Integrated Pest Management in Multi-story Public Housing for the Elderly Nancy Crider, DrPH

1. Integrated Pest Management in Multi-story Public Housing for the Elderly Nancy Crider, DrPH University of Texas Health Science Center – Houston School of Nursing

2. Acknowledgements • Tom Neltner • Dr. Chang Lu Wang • Dion Lerman • Allison Taisey • Houston Housing Authority • National Center for Healthy Housing • North East IPM Center

3. Problem • The problem under consideration is the effect of Integrated Pest Management (IPM) on the control of cockroaches in a 200 unit multi-story apartment building for the elderly, in Houston, TX, with a known cockroach infestation

4. Significance of Study • Cockroaches long considered an undesirable fact of life for residents of public housing are now a recognized health hazard. • Previous IPM research primarily children living in multi-family housing in the North. • Challenge of maintaining a pest free indoor environment may be different for the elderly living in tropical southern climate.

5. Cockroaches Cause Asthma • Institute of Medicine Report (2000)Clearing the Air: Asthma and Indoor Air Exposures • Cockroaches cause allergies and asthma in sensitive individuals • Third National Health and Nutrition Examination Survey (NHANES) • 43% of individuals in the US, ages 6-59 allergic to at least one indoor allergen • 26% of these sensitive to German cockroach.

6. Inner City Asthma Study (1999) Combination of cockroach sensitization and exposure are associated with an increase in clinical symptoms and increase use of health care system

7. Cockroach Allergens • Cockroach “frass” (droppings, shed skins and remains of dead cockroaches) found in household dust are the source of potent allergens. (Bla g1, Bla g2) • Allergens are proteins and are reported as units per gram of dust. • Threshold for sensitization > 2U/g of dust • Threshold for asthma morbidity > 8U/g dust

8. Schal at al (2008) • Studied the amount of allergen present in each pellet of cockroach feces • 1 pellet of cockroach feces = ~1mg; • 1 mg of feces =500 Units of Bla g1 • 1 female cockroach = 3 mg feces per day • 1 day = ~1500 Units of Bla g 1

9. Chew et al (2006) • 93% of the 321 NYC public housing units had detectable levels of CR allergen. • (90% > 1U/g ; 71% > 8U/g) • 37% of households had at least on resident with asthma. • Higher asthma prevalence and morbidity compared to national average. • (26%) of children <18 years • (20%) of all adults

10. Cohn et al (2006) • Elevated concentrations of cockroach allergens more prevalent in • High-rise apartments • Urban areas • Multi-family units • Pre-1940 housing • Low income households.

11. Cohn et al (2006) continued • Odds ratio (OR) for elevated concentrations of Bla g1 consistently increased with reported presence of cockroaches and more recent observation of cockroaches. • 100% of tenants reporting >50 cockroaches/day had Bla g1 levels >8U/g (OR 599) • 77% who reported sightings in the last week had Bla g1 levels >2U/g (OR 8.3); 53% had levels >8U/g (OR 222.9)

12. Other Studies • Curtain-Brosnan et al found reports of roaches by parents were associated with clinically relevant levels of Bla g1; however negative reports were not sufficient evidence of low CR allergen exposure • Johns et al (2000) 20% of homes with no reported infestation had significant levels of Bla g1

13. Wang et al (2006) • Reported the higher the cockroach count the higher the concentration of Bla g1 and Bla g2 cockroach allergen. • Bla g1 concentrations >8U/g of dust were found with a moderate cockroach infestation (10 CR/trap/night)

14. Lewis et al (2003) • Found higher prevalence and asthma morbidity in woman sensitized to cockroach allergen and even higher in those sensitized and exposed to high levels of cockroaches. • Those sensitized and exposed to concentrations >2U/g were 3X more likely to have been treated in hospital emergency departments and use steroids

15. Lewis et al (2003) continued • When adjusted for poverty and race the association between cockroaches and asthma persisted • After allowing for effect of cockroaches the effect of race and poverty lost significance.

