Housing and respiratory health: Exposures, health effects and interventions

Housing quality and affordability are well established as social determinants of health through direct and indirect mechanisms. Respiratory illnesses related to housing are nearly all the result of housing disrepair that allows intrusion into the home of environmental agents that are directly or indirectly associated with disease. Structural deficiencies such as leaks, cracks in the foundation or holes in the home's exterior can facilitate the presence of mould, which is causally linked to the development of asthma and is associated with exacerbation of asthma symptoms in children and adults. Indoor cleanliness can also contribute to the presence of mice and cockroaches. Proper ventilation can improve air quality, reducing exposure to PM, VOCs and infectious respiratory agents. Disparities in exposure to the housing conditions associated with respiratory disease are readily apparent across socioeconomic lines. Low-income families are less likely to be able to afford the costs of maintaining a home, which prevents them from making repairs that could improve respiratory health.Copyright © ERS 2023.

To What Extent do Social Determinants of Health Modulate Presentation, ITU Admission and Outcomes among Patients with SARS-COV-2 Infection? An Exploration of Household Overcrowding, Air Pollution, Housing Quality, Ethnicity, Comorbidities and Frailty.

Background: Internationally, researchers have called for evidence to support tackling health inequalities during the severe acute respiratory syndrome coronavirus 2 (COVID19) pandemic. Despite the 2020 Marmot review highlighting growing health gaps between wealthy and deprived areas, studies have not explored social determinants of health (ethnicity, frailty, comorbidities, household overcrowding, housing quality, air pollution) as modulators of presentation, intensive care unit (ITU) admissions and outcomes among COVID19 patients. There is an urgent need for studies examining social determinants of health including socioenvironmental risk factors in urban areas to inform the national and international landscape. Methods: An in-depth retrospective cohort study of 408 hospitalized COVID19 patients admitted to the Queen Elizabeth Hospital, Birmingham was conducted. Quantitative data analyses including a two-step cluster analysis were applied to explore the role of social determinants of health as modulators of presentation, ITU admission and outcomes. Results: Patients admitted from highest Living Environment deprivation indices were at increased risk of presenting with multi-lobar pneumonia and, in turn, ITU admission whilst patients admitted from highest Barriers to Housing and Services (BHS) deprivation Indies were at increased risk of ITU admission. Black, Asian and Minority Ethnic (BAME) patients were more likely, than Caucasians, to be admitted from regions of highest Living Environment and BHS deprivation, present with multi-lobar pneumonia and require ITU admission. Conclusion: Household overcrowding deprivation and presentation with multi-lobar pneumonia are potential modulators of ITU admission. Air pollution and housing quality deprivation are potential modulators of presentation with multi-lobar pneumonia. BAME patients are demographically at increased risk of exposure to household overcrowding, air pollution and housing quality deprivation, are more likely to present with multi-lobar pneumonia and require ITU admission. Irrespective of deprivation, consideration of the Charlson Comorbidity Score and the Clinical Frailty Score supports clinicians in stratifying high risk patients.

COVID-19 and the Built Environment: Informal Sector, Housing, and Shock Challenges in Nigeria

Housing is a basic need and a key unit of a human being's survival. It often represents the largest investment and biggest achievement in an individual's life. The continuous challenge in housing requirements vis-à-vis the recent outbreak of COVID-19 has subjected many to staying at and working from home. This has demanded the need to reevaluate housing quality and housing environments. This assessment cannot be underestimated in Nigeria, as scholarly works have reported the low standard of housing across the country. Inadequate housing and low-income levels have subjected countless people to living in unhabitable apartments at the detriment to personal health. This chapter evaluates housing planning and design in residential areas, with a specific focus on informal settlements, throughout Nigeria. Problems such as lack of space, lack of adequate security, and light and noise pollution are reported to affect one's residence. Other factors identified include the inadequate level of understanding of the COVID-19 pandemic, its prevention, and the relevance of physical distancing. Based on observation, the lack of work and low level of literacy have affected peoples' adherence to public laws—nationwide. It is recommended that the government continue to stimulate more public information on the preventive measures of COVID-19, create job opportunities, and ensure better housing quality and standards for its citizenry, especially the less fortunate. It is expected that this will promote the well-being of the population and mitigate against future shocks as well as the spread of disease outbreaks. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Review of the Impact of Housing Quality on Inequalities in Health and Well-Being.

