoresignificantlead‐basedpainthazards. Theprevalenceofleadhazardswasstronglyassociatedwithhousingage,with hazards identified in 68% of pre‐1940 housing units compared to 8% of homes builtduring the period from 1960 – 1977 (Jacobs et al., 2002). Further, it was found thatapproximately 1.2 million of these housing units were home to low‐income families withchildrenundertheageofsix(Jacobsetal., 2002). Fortunately,evaluations indicate thatleadhazardcontrol interventions canbeeffective insignificantly reducing leadlevels inthehome.Corrective measures include: paint stabilization, moisture control, treatment of frictionsurfaces, and enclosure and removal of certainbuilding components coatedwith lead paint,cleanup, and “clearance testing,”have beenshowntobeeffectiveinreducingdust‐lead levelsoveranextendedperiod (Galkeet al., 2001;Wilson et al., 2006). However, leadhazards canredevelopifthehomeisnotproperlymaintained.

Figure 6: Decline in Children’s Blood Lead Levels due to Regulation

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MoldandMoisture

TheHealthandCostBurden–Mold(fungi)exposure cancauseor is associatedwithadversehealtheffects inadditiontothoseassociatedwithallergic sensitization(e.g.,asthma, rhinitis).Immune suppressed individuals can be directly infected by exposure to mold. Exposure tomold‐producedtoxins infood(i.e.,mycotoxins)has been longunderstoodto produce illnesssuchaslivercancerfromaflatoxinexposure. Thereissomeindicationthatexposureofinfantsto thetoxin‐producingmoldStachybotrysmayberelated to serous lunginjury (referredtoasacute idiopathic pulmonary hemorrhage); however, the causal relationship has not beenconfirmed(MazurandKim,2006). Exposuretovolatileorganic compoundsthatareproducedby different mold species can also cause irritation of the eyes, nose, and throat as well asheadacheand fatigue. Damp conditions cansupport the growthofmold, bacteria, anddustmites,andresearchhasrevealedassociationsbetweendampconditionsandrespiratoryillnesswithoutidentificationoftheunderlyingcausalagent(s)(IOM,2004).

TheHomeConnection– It is important to mitigate all sources of excessmoisture in homes,includingbothinteriorandexterior sources. Effectivemeasures includeslopingsoil sowaterdrains away from foundations, repairing/redirecting down spouts, promptly fixing leaksthroughthebuildingenvelopeandplumbing leaks, andensuring that thehomehasadequateventilation. Mold cangrow on anyorganic substrate (paper, wood, and textiles) ifmoisturelevelsaresufficientlyhigh. Moldyporousmaterialsthatcannotbecleanedshouldberemovedanddiscardedusingproperprecautions(U.S.EPA,2002a).

Pesticides

TheHealthandCost Burden–Pesticidesareoneof themost commonsubstances associatedwithpoisonexposuresintheU.S. In2005,theAmericanAssociationofPoisonControlCentersreported101,746pesticideexposure incidents, 23ofwhichled to fatalities (Lai et al., 2006).Almosthalfoftheseincidents(49,232)involvedchildrenyoungerthan6years(Laietal.,2006).Exposureto toxicpesticidescanresultinirritationtotheeyes,noseandthroat;damagetothecentral nervous system and kidneys; reproductive disorders; and an increased risk ofdeveloping cancer. In particular, organophosphate (OP) pesticides, which account forapproximately half of all pesticides used in the U.S., can affect the respiratory and nervoussystems(CDC,2005).

TheHomeConnection – Useof toxic pesticides is widespread inAmericanhouseholds. EPAestimatesthatAmericansuseoverfivebillionpoundsofpesticideseachyear,andthat74%ofU.S. households use pesticides in the treatment of rodent and insect infestations (U.S. EPA,2004). Pesticide residues can remain in homes for a considerable time period. A nationalsurvey that was recently conducted by HUD and the U.S. EPA found residues of DDT andchlordane, in41%and64%ofhomes,respectively,eventhoughtheuseofthesepesticideshavenotbeenusedformorethan20years (Stoutetal.,2009). Todiminishtheriskofpoisoning, arecommended alternative approach to rodent and insect control is IPM, which, as discussedearlier,minimizestheuseofpesticides.

