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Ensuring an Asthma-Safe Home: The Role of Tenants and Landlords


Creating a safe and healthy home for someone with asthma is challenging. The home can play host to many serious asthma triggers, including pests like cockroaches and dust mites, dampness, and ventilation problems that allow accumulation of particulate matter and other types of air pollution. People spend a significant portion of their time inside their home, and about 20% to 30% of asthma cases are linked to home environmental conditions.

While there are certainly steps that individual households can take to reduce these triggers in their home, renters often face unique barriers.

For example, while a household can take steps to remediate a pest problem in their apartment, the infestation may be present in the entire building. Mold and fungi due to leaks or dampness may be caused by structural problems outside of the renter’s control. Tenants may also be restricted in the changes they can make to their unit, like removing carpeting.

Given that over a third of U.S. households rent and one in four live in multiunit buildings, challenges like these warrant particular attention. Moreover, communities of color are both disproportionately burdened by asthma and more likely to live in rental housing.

Preventing and resolving housing issues is most successful when landlord and tenant work together. Multnomah County, Oregon’s Public Health Department, created a resource that highlights these opportunities: What Makes a Healthy Home: A Guide for Landlords and Tenants. The toolkit outlines the seven principles* of a healthy home (dry, clean, safe, ventilated, pest-free, maintained, and contaminant-free), and outlines how both tenants and landlords can play a role in maintaining the healthy status of a unit.

Regarding moisture, for example, the guide explains how landlords are responsible for ensuring all fans are in proper working order and are ventilated outside of the property, regularly inspecting the gutters and making sure all windows are well sealed. Tenants, on the other hand, are in charge of using the fans when showering or cooking, communicating water leaks to landlord immediately, and keeping their unit temperature around 68 degrees to both prevent mold and keep it well ventilated.

While in many case tenants and landlords can work together to solve these problems proactively, if a problem does arise that the landlord is not addressing, tenants have rights. When considering issues of tenants rights, it would be wise to seek legal assistance, especially before taking any action regarding the lease or payment. The U.S. Department of Housing and Urban Development (HUD) allows tenants to search for legal aid by state.

Most states have an implied warranty of habitability, which means that landlords must keep their properties “habitable” even if the upkeep isn’t specifically stipulated in the lease. Every state except Arkansas requires rental housing be kept in “livable condition,” which means that it must have safe electrical, plumbing, heating, and ventilation systems, as well as clean and safe hallways and stairs. These requirements also require garbage removal and vermin extermination. Beyond these baseline standards, the definition of “habitable” varies under state and local law. Households living in Section 8 or other federally-sponsored housing are covered under more strict federal standards.

If an issue goes unaddressed, tenants can contact the building manager with a written request about the situation. It is important to document the problem in detail including photos, a description of the issue, and the date and time of the issue. If the building manager is not responsive, however, tenants can request a city or county inspection for violations. Each state has slightly different processes for such complaints, but a call to the local health department is often a good place to start.

Finally, the U.S. Fair Housing Act (FHA) and the Americans with Disabilities Act (ADA) provide additional protections for individuals with disabilities who live in subsidized rental housing. Asthma is specifically classified as a disability under FHA and ADA. Tenants with asthma have “a legal right for reasonable accommodations to rules, policies, practices or services. They also are entitled to structural changes by the reasonable modification provision when a particular asthma trigger in the housing environment impacts their disability.” FHA and state fair housing laws provide similar protections for market-rate housing.

The process of submitting a formal complaint or request for accommodations can be challenging and new for tenants. Many tenants often don’t feel comfortable making complaints about their housing quality due to uncertainty as to how their landlord will respond or fear of retaliation. This is especially true for tenants living in high-demand rental markets where eviction rates are high. Many tenants also face other barriers to submitting complaints, including language access and work schedules. Local asthma coalitions, tenants rights organizations, and  local public health departments can provide support to tenants through this process. While there is no comprehensive list of asthma coalitions, you can usually find resources by searching “asthma coalition city, state” or “public health department city, state.” Some of these groups even coordinate environmental assessments using the EPA environmental assessment checklist and are able to triage violations directly.