Housing quality is essential for population health and broader well-being. The World Health Organization Housing and health guidelines highlight interventions that protect occupants from cold and hot temperatures, injuries, and other hazards. The COVID-19 pandemic has emphasized the importance of ventilation standards. Housing standards are unevenly developed, implemented, and monitored globally, despite robust research demonstrating that retrofitting existing houses and constructing high-quality new ones can reduce respiratory, cardiovascular, and infectious diseases. Indigenous peoples, ethnic minorities, and people with low incomes face cumulative disadvantages that are exacerbated by poor-quality housing. These can be partially ameliorated by community-based programs to improve housing quality, particularly for children and older people, who are hospitalized more often for housing-related illnesses. There is renewed interest among policy makers and researchers in the health and well-being of people in public and subsidized housing, who are disproportionately disadvantaged by avoidable housing-related diseases and injuries. Improving the overall quality of new and existing housing and neighborhoods has multiple cobenefits, including reducing carbon emissions.

Vulnerability and resilience in the metropolitan area of Munich during the pandemic: a qualitative assessment of environment, housing, tolerance, and inclusion

Einleitung The EU project SonarGlobal was conducted in five countries, including Germany, to reveal contributing factors to vulnerability and resilience in the context of the COVID-19 pandemic. The data obtained in Munich indicated that the characteristics of the city and its suburban districts are crucial determinants of vulnerability. This study questions the aspects of environment, housing, tolerance, and inclusion of the Munich metropolitan area to explore the mechanisms that increase vulnerabilities or resilience during the pandemic. Methoden In this qualitative study, in-depth interviews were performed with 82 people living in Munich and its suburban districts and who were faced with at least one mechanism that has the potential to create a biological or social disadvantage, such as age, gender, disability, health problems, occupation, or immigration status. We also interviewed 19 experts and community representatives on specific vulnerability and resilience mechanisms. Living conditions were questioned according to the physical and social environment, housing, stigma, discrimination, and support for inclusion. After the first round of coding, subcodes were created and the second round of coding was done as. This was followed by developing categories covering challenges and resilience factors. Ergebnisse 29 participants were from rural districts surrounding Munich while 53 were living inside urban districts. They originated from 22 different countries. Nine challenges (1. Common places for socialization and inclusion being closed;2. Interruption of organized support for inclusion;3. Isolation in over-centralized institutions and shelters;4. Limited access to IT technology;5. Limited solidarity between neighbours;6. Worsened housing conditions;7. Housing insecurity;8. Increased racism;9. Discrimination and stigma regarding adherence to COVID-19 rules) and four resilience factors (1. Being close to green places;2. Having outdoor spaces at home;3. Solidarity initiatives and strong relationships in neighbourhoods;4. Alternative means for organized support) were determined. For international students, refugees, seasonal workers and other immigrants, the challenges were more intense, while they reported the only significant resilience factor as being close to nature. The alternative support ways developed by the organizations could not be strong in the face of challenges. Stigma towards the disabled, immigrants and Muslims has increased, against which a significant resilience factor did not develop. In rural districts, challenges played a minor role while resilience factors were more effective. Schlussfolgerung The COVID-19 pandemic has deepened the inequalities in people living in the metropolitan area of Munich and with a greater extent in people living in the urban district in terms of environment and housing, reduced the tolerance towards and inclusion of the most disadvantaged segments of society, and aggravated discrimination.