16. Arbes et al (2004) • Found that cockroach allergens Bla g1 and Bla g2 present in low income housing could be reduced through a combined intervention program that included occupant education, insecticide use and professional cleaning.

17. Integrated Pest Management (IPM) • A team approach designed to control pests by eliminating food, water and harborage • Involves inspection, identification, maintenance, monitoring, and action • Requires education and behavior change • Can dramatically reduce both pesticide use and numbers of pests.

18. Goal of IPM • The goal of IPM as defined by the Environmental Protection Agency (EPA) is to control pests by the most economical long term means with the least possible hazard to people, property, and the environment.

19. HUD Promotes IPM • HUD has promoted IPM for decades • Issued Maintenance Guidebook in 1995 • Issued Voluntary Guidance in 2006 • Revised Guidance in 2007, 2008, 2009 and 2011. • Funded IPM & Healthy Homes Training

20. Pests and Pesticides • Unresolved cockroach infestations promote the inappropriate use of toxic pesticides. • 75% of US households used pesticide indoors during the past year. • 80% of most people’s exposure occurs inside

21. Pesticide Use • According to the EPA, the concentration of 12 frequently used organic pollutants is 2-5X higher inside homes regardless of rural or urban location • Chew et al. (2006) reported that the use of low-toxicity pesticides was less common in buildings occupied by senior citizens compared to family units (80% vs 91%; p=.003)

22. Methods • Cockroach counts, used as a proxy for Bla g1 and Blag2 cockroach allergen. dust sampling • Paired sample design – each unit served as its own control • Systematic random sample – random starting point on each level, turn right and sample every third apartment

23. Data Collection • The Community Environmental Health Resource Center (CEHRC) Sampling Procedures used to determine/categorize extent of infestation • Maintenance staff trained to place glue traps for monitoring

24. Data Collection (355) glue traps were placed in 71 of the 73 randomly selected units (5 traps/unit). • Traps were in place for 2 nights. Units were categorized by level of infestation

25. Intervention • 2- day “Essentials for Healthy Homes Practitioners” • 1-day “Integrated Pest Management in Multi-Family Housing” • Baseline counts shared at end of training. • Property manager and team developed IPM plan with support of researcher

26. Data Analysis • STATA statistical software package was used to analyze baseline and follow-up counts. • Paired t-tests completed to determine if there was a significant decrease in the number of cockroaches after the IPM training compared to baseline. • ANOVA by building level stratified by wing completed to determine if there was a statistical difference between levels and/or wings of the building

27. Results

28. Results

29. Results Paired t-tests by trap location

30. Results One way ANOVA by wing

31. Qualitative Analysis • Feedback from the property manager, maintenance staff, service coordinator (social worker), pest control professional and housing authority administrative staff was obtained using a structured questionnaire. • How have your pest control practices changed as a result of the IPM training? • Has the pest control contract been modified as a result of the IPM training? • Have there been any modifications to the annual operating plan as a result of the IPM training?

32. Discussion • Cockroach infestations in multi-story/ multi-family housing are not solely determined by the actions of individual tenants. • Infestations are at least partially determined by the built environment, the physical structure and failure to maintain the property

33. Discussion • IPM education can change behavior and ultimately decrease pesticide exposure by controlling cockroach infestations. • The challenge of maintaining a pest free indoor environment may be different for the elderly due to loss of function associated with normal aging and the impact of chronic disease.

34. Discussion • Clear communication of policies, a team approach and commitment of team members are key components of a successful IPM plan. • Resident education is important. • Leases should include the tenant’s role in IPM • Lease enforcement can make a difference.

35. Limitations • Single property & small sample size do not allow generalization to all public housing. • Responsiveness & interest of pest control professional • Motivation and commitment of property manager and staff • Availability of support staff (Social Worker) to assist elderly tenants

36. Recommendations • Establish an ongoing monitoring system • Utilize support services to assist residents who are physically unable to clean or prepare for treatment by the PCP • Purchase HEPA vacuum that can be routinely used by maintenance & janitorial staff and loaned to tenants • Identify & train resident “peer” educators to assist with glue trap monitoring and provide tenant education and support.