For households living in rental housing, the challenges to creating a healthy home environment can be significant. Ideally, tenants and landlords can work together to prevent asthma triggers and remediate any issues. However, while protections and processes are in place to support this collaboration, in practice resolving these problems can be time-consuming and discouraging for tenants. Understanding their rights as tenants and enlisting the support of local organizations can be critical to a tenant’s success.


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*Note: At the time that What Makes a Healthy Home: A Guide for Landlords and Tenants was published, there were seven accepted principles of healthy housing. An eighth, "thermally-controlled," has since been adopted by the healthy homes community.

A version of this article was published in July 2013 as "How to Create an Asthma Safe Home Part II: Solutions for Tenants and Landlords" on the Propeller Health site. The author has modified portions of the article for publication here.




Justine Marcus is currently pursuing a dual degree, Masters in City Planning and Masters in Public Health, at the University of California Berkeley. Through her graduate studies, Justine is exploring how community infrastructure‎ – from housing, to water, to governance ‎– can be used to address health disparities and build community power. She is currently a graduate student researcher for the UC Berkeley Center for Community Innovation, where she is examining the health and material impacts of evictions on households. Justine is a proud Wisconsinite and lifelong public school alumna.  

Threats or Promises: Which Way for the Trump Administration on Childhood Lead Poisoning Prevention?

Recent news articles suggest that Trump’s EPA hopes to drastically cut funding and staff for its lead poisoning prevention programs ("EPA Memo Outlines Plans to Defund Lead-Paint Program," in Remodeling, April 4; and "Trump’s EPA Moves to Dismantle Programs that Protect Kids from Lead Paint," in The Washington Post, April 5). This follows on the heels of a high-level meeting between the EPA’s new administrator, Scott Pruitt, and the National Association of Home Builders (NAHB). NAHB complained about so-called “excessive” regulations, specifically EPA’s Renovation, Repair, and Painting (RRP) Rule

But it was exactly inadequate regulations that led to the Flint crisis and others like it, such as the East Chicago disaster in Indiana, the vice-president’s home state.
 
The fact is that congressional action and regulations have worked: Blood lead levels in the nation’s children have been greatly reduced  as a result of the implementation of statutes and regulations (see "U.S. Policies vs. Children's Average Blood Lead Levels" below). When we as a nation mandated the removal of lead from food canning, gasoline, new residential paint, plumbing and other sources, all through regulations, it worked. If anything, the regulations should be strengthened, not weakened, because over half a million children still have blood lead levels above the CDC reference value.1 

Some industries have supported these regulations over the years,2 but a few others have actively opposed them.3 Most recently for example, the National Association of Home Builders (NAHB) wants the EPA’s RRP regulation restricted to only pre-1960 housing, even though lead paint was not banned (by regulation) until 1978. They want “training” of their contractors to be only online, when in fact construction contractors don’t really learn that way. They want a new cost-benefit analysis, even though many previous studies have already shown that the benefits far outweigh the costs.4, 5 NAHB already succeeded in previous years in eliminating a dust testing requirement that has existed for years in federally assisted housing rehab work with scientifically proven positive results.6 (Children’s blood lead levels in assisted housing are lower than in non-assisted low-income housing, and dust testing [dust is one of the main ways children are exposed] is the major reason why). NAHB should protect the interests of its members by ensuring that homes are safe, not cutting corners and weakening laws and regulations that, if anything, need to be strengthened. And it should work to ensure that its member contractors don’t inadvertently do sloppy work that can cost $100,000 per house to clean up.7

Furthermore, preventing childhood lead poisoning not only protects children, it will create at least 75,000 good-paying jobs.8

During his campaign, the president promised to fix things that don’t work right. What better example is there that lead poisoning needs to be fixed than the 24 million homes that still have lead paint hazards, or the 6-10 million homes that still have lead water pipes? The solution is not to weaken regulations or to cut budgets but to strengthen them, putting the resources in place to end this preventable disease. Lead problems are a sign of our crumbling infrastructure, something the president also vowed to fix. We think that an infrastructure bill should include lead poisoning prevention. 