Sharing a home under lockdown in London

Since the beginning of the Covid-19 pandemic, there has been a wave of research into the interaction between the coronavirus and housing. This study examines the experience of adult sharers, using qualitative evidence from an online survey, during the early months of the pandemic. This contributes to the evidence about housing quality, particularly the adaptability and flexibility of the dwelling and wellbeing under the pressures of lockdown. Few homes were built to perform the multiple functions leisure and work, particularly London homes—which are the smallest in the country in terms of floor area per inhabitant. As office-based work shifted to the home in the early stages of lockdown, adult sharers faced a range of practical and spatial challenges. Those working from home had to reconsider (and sometimes reconfigure) their homes as workspaces, and negotiate the use of space with fellow residents. Many ‘solutions’ were deemed inadequate and lockdown conditions generated interpersonal tensions in many sharer households, but strengthened bonds in others. The pandemic changed sharers’ aspirations for their future housing. The findings are relevant for planning and housing policy, including standards for new-build residential units and the requirements for existing houses in multiple occupation (HMOs). POLICY RELEVANCE New evidence is provided on how homes were used under conditions of stress: both the pandemic and the consequent shift of homes into workplaces were unexpected shocks. The effect of these shocks was magnified for adult sharers. Their experience underlines the importance of designing quality homes whose size and spatial configuration permits flexible arrangements of furniture and uses. Planning policy and design approaches should reflect this need for flexible and varied uses. The evidence also suggests the need to review overall space standards (not just bedroom sizes) in HMOs. © 2022, Web Portal Ubiquity Press. All rights reserved.

LONGITUDINAL PATTERNS OF POPULATION AND INDIVIDUAL-LEVEL HEALTH-RELATED SOCIAL NEEDS

BACKGROUND: While almost half of US adults report a health-related social need (HRSN), little is known about how an individual's HRSNs change over time. Existing research on HRSNs has mostly focused on cross-sectional studies and has been geographically localized. To overcome these limitations, we examined longitudinal patterns of HRSNs among a large nationwide cohort of Medicare beneficiaries. METHODS: We used data from a longitudinal nationwide cohort of individuals ≥65 years of age enrolled in Humana Medicare Advantage plans. Four surveys were administered approximately quarterly between Q4 2019 to Q4 2020 and asked validated questions about financial strain, food insecurity, loneliness or social isolation, housing insecurity, poor housing quality, utility insecurity, and unreliable transportation. We restricted our analyses to those who responded at least in part to all 4 surveys. We used Sankey plots to visualize transitions in individual patients' total number of reported HRSNs over time. We also used baseline patient characteristics drawn from medical and pharmacy claims data to characterize 3 distinct groups: 1) no HRSN across all quarters, 2) any fluctuation between 0 and ≥1 HRSN, and 3) ≥1 HRSN across all quarters. RESULTS: Of 18,881 individuals, the overall number reporting HRSNs was relatively consistent over time. Specifically, financial (29.6-31.3%), food (18.7-19.8%), and housing quality (15.9-17.3%) were the most frequent needs across each quarter. However, when characterized at the individual level, patients reported substantial fluctuations in need: 27.7% reported no HRSNs in all four quarters;45.5% fluctuated between having 0 and ≥1 HRSN across the four quarters;26.8% reported ≥1 HRSN in all 4 quarters. For example, of those who reported one HRSN in Q1, 44.8% transitioned to no need in Q2. Demographic and clinical characteristics differed across the three groups. For example, female gender, Black race/ethnicity, residence in the South, and higher comorbidity burden were disproportionately represented in those reporting ≥1 HRSN in each quarter, followed by those with fluctuating needs. CONCLUSIONS: In this nationwide survey of health-related social needs among Medicare beneficiaries, while the overall prevalence of HRSNs was consistent over time, we observed marked fluctuation in individuals' needs during the year observed. This fluctuation occurred over all quarters and did not change after the COVID-19 pandemic began. Our findings have important ramifications for health systems or communities that wish to offer support for these patients. In some populations, screening for needs may have to happen more frequently than typically done at present. Support may need to be offered rapidly as patients experience a change in need. Key demographic and clinical characteristics also appear to differ for patients experiencing consistent or fluctuating needs, which could be used as potential identifiers for those at greatest need.