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AirborneContaminants

Research has demonstrated that contaminant levels in the indoor environment are oftenconsiderably higher than in outdoor air (Mitchell et al., 2007). Important contaminants inindoor airwith respect to occupant health include carbonmonoxide and other combustionproducts,environmentaltobaccosmoke,radon,andvolatileorganiccompounds.

CarbonMonoxide

The Health and Cost Burden – Exposure to high doses of combustion products can lead tosevereandevenfatalconsequences. Theburningofanyfuel,suchasoil, naturalgas,kerosene,andwood, can release avariety ofcombustion products of healthconcern, including carbonmonoxide(CO), nitrogenoxides(respiratoryirritants),polycyclicaromatichydrocarbons(e.g.,the carcinogen benzo[a]pyrene), and airborne particulate matter (can adversely effectrespiratoryandcardiovascular systems). Eachyear, exposure to COresults inapproximately500deathsand15,000emergencydepartmentvisits(CDC,2007a). Apoisonousgas,COcannotbeseen, smelled, ortasted,andin largedoses itcancauselong‐termneurologicaldisabilities,coma,cardio‐respiratory failure, anddeath. Chronic low‐levelexposurecanalsoposeahealthhazard, causing viral‐like symptoms, suchas fatigue, dizziness, headache, anddisorientation.Fatal andnon‐fatal COpoisoningscanresult fromexposure tomotorvehicleexhaustor fromexposure to consumerproducts in the home. Themiddle‐aged orelderlyaccount for nearly60%ofunintentionalCOfatalitiesinthehome.Riskfactorsforolderadultsincludepre‐existingmedical conditions that affect tolerance to carboxyhemoglobin, alcohol andrecreational druguse,andthetendencytoownolderconsumerproducts (CPSC,2004). Unbornfetusesarealsoat increased risk for CO poisoning, as fetal CO accumulation may differ from the mother’s(Abelsohnetal.,2002;Liuetal.,2003).

TheHomeConnection– Improper venting, poormaintenance, andmisuseofheatingsystemsand cooking appliances can dramatically increase exposure to CO and other combustionproducts.Itisestimatedthat64%ofCO‐relatedemergencyroomvisitsand66%ofCOfatalitiesare attributable to household exposures (CDC, 2007a; CPSC, 2004). Notably, the greatestnumbersofCOdeathsoccur inwintermonthsandafternaturaldisasters,whenresidentsaremore likely to use fuel‐burning furnaces andalternative heating andpower sources indoors,such as portable generators, charcoal briquettes, and propane stoves or grills (CDC, 2007a).Otherpractices thatcanresult increasedlevelsofcombustionproducts includetheuseofgasovensor stoves forheating, theuse ofunventedportableheaters, and idling cars inattachedgarages. Preventative measures include proper installation, use, and maintenance of fuel‐burning appliances, installation of ventilation fans in garages, the use of CO detectors, andincreasedpubliceducationefforts.

EnvironmentalTobaccoSmoke(ETS)

TheHealthandCostBurden–Exposureto ETS, orsecondhandsmoke, cancause respiratoryillness,heartdisease, cancer,aswell asotheradversehealtheffects(HHS,2006). EachyearintheUnited States, secondhand smoke exposure is responsible for 150,000 to– 300,000newcasesofbronchitisandpneumoniainchildrenagedlessthan18months.Exposureofadultstosecondhand smoke has immediate adverse effects on the cardiovascular system and causes

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coronary heart disease and lung cancer. Exposure to ETS kills approximately 46,000 adultnonsmokers fromcoronary heartdiseaseand3,000fromlungcancereachyear (HHS, 2006).Theelderlyinparticularbearadisproportionateburdenofthenegativeeffectsofsmokingandsecondhandsmoke. Everymajorcauseofdeathamongtheelderly–cancer,heartdisease,andstroke – is associated with smoking or secondhand smoke. Overall, it is estimated thatapproximately 50,000 deaths result annually from exposure to secondhand smoke (CA EPA,2006).