At HUD, the new Secretary, Dr. Ben Carson, promised to “enhance” lead poisoning prevention and healthy housing, proposing to increase the budget for that program from $110 million to $130 million. But at the same time, the proposed HUD budget wipes out the multi-billion-dollar Community Development Block Grant (CDBG) program. Many local jurisdictions use CDBG to provide their local “match” funding, anywhere from 10% - 25%, for lead hazard control. So, even though the proposed increased funding for the lead program is welcome, it appears that with the CDBG proposed elimination, the net effect will reduce, not increase, the total HUD resources to protect our children from lead poisoning. Why give with one hand only to take away more with the other? 

The National Safe and Healthy Housing Coalition has produced a number of recommendations that will protect our children

We urge the new administration and the new Congress to act on those recommendations to improve (not weaken) regulations and to propose a budget that will get the job done.

Instead of paying over $50 billion a year for lead poisoning, let’s solve the problem, not eliminate EPA programs or reduce HUD funding. At its beginning, the Flint fiasco was supposedly an attempt to save money, and NAHB’s wishes sound just like that, don’t they? We cannot afford another Flint, and we cannot afford to continue to pay the high costs of needlessly poisoned children. In Flint and across the nation, we will now spend far more now than had we acted to solve the problem in the first place. And we do know how to solve it. We should act on what we know, put our people to work, protect our children, and stop wasting money by caving in to a few narrow short-sighted industries at the expense of the rest of us.





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1 Wheeler, W., & Brown, M. J. (2013, April 5). Blood lead levels in children aged 1–5 years — United States, 1999–2010. Morbidity and Mortality Weekly Report (MMWR), 62(13), 245-248. Retrieved April 6, 2017, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6213a3.htm

2 National Safe and Healthy Housing Coalition. (2016). Declaration of the Lead and Environmental Hazards Association. Retrieved April 6, 2017, from  http://www.nchh.org//Portals/0/Contents/LEHA_Declaration_2016.pdf 

3 Jacobs, D. E. (2016 July-August). Lead poisoning: Focusing on the fix. Journal of Public Health Management and Practice, 22(4):326-330. doi: 10.1097/PHH.0000000000000430. Retrieved from http://journals.lww.com/jphmp/Citation/2016/07000/Lead_Poisoning___Focusing_on_the_Fix.2.aspx
   
4 Gould, E. (2009, July). Childhood lead poisoning: Conservative estimates of the social and economic benefits of lead hazard control. Environmental Health Perspectives, 117(7), 1162-1167. Retrieved April 6, 2017, from https://ehp.niehs.nih.gov/wp-content/uploads/117/7/ehp.0800408.pdf

5 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved April 6, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540
 
6 Ahrens, K. A., Haley, B. A., Rossen, L. M., Lloyd, P. C., & Aoki, Y. (2016, November). Housing assistance and blood lead levels: Children in the United States, 2005-2012. American Journal of Public Health, 106(11), 2049-2056. Retrieved April 6, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27631737
 
7 Jacobs, D. E., Mielke, H., & Pavur, N. (2003, February). The high cost of improper removal of lead-based paint from housing: A case report. Environmental Health Perspectives, 111(2), 185-186. from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1241348/
 
8 National Center for Healthy Housing & National Safe and Healthy Housing Coalition (2017, February). Find It, Fix It, Fund It: A lead elimination action drive: Policy recommendations to Congress and the new administration. Retrieved April 6, 2017, from http://bit.ly/FFFAdmin

9 Jacobs, D., & Weinberg, A. (2017, February 22). Infrastructure and mortgages: What about the kids? National Center for Healthy Housing website. Retrieved April 6, 2017, from http://bit.ly/Infra_Kids



Dr. David Jacobs, former Director of the Lead Poisoning Prevention Program at the U.S. Department of Housing and Urban Development, is the Chief Scientist for the National Center for Healthy Housing and an adjunct professor at the University of Illinois at Chicago School of Public Health

Infrastructure and Mortgages: What about the Kids?