37. Further Study • The relationship of cockroach infestation and exposure to cockroach allergens to clinical symptoms, the use of steroids to treat asthma, hospitalizations and emergency room use are indicated to determine if the control of cockroaches using IPM significantly decrease clinical symptoms and the use of costly health care resources in the elderly.

38. Summary of Results • IPM education, the establishment of a team approach and the adoption of IPM strategies provided an effective solution to a long standing cockroach infestation. • The study found a significant decrease in the average number of cockroaches after IPM education and implementation of IPM principles at the study property (P < 0.0003).

39. Conclusion • IPM education and the adoption of IPM strategies offer a viable alternative to traditional pest control methods • The adoption of IPM will improve the living conditions and health status of elderly residents living in public housing. • IPM has the potential to decrease asthma morbidity and the utilization of expensive health care resources.

40. References • Arbes S.J. et al. (2004). Cockroach allergens (bla g 1 and bla g 2) in low income urban housing reduced through a combined intervention program (occupant education, insecticide application and professional cleaning). Journal of Allergy and Clinical Immunology, 113, 109. • Chew, G. L., Carlton, E. J., Kass, D., Hernandez, M., Clarke, B., Tiven, J., Garfinkel, R., Nagle, S., & and Evans, D. (2006). Determinants of cockroach and mouse exposure and associations with asthma in families and elderly individuals living in new york city public housing. Annals of Allergy, Asthma & Immunology, 97(October), 502-513. • Cohn, R. D., Arbes, S. J., Jaramillo, R., Reid, L. H., & and Zeldin, D. C. (April 2006). National prevalence and exposure risk for cockroach allergen in U.S. households. Environmental Health Perspectives, 114(4), 522-526. • Crider, N.M., (2010). Integrated pest management in multi-story public housing for the elderly in Houston, Texas. Unpublished doctoral dissertation, Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX • Curtin-Brosnan, J., Matsui, E. C., Breysse, P., McCormack, M. C., Hansel, N. N., Tonorezos, E. S., Eggleston, P. A., Williams, D. L., & Diette, G. B. (Nov 2008). Parent report of pests and pets and indoor allergen levels in inner-city homes. Annals of Allergy, Asthma & Immunology : Official Publication of the American College of Allergy, Asthma, & Immunology, 101(5), 517-523. • Eggleston, P. A., Wood, R. A., Rand, C., Nixon, W. J., Chen, P. H., & and Lukk, P. (October 1999). Removal of cockroach allergen from inner-city homes. Journal of Allergy and Clinical Immunology, 104(4), 842-846. • Gergen, P. J., Mortimer, K. M., & Eggleston, P. A. (1999). Results of the national cooperative inner city asthma study (NCICAS) environmental intervention to reduce cockroach allergen exposure in inner city homes. Journal of Allergy and Clinical Immunology, 103, 501-506. • Lewis, S. A., Weiss, S. T., Platts-Mills, T. A. E., Burge, H., & and Gold, D. R. (2002). The role of indoor allergen senstitization and exposure in causing morbidityt in women with asthma. American Journal of Respiratory and Critical Care Medicine, 165, 961-966. • Schal, C. (2008). The ABC's of indoor health: Allergens, baits, cockroaches: A tale of cockroach IPM in 2 environments. Translating Healthy Homes Research Teleconference. • Wang, C., & Bennett, G. W. (2006). Comparative study of integrated pest management and baiting for German cockroach management in public housing. Journal of Economic Entomology, 99(3), 879-885.

41. Contact Information Nancy M. Crider, DrPH, MS, RN Assistant Professor University of Texas HSC Houston 6901 Bertner Av., Rm 766 Houston, TX 77030 Telephone: 713-500-2074 Email: nancy.m.crider@uth.tmc.edu