TheHomeConnection–Indoorairqualitycanbeimprovedbyremovingenvironmentaltobaccosmokefromthehome. TheSurgeonGeneralhasconcludedthateliminatingsmokinginindoorspaces is theonlywayto fullyprotectnonsmokers fromsecondhandsmokeexposure. It hasbeendemonstrated thateliminating exposure to smoke can result inhealthimprovementsatanyage, includinginthose65andover(TCSG,2001).BecauseETScanmigratebetweenunitsinmultifamilyhousing, it isespeciallyimportantthattheavailabilityofsmoke‐freemultifamilyhousingbeincreased. However,whilenon‐residentialsmokingbanshaveproventobeeffectiveinreducingexposuretoETS,thesameevidencedoesnotyetexistforeffortstosupportsmoke‐freehomepolicies.

Radon

The Health and Cost Burden – Radon is a radioactive, odorless, colorless gas that occursnaturallyintheearth’scrustandcanpercolateuptothesurfaceeitherthroughporoussoilsorwater. Exposureto radongas leads to approximately20,000annual lungcancerdeaths (U.S.EPA, 2008b). Itistheleadingcauseoflungcanceramongnonsmokers (U.S. EPA,2008b),andthe risk is even greater for smokers due to the synergistic effects of radon and smoking.Excessive exposures in the home are typically related to ventilation, structural integrity andgeographiclocation.

TheHome Connection – Radon can enter homes through openings in floors and walls andthroughwater.Homescanbeeasilytestedforradongasusingshorttermtests(2to6days)orlong termtests(>90days). Ifelevatedlevels aredetected, a radonmitigationsystemcanbeinstalledwhichvents radongasfromunder thefoundationof thehomethroughapipeto theoutside. Research indicates that active systems placed in homes in high‐risk areas post‐construction have effectively lowered radon levels. The most cost‐effective approach is toincorporateradonresistanceintonewconstruction. Someinterventionstoremoveradonfromwaterhavehadpromisingresultsaswell.Passivesystems(nooperatingfan),particularlythoseinnewconstruction,arestillinneedofformativeresearch(NCHH,2009).

VolatileOrganicCompounds(VOCs)

TheHealth andCost Burden – Individual VOCs vary greatly in their potential health impact,ranging from compounds that posevery little healthrisk to thosesuchas benzene, whichisclassifiedasaknownhumancarcinogen(U.S.EPA,2009). Informationonhumanhealtheffectsis generally based on research in occupational settings where exposure levels are generallymuchhigherthaninhomes. ExposuretoVOCscanresult ineye,nose, andthroatirritation,aswell as nausea, headaches, and loss of coordination (U.S. EPA, 2007). There is also limitedevidencethatexposuretoVOCscanexacerbateasthma(Mitchell etal.,2007).Formaldehyde, a

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VOCthatiscommonlyfoundinindoorairbecauseofitsuseinconsumerproductsandbuildingmaterials(e.g.,plywoodandothermanufacturedwoodproducts),cancausecancauseirritationto the eyes, nose and throat, at relatively low levels and is classified as a probable humancarcinogenbytheInternationalAgencyforResearchonCancer(IARC,2008).