During the 2016 election season, Donald Trump (the Republican presidential nominee, now president) proposed spending $1 trillion dollars on infrastructure to put people to work and rebuild the sinews of the nation. Democrats have also called for infrastructure improvements. Those improvements must include making our homes and schools safe for our children. In its recent (January 2) editorial, "Housing that Ruins Your Finances and Your Health," The New York Times wrote, “One solution would be for Fannie Mae to eliminate dangerous lead conditions in foreclosed homes.” But lead requirements are antiquated or nonexistent not only at Fannie Mae but also at Freddie Mac and HUD’s FHA single-family mortgage insurance program. These federal housing programs are the only ones that were not reformed back in 1999 and are long overdue to be fixed.

In years past, both parties worked together to reduce childhood lead poisoning. But Flint is only the tip of the iceberg, and parents of lead-poisoned children are demanding that we do more to put a stop to the needless suffering. Lead poisoning costs us an estimated $50 billion annually for healthcare, substandard school performance, and lost work productivity (2008 dollars).1 The real tragedy is that we know how to fix lead hazards. The disasters in Flint and elsewhere could have been prevented and will now cost much more than if we had made the necessary upfront investments and reforms. The inadequate lead requirements at FHA, Fannie Mae, and Freddie Mac should comply with HUD lead-safe housing regulations, but they currently do not.

Traditionally, infrastructure spending only goes for roads and bridges and the basic equipment and structures that are needed for a country to function properly. But many are surprised to learn that the lead services lines bringing water into their homes are NOT part of the “infrastructure” and that the burden was on families to replace them. They are also surprised that home inspections required by mortgage companies do not include lead inspections. 

We think infrastructure and federally guaranteed mortgages should be used to make our homes safe for our children. Indeed, we have “shared” our homes with guests and friends and, of course, our families. But 37 million homes built before 1978 have lead paint,2 and at least six million homes have lead water service lines. This “shared” lead has poisoned millions of our children, sometimes poisoning one child after another as one family leaves and another moves in. Existing FHA, Fannie, and Freddie underwriting standards are part of the problem, but they could be part of the solution.

The biggest culprit is old single-pane painted windows, which have the highest lead paint and lead dust levels of any building component. Replacing windows is already a proven strategy. In a pilot program, Illinois replaced lead-contaminated windows in Peoria and Chicago in 500 homes,3 resulting in huge and sustained lead dust reductions not only on windows but also on floors; and many other studies have reached similar conclusions.

The time has come to replace all those old contaminated windows, those lead drinking water pipes, and the other lead hazards in our homes. Enormous benefits follow if infrastructure funds are used to address lead in homes:
  • First, over 75,000 jobs – good-paying jobs for both made-in-America window manufacturing and installation workers;
  • Second, increased property values anywhere from $5,900 to $14,300 per home4
  • Third, a return on investment of at least $17 per dollar spent on lead remediation or removal5
  • Fourth, up to $500 per household saved each year on reduced fuel bills, because new windows are more energy efficient.6 
With the right infrastructure improvements, we can all share safe drinking water and lead-safe homes. 

The evidence is clear – whether in small towns or big cities, rural or urban: We all win when we eliminate lead hazards and protect our children. Our traditional approach has been to respond only after a child is poisoned, but there is no reason to wait until the damage has already been done. We should test our homes and schools, not just our children’s blood. And we should insist that housing finance institutions like FHA, Fannie, and Freddie do the right thing and eliminate those hazards before children are poisoned.