Physical and visual (social) isolation increases tumor aggressiveness in thermoneutral housin temperatures in murine mammary cancer models

Correct interpretation of tumor progression data, including the influence of host biology, in mouse models of breast cancer requires models and conditions that faithfully recapitulate human disease and human host status. Our previous attempts to investigate the effects of social isolation have proven inconclusive due to premature mortality in tumor-bearing animals. Those studies were completed in standard temperature (ST), which commonly is 70-72°F (21-22°C) for in vivo murine research based on laboratory animal care and use guidelines. Previous work from the Repasky lab (Kokulus, 2013), which we have validated (Gaymon, 2020), demonstrates that ST housing results in chronic cold stress and immune suppression mediated by an increase in norepinrephrine (NE) levels, leading to increased tumor aggressiveness. Based on these findings, we investigated the effects of social isolation on BALB/cJ-4T1-luc and C57BL/6J/E0771 tumor progression and metastasis in thermoneutral housing conditions (84-85°F). Mice were first acclimatized to thermoneutral temperature and/or isolation for two weeks in cages that were unilaterally draped to provide physical and visual isolation. In BALB/cJ mice, 4T1-luc tumors were significantly larger in isolated mice compared to group-housed (GH) mice at day 18 (p<.0001). Statistically larger tumors were observed in isolated mice compared to GH mice through day 24 and final tumor masses were Salso significantly different (p=.004). Spleen masses were not statistically different. In C57BL/6J mice, E0771 tumors were significantly larger in isolates at Day 25 (p=.002). Final tumor masses were statistically (p=.002) different while no difference in spleen sizes were observed. Data on metastasis will be presented at the meeting. We hypothesized that social isolation may perturb immune function and next investigated the growth of 4T1-luc xenograft tumors in NSG mice. 4T1-luc/NSG tumor progression and metastasis data will also be presented at the meeting. We conclude that syngeneic breast tumor growth in immunocompetent BALB/cJ and C57BL/6J mice demonstrates that social isolation is a bona fide stress with sufficient influence to exacerbate breast cancer growth. These data are potentially clinically important due the known relationship of social support to survivorship outcomes in patients and the high-risk of depression and isolation in patients following breast cancer diagnosis. The data may provide additional insight into possible effects of COVID-19 isolation on breast cancer progression.

Feasibility of Telemedicine Home Assessments for Identification of Asthma Triggers in a Rural State

Rationale: Identification and control of environmental triggers is one of the cornerstones of asthma management. Access to homes, underscored during the COVID-19 pandemic, frequently limits mitigation efforts. We sought to determine the feasibility of telemedicine for identification of home asthma triggers. Methods: Patients age 5-18 years with persistent asthma, recent exacerbation, home Internet access, and stable residency were eligible. Families were randomized to standard of care (SOC) or telemedicine (TELE);virtual assessments were performed at 2, 4, and 6 months. Data included demographics and standardized assessment of the home environment. Results: Eighteen participants were enrolled (9 TELE, 9 SOC). There were no significant differences in baseline demographics between groups. Sensitization to pollens and dust mites was most common in both groups. Housing conditions were similar. In both groups, 89% lived in detached homes with forced air (standard filter) being the most common heating source (33%). Visible signs of pests/mold were seen in <12%. 89% use scented air fresheners/candles/potpourri. The SOC group had more pets (67% versus 33%) and smoking in the home (22% versus 11%). There was less evidence of mold in the TELE group (0 versus 22%). All SOC participants use bleach/ammonia cleaning products (78% in TELE). Thirteen participants (72%) completed at least one virtual home visit. No significant barriers were identified to telemedicine encounters. All participants reported “completely” or “very” satisfied with telemedicine visits. Conclusions: Virtual home assessments for identification of asthma triggers is a feasible alternative to in-person home visits, and it is well accepted by patients.