TheHomeConnection–IndoorairqualitycansufferasaresultofhighindoorconcentrationsofVOCs. VOCscanbefoundinsyntheticpaints,glues,polishes,waxes, carpets,plastics,cabinets,air‐fresheners,andbuildingmaterials commonlyusedinhouseholds. Asaresult, indoorVOCconcentrationstendtobetwotofivetimeshigherthanoutdoorconcentrations(U.S.EPA,2007).The interactions between VOCs and other indoor air contaminants, including combustionproducts,arelikelycomplexandmaycontributetotheproductionofanynumberofsecondarypollutantsincludingparticulatematter(Mitchelletal.,2007). Improperventingandmisuseofproducts containing VOCs can exacerbate this indoor air quality problem (U.S. EPA, 2007).Constructionofdetachedgarages isanimportantwayto lower indoorVOCconcentrations,asmany VOC‐emittingmaterialsarestoredthere, andoverall, the use ofVOC‐emitting productsshouldbelimitedwhenpossible(NCHH,2009). Low‐orno‐VOCemittingalternativesarenowavailableformanyproducts usedinthehome, including: paints, primers, sealants, adhesives,carpets, and flooring materials. These products are often included in green constructionspecifications.

AdditionalHazards

Inadditionto thehealthconditionsdiscussedinthisAppendix,therearemanyotherpotentialresidential health hazards for which the evidence linking illness or injury to the homeenvironmentisnotasclear. Emergingissuesofconcernincludedeficienciesinandaroundthehome, suchas a lack of greenspace, security, or adequatedrinkingwater. Pooroutdoor airquality may have effects in the home as well, as polluted air migrates indoors. Bed buginfestations, once thought to behave been largely eradicated in the U.S., have reemerged inrecentyears,particularlyinurbancenters. Thoughthecurrentevidencedoesnotsuggestthatthey, likeotherpests, carry infectiousdiseasesorhavealinktoallergiesorasthma, theirbitescan be associated with itching and skin infections. Also, bed bug infestations are oftencontrolled using multiple applications of pesticides, which can be costly and present anexposurehazardtoresidents.

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AppendixB:HUDHealthyHomesActivitiesandAccomplishments

Asapioneerofthehealthyhomesconcept, theHUD’sHealthyHomesprogramhascontributedto theunderstanding of housing conditions and their links to residents’ health andeffectiveinterventionsandpreventivemeasures. Great strideshavebeenmade tovalidatethehealthyhomes concept and set the stage to improve the lives of the most vulnerable populations.Progress has been the result of grant programs, interagency agreements, contracts, andcollaborationswithotherHUDoffices. HealthyHomesprogramactivitieshavefocusedonfourcategories:1)supportingresearch;2)interventionimplementation;3)outreachandeducation;and4)creatingtoolsandresources.SinceFY1999,123grantshavebeenawardedforatotalofapproximately $100million.Outreachandeducationpromotes thehealthyhomes concept tothegeneralpublic andeducateshousingprofessionals. Over20,000peoplehavebeentrainedinhealthyhomeconcepts throughgrant activities, andmorethan1.5millionindividualshavebeenreachedbygranteeeducationandoutreach. Toolsandresourcesareprovidedtogranteesand local health andhousing programs to establish local capacity to address homehazards.Research projects are solicited to provide insight into key knowledge gaps on housing andhealth, and interventions are performed to directly improve the quality of life of residents.Reflecting onpast successesallowsustodeterminewhereresourceshavebeeneffectiveandwhat futureactivitieswouldbest compliment current achievements andadvance the fieldofhealthyhousing.

ResearchandEvaluationIt is critical to understand how elements in the home environment impact health and todetermine the best methods to identify and control residential hazards with the greatestefficacyandefficiency. Thereisconsiderableinformationaboutleadhazardcontrolstrategies;however, the bestremediationandhazardcontrol techniques forotherresidential hazards inthehome are not yet as well understood. TheOHHLHC supports a variety ofresearch andevaluationactivitiesonarangeofhealthyhomes issues suchas thedevelopmentof improvedprotocols for mold sampling, developing standardized methods for dust sampling, andevaluatingtheeffectivenessofresidentialinterventionstoimproveasthmacontrol. ResearchisconductedthroughHealthyHomesgrantprograms,contracts,andinteragencyagreementswithkey federal partners. Disseminationofthis valuableresearch is conductedprimarily throughthe publication of articles in peer‐reviewed scientific and professional journals and thepresentationoffindingsatnationalconferences. Todate,OHHLHCgranteesandpartnershavepublishedmore than 30 papers on healthy homes research issues withmore submitted forpublication.