As part of our new national infrastructure initiative, let’s include solving the lead problem. We urge the new president and Congress to protect our children. Let’s not wait for another Flint or another poisoned child. Get Fannie, Freddie, and FHA to do the right thing. Get rid of those old lead-contaminated windows and old lead pipes and put our people back to work to protect our children and our future.

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1 Tresande, L., & Liu, Y. (2011, May). Reducing the staggering costs of environmental disease in children. Health Affairs 30(5), 863. Retrieved February 21, 2017,
from http://content.healthaffairs.org/content/30/5/863.long
2 Cox, D. C., Dewalt, G., O'Haver, R., Salatino, B. (2011, April). American healthy homes survey: Lead and arsenic findings. Washington, DC: U.S. Department of Housing and Urban Development. Retrieved February 21, 2017, from  https://portal.hud.gov/hudportal/documents/huddoc?id=AHHS_Report.pdf
3 Jacobs, D. E., Tobin, M.,Targos, L., Clarkson, D., Dixon, S. L. Breysse, J., et al. (2016, September-October). Replacing windows reduces childhood lead exposure: Results from a state-funded program. Journal of Public Health Management & Practice, 22(5), 482-491. Retrieved February 21, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26910871
4 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved February 21, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540
5 Gould, E. (2009, July). Childhood lead poisoning: Conservative estimates of the social and economic benefits of lead hazard control. Environmental Health Perspectives, 117(7), 1162-1167. Retrieved February 21, 2017, from https://ehp.niehs.nih.gov/wp-content/uploads/117/7/ehp.0800408.pdf
6 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved February 21, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540



 
Dr. David Jacobs, former Director of the Lead Poisoning Prevention Program at the U.S. Department of Housing and Urban Development, is the Chief Scientist for the National Center for Healthy Housing and an adjunct professor at the University of Illinois at Chicago School of Public Health

Anita Weinberg is a Clinical Professor and the Director of the ChildLaw Policy Institute at Loyola University Chicago School of Law, which spearheaded lead poisoning prevention efforts in Illinois for over 10 years.

Alternative Financing Mechanisms: Exploring Options for Healthy Homes Services



The National Center for Healthy Housing (NCHH) is a “go-to” resource for practitioners in the housing as healthcare industry. We get inquiries regularly: “Where is this being done? By whom and how?” We also look at the industry landscape ourselves and ask the same questions.

As we looked at the landscape in 2015, we closely reviewed the robust evidence base about the potential for transforming health outcomes and reducing healthcare costs by incorporating home-based interventions into patient care. Such interventions target social determinants of health, and investing in them has the potential to reduce the burden of preventable housing-related illness dramatically. The investing bit caught our attention, because we heard two conflicting scenarios.

On the one hand were states or individual managed care organizations providing Medicaid coverage for services delivered in the home environment related to asthma and lead exposure. On the other hand were states that indicated an interest in delivering home environment services but had not yet achieved Medicaid coverage. It seemed like their only option was to wait for Medicaid expansion coverage. But was it? As these conversations continued, we were aware of some states utilizing other financing mechanisms as either a complement or alternative to healthcare financing. The inevitable a-ha moment happened, and a series of questions followed: “What if more people know about these alternative financing mechanisms being used by certain states?” “Can someone, somewhere adopt an existing model as-is or with some modification?” “Is there a chance to increase the number of people receiving home environment services around the country?” We liked all the positive answers to these questions, and what followed was the alternative financing mechanism information project – after we secured funding from the W.K. Kellogg Foundation, of course. (Yes, our ideas depend on funding to be actualized.)

In 2016, NCHH interviewed several states providing one or more home-based asthma services, childhood lead services, or healthy home services using funding other than Medicaid or grants. The interviews provided information on the funding mechanism and how it operates, the program being funded and how it operates, outcome and evaluation information (where available), and lessons learned. We are pleased to share our findings of 12 different financing mechanisms.