SponsoringInterventionstoMitigateResidentialHazardsInterventionstomitigateresidentialhazardscandirectlyimprovethehealthandqualityoflifeofresidents.TheHealthyHomesDemonstration(HHD)grantshavefacilitatedimprovementsinthousandsofunitsnationwide. Asstatedinthe2008HHDNOFA, thegoalofthegrantprogramis to “Develop and implement demonstration projects that address multiple housing‐relatedproblems affectingthehealthofchildrenandother sensitivesubgroups.” Inrecentyears, theHHDNOFAhasplacedgreateremphasisontherequirementthatgranteesevaluatetheefficacyofinterventions,includingcost‐effectiveness.Interventionstrategiescanrangefromeducation‐focused approaches to those that consist primarily of physical upgrades to new or existinghomes, although most Healthy Homes program‐supported interventions aremultifaceted in

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nature. Todate,morethan7,500interventionshavebeenconductednationwideusinghealthyhomesprinciples.

OutreachandEducationOHHLHCactivitiessupportpubliceducationandoutreach thatfurthers thegoalofprotectingchildrenandothervulnerablepopulationsfromresidentialhazards. Activitieshavefocusedonthreemainobjectives:increasinggeneralawarenessofresidentialhazards,educatingresidentsaboutpreventivemeasures,andreachingouttohousingandhealthprofessionals.TheOHHLHChas supported grants with education and outreach components, funded the creation anddissemination of targeted educational materials, and entered interagency agreements todevelopandprovidetrainingprograms.

ToolsandResourcesTheOHHLHChasdeveloped various tools andresources through its grantees to helpensurethat local healthy homesprograms are successful andsustainable. Issuepapers, assessmenttools, samplingmethods,guidancedocuments,andgeneralpublicationsareavailableto assistgrantees, researchers, residents,andotherhousingandhealthagencies. Theseresourceshelpto establish best practices and disseminate up‐to‐date information in an effort to increaseeffective and efficient identification and control of homehazards – and are available to thepublic (in limited quantities) at no cost. Materials have thus far been developed primarilythroughcontractsandinteragencyagreements.

HighlightsoftheHealthyHomesprogram’saccomplishmentsoverthelastdecade:

ResearchandEvaluation

o ArandomizedcontrolledtrialinCleveland,Ohiodemonstratedsignificant improvementin asthma symptoms (including reduced acute care usage) among children followingremediationfocusingonmoldandmoistureproblems intheir homes (Kercsmaretal.,2006).

o HUDteamedwiththeNIEHSto implementtheNationalSurveyofLeadandAllergensinHousing in 1999/2000. The survey resulted in estimates of the prevalence anddistribution patterns for lead‐based based paint hazards inU.S. housing and the firstnationalestimatesofthedistributionpatternofkeyresidential allergensinthenation’shousing(Jacobsetal.,2002;Arbesetal.,2003;Cohnetal.,2005).

o DevelopmentoftheEnvironmentalRelativeMoldinessIndex(ERMI),whichisbasedonobjective,DNA‐basedanalyses,throughcooperativeresearchbetweenagranteeandanEPAscientist. ContinuedcooperationbetweenHUDandEPAresultedintheanalysisofanationally representativeset ofdustsamples from theAmericanHousing SurveyusingtheERMI(Vesperetal.,2007).

o Contract‐directed research on inter‐laboratory variability in analysis of commonallergensinresidentialdust,whichhasleadtothesponsoringoffollow‐upeffortstohelpstandardizedustpreparationandextractionmethods for allergenanalyses (Pateetal.,

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2005). Grant‐funded researchers are currently testing dust sampling methods in thelaboratoryandfieldwiththegoalofidentifyinganoptimumprotocol.

o Grant‐funded research conducted by Air Quality Sciences in the Atlanta, Georgiametropolitan area documented a low prevalence ofwater indicatormolds in air andsettleddustofhomeswithoutknownmoldandmoistureproblems(Horneretal.,2004).

o Astudydemonstratedthat intensive IPMtreatments anduseofthe“dust leadcleaningprotocol”ledto significantreductions incockroachpopulationsandcockroachallergenloadingsinheavilyinfestedunitsofpubliclyassistedhousing(see:http://www.ehw.org/Asthma/ASTH_HUDRoach_Sum.htm). Additional research in two cities has demon‐stratedtheeffectivenessandfeasibilityofanIPMapproachinpublichousing.

SponsoringInterventionstoMitigateResidentialHazards

o InNewYorkState,theErieCountyHealthDepartmentandpartnersworkedtogethertoprovidecompleteinspections forlow‐incomefamilieswithchildrenmovinginto rentalhousing.PotentialrenterswereidentifiedbytheDepartmentofSocialServicesHousingAssistance program andencouraged to participate in the program. Health inspectorswere then sent to participating locations to identify hazards, and landlords wereinformedofany housingcode violations. Landlordswere also providedwith trainingandmaterials,suchascarbonmonoxideandsmokedetectors.

o InSeattle,Washington, aHealthyHomes grant to non‐profit NeighborhoodHouseandpartners wasusedto upgrade 35newgreen‐built public housingunits (built throughHUD’sHOPEVIprogram)to“BreatheEasyHomes.”Thesehomeshavespecialfeaturestoimproveindoorairqualityandreduceindoorasthmatriggersandotherairpollutants(Takaroetal.,2008).

o InCuyahogaCounty,Ohio, thegrantee(CuyahogaCountyBoardofHealth)ispartneringwith a weatherization program to provide an integrated approach to improve bothenergy efficiency and indoor environmental quality. A strategy involving weatheriz‐ation/healthy homes partneringwas also implemented inWashingtonState thoughagranttonon‐profit,OpportunityCouncil.

o Grant‐fundedprojectsto theBostonPublicHealthCommissionandtheHarvardSchoolofPublicHealthincludedinterventionsinprivateandpublichousing,respectfully,whichhadstrongIPMcomponents. Inbothinstances,evaluationsidentifiedimprovements inthesymptomsofasthmaticchildrenfollowingtheinterventions.

o InNorthCarolina,granteeAdvancedEnergyisstudyingallergensandhealthoutcomesinhomes thathavebeenretrofittedwithanationalhigh‐performance homespecificationpackage that aims to managemoisturewhile improving indoorair quality andenergysavings.

o InMinneapolis andSt.Paul, Minnesota, theCity ofMinneapolis’projectEnvironmentalActionforChildren’sHealth(EACH)involvedworkwithdaycareproviders,localschools,

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hospitals, andmedical home service providers to identify children with asthma andperformhomeinterventionstoreduceseverityofasthmaandimprovemoisture, safety,andventilationconditions.

OutreachandEducation

o Sponsorshipof the2008 NationalHealthyHomesConference: Building aFrameworkforHealthy Housing. Working with federal partners CDC, EPA, and USDA, the OHHLHCgathered a broad community of experts to discuss regulatory, policy, research, andoutreachneedsandtheirimplicationsinthedevelopmentofcomprehensive, integratedapproaches linkinghealthandhousingto ensuresafe, healthyandefficienthomes. Theconference examinedthe lessons learnedfromthenational leadpoisoningpreventionstrategyandthecurrentstateoftheartinordertobeginbuildingtheframeworkneededto develop a national healthy housing agenda. More than 1500 policy‐makers,practitioners,andmembersofthepublicattendedthethree‐dayeventheldinBaltimore.

o SponsorshipofHUD’sHealthyHomesforHealthyKidsCampaign,atravelingexhibitthatdisseminateshealthandsafetymessagesina“homeenvironment.”Theexhibitincludesa Healthy Homes Pavilion and has been displayed at fairs and community eventsthroughout the country. HUD’s Office of Field Policy and Management (FPM) hasprovidedtheOHHLHCwithcritical supportonthiscampaign, contacting localofficials,coordinating participation, offering Public Affairs assistance, and attending programplanningmeetingtoprovidelocalinsight. AUSDAextensionagentalsoconducts“peer‐to‐peer” training to community residents at locations where the pavilion has beenexhibited.

o Development of a National Healthy Homes Training Center and network through aninteragency agreement with the CDC. This training center offers a two‐day course,deliveredthroughanationwidenetwork,onbasichealthyhomesprinciples forhousing,health and other professionals, and is developing specialized pilot courses gearedtowardskeyaudiencesandemergingtrends.

o Reaching an estimated 1.6 million consumers through the USDA’s CSREES, whichpartners with universities and other federal agencies to offer public outreach andeducation. AninteragencyagreementwithUSDAallowedtheOHHLHCtotapinto theirexistingnational infrastructuretoreachthegeneralpublicanddisseminateinformationto healthy homes training programs within the CSREES network. Support is alsoprovided in coordination with both CSREES and the Alabama Cooperative ExtensionSystem through a Healthy Homes Partnership website, which is a listing of healthyhomesresourcesavailablebystate(http://www.healthyhomespartnership.net).

o CoordinationwithPIHtoprovideIPMtrainingforpublichousingauthoritystaffthrougha USDA interagency agreement. In May 2007, PIH distributed aNotice on IPM to allpublichousingagencies,encouragingthemtoexploreIPMimplementationoptions. TheOHHLHCisworkingwithPIHtosupplementthisNoticewithIPMeducationandtrainingforagencystaff.

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o Development of educationalmaterial including DVDs, fact sheets, websites, an onlinenurses training site, and publications for diverse audiences, with the help of variousfederal partners and grantees. Specifically, through an interagency agreement withUSDA, theOHHLHChas supported thedevelopment of the booklet, Help Yourself to aHealthyHome(English,Spanish,Hmong,VietnameseandBosnian)andtheDVDandUserGuideHealthyHomes:AssessingYourIndoorEnvironment(English,Spanish).

o Development and distribution of educational material regarding safe rehabilitationpractices to homeowners andothers involvedintherebuildingofareashitbynaturaldisasters. RebuildHealthyHomes:Safe RehabilitationofHurricane­DamagedHomeswascreatedspecificallyforstudentshelping inthecleanupeffortsafterHurricaneKatrina.Post‐floodingrehabguidancewasalsodevelopedinEnglishandSpanishthroughajointproject withHUD’s Office ofPolicy Development andResearch (PD&R). TheOHHLHCdistributed this guidance to state task forces assembled to address flooding in theMidwest.

ToolsandResources

o A National Healthy Homes Clearinghouse created by the National Center for HealthyHousingwiththesupportofaHUD‐CDCpartnership. TheClearinghouseisafirstcutatacentralized website for information on healthy homes issues and contains over 600articles,includingfederalpublicationsandpeerreviewedjournals.

o AHealthyHousingReferenceManual andtheaccompanyingHealthyHousing InspectionManualdraftedthroughaninteragencyagreementwiththeCDC. TheInspectionManualcoversavarietyofhousing‐relatedhazardsandisintendedtobeavoluntaryassessmenttool, foruse (specific sectionsor in its entirety)by property managers, code officials,environmental, public health, housing, energy conservation, and weatherizationprofessionals.

o Guidance on moisture resistant construction, published in coordination with thePartnershipforAdvancingTechnologyinHousing(PATH)withinPD&R.

o DevelopmentofaninitialWeatherizationPlusHealthassessmenttoolthroughacontractwith ICF International. The tool incorporates health concerns into aweatherizationassessmentandisbeingusedbycurrentaswellasformergrantees.

o DevelopedatooltoassistHealthyHomesTechnicalStudiesandDemonstrationgranteesindevelopingqualityassurance(QA)plansandestablishedadustsamplingprotocolforHealthy Homes grantees to use for collecting dust samples for allergen analyses. Asystemwas also establishedtoprovidegranteeswithquality control dust samples forallergenanalyses.

o Established a protocol for grantees to collect household dust samples for allergenanalyses. Thisenvironmental samplingmethodprotocol,whichcalledforvacuumdustcollection,wasalsotheresultofacontractwithBattelle.

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AppendixC:FocusAreasofInitialStrategicPlanning

Following are the potential concepts and goals, whichwere considered during the planningprocess,tobeincorporatedintoHUD’sHealthyHomesStrategicPlan:

1) Promote the inclusion of health considerations into green and energy efficientconstruction.

2) Increasetheemphasisonidentifyingkeyresearchquestionsandsupportinglarger,moredefinitivestudies.

3) Increasetheemphasisoninjurypreventioninhomeassessmentsandinterventions.

4) Expandtargetpopulation(currentlychildren)to includeotherhighriskpopulations, inparticulartheelderly.

5) Promotehealthyhousingconceptstostrategicprivatesectorentities,suchasdevelopersandinsurancecompanies.

6) Improveoveralldisseminationofhealthyhousinginformation, includingbestpractices,topartners,grantees,andthepublic.

7) Develop standard, evidence‐based healthy housing assessment tools and interventionprotocols.

8) Support the development of objective standards for what is considered a healthyresidentialenvironment.

9) Conductcost/benefitanalysisontheeffectivenessofahealthyhomesapproachthroughtheanalysisofhealthandfinancialoutcomes.

10) IncreasecollaborationinternaltoHUDandwithotherfederalhousingprograms.

11)Promote healthy housing concepts in post‐disaster environments, such as thedisseminationofinformationonsaferehabandrecoverypractices.

12)Promotetheincorporationofhealthyhomesprinciplesintoongoingpractices/systems.Examples include housing codes, rehab specs used by housing and developmentagencies,andmaintenanceplansformultifamilyhousing(withaparticularfocusontheincorporationofIPMinlow‐incomehousing).

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AppendixD:AbbreviationsUsedinthisDocument

AHHS AmericanHealthyHomesSurvey

AI/AN AmericanIndians/AlaskanNatives

CDC U.S.CentersforDiseaseControlandPrevention

CPD HUD’sOfficeofCommunityPlanningandDevelopment

CO CarbonMonoxide

CSREES USDA’sCooperativeStateResearch,Education,andExtensionService

DOE U.S.DepartmentofEnergy

EPA U.S.EnvironmentalProtectionAgency

ETS EnvironmentalTobaccoSmoke

OHHLHC HUD’sOfficeofHealthyHomesandLeadHazardControl

HHD OHHLHC’sHealthyHomesDemonstrationgrantprogram

HHI OHHLHC’sHealthyHomesInitiative

HHTS OHHLHC’sHealthyHomesTechnicalStudiesgrantprogram

HUD U.S.DepartmentofHousingandUrbanDevelopment

IARC InternationalAgencyforResearchonCancer

ICC InternationalCodeCouncil

IEQ IndoorEnvironmentalQuality

IPM IntegratedPestManagement

NCHH NationalCenterforHealthyHousingNIEHS NationalInstituteofEnvironmentalHealthSciences

NIST NationalInstituteofStandardsandTechnology

NOFA HUD’sNoticeofFundingAvailability

NSLAH NationalSurveyofLeadandAllergensinHousing

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OAHP HUD’sOfficeofAffordableHousingPreservation,OfficeofHousing

PD&R HUD’sOfficeofPolicyDevelopmentandResearch

PIH HUD’sOfficeofPublicandIndianHousing

USDA U.S.DepartmentofAgriculture

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60Office of Healthy Homes and Lead Hazard Control

U.S. Department of Housing and Urban Development