This project does several things, but I would like to highlight one major feature—the “behind-the-scenes” information that the interviews provide.

The Montana Asthma Home Visiting Program (MAP) website tells us about the program. It is the interview that lets us know that not only does the program receive funding from the Master Settlement Agreement (MSA), it began to receive funding in 2007, nine years after the MSA accord was reached! This implies that even if MSA funds have not been a source for home-based asthma services or lead-based follow-up services, it is a potential source. Who else can begin to receive funding from their state’s MSA for home environment services?

One of the Massachusetts program interviews tells us how a trade-off was instrumental to raising funds for the program. The state amended the lead law to remove liability from organizations, and as a trade-off they accepted “surcharge on fees assessed by certain boards of registration, or state agencies for the licensure or certification of certain professionals, and on fees assessed for the renewal of such licensure or certification.” These surcharges raise about $2.5 million annually for Massachusetts Lead Education Trust Fund, income that would otherwise have been unavailable to support lead education services in the state!

The Maine interviewee spoke about the need to make the distinction between primary and secondary prevention. Just like several other states, Maine had a secondary prevention program. But secondary prevention only reacts after the fact. With the Lead Poisoning Prevention Fund, Maine now tests homes not just after a child has been poisoned in it, but before poisoning can happen to prevent poisoning.

Here are two things that stand out from the New Jersey’s project ReHEET interview: One, you can start where you are: Although they have received funding as high as $480,000, they have also worked with funding as low as $80,707! They began work with a few units. Two, the interviewee also pointed out how addressing more than one issue when intervening in a home lowers cost. They are committed to promoting energy and weatherization services to be incorporated with healthy homes services as a total package. Was someone thinking this might be a good idea? It is. They are working with it in New Jersey.

The page includes many more insights from our interviewees. For practitioners, we hope you are thinking “If them, why not us?” That’s what we are thinking too. Unhealthy homes are costing our nation too much in lost school and work days, medical expenses, and reduced quality of life. We encourage states and nonprofits to continue exploring alternate financing mechanisms that can support implementing evidence-based interventions for healthy homes.


Visit NCHH's Alternative Financing Mechanisms page here. Visit NCHH's Healthcare Financing page here.


Dr. Lillian Agbeyegbe is a public health practitioner with over a decade of experience in program development, implementation, and evaluation. As a project manager, she leads and supports NCHH’s Housing as Healthcare portfolio by developing resources, training, and providing technical assistance to support states in providing healthy home services.

The Silent Killer


No one heard the door open or a window shatter. Nobody saw a figure enter the small, darkened one-story home at the corner of Antioch Avenue in a slumbering Maryland neighborhood. There were no shouts, screams, or cries for help; the killer was silent, efficient, and dispassionate. And after the deed was done, the faceless killer simply vanished, virtually into thin air. By the time the sun rose the following morning, a single father and seven children were dead. There were no signs of entry and no fingerprints, footprints, or tire marks to assist the police. But there was one critical piece of evidence that helped the authorities to identify the killer: A portable gas-powered generator was discovered inside the home, its gas tank now empty....

And who did it? Carbon monoxide, often called "the silent killer."

It almost sounds like the premise for a horror movie, but that was a true story. The tragedy occurred in April 2015 in a small community on Maryland’s Eastern Shore, roughly 20 minutes from Salisbury University. Rodney Todd had separated from his wife a few years back, and the now-single dad was trying his best to keep the lights on and the food on the table for his seven children. He was committed to keeping his children, ranging in age from six to 15 years, happy, healthy, and safe. But his income from a dining services job at the University of Maryland Eastern Shore campus wasn’t enough to cover their living expenses. With no electrical service to his home, Mr. Todd installed a portable gas-powered generator to keep the lights and heat functioning through the cold nights.

What Mr. Todd didn’t know or understand was that he’d installed a combustion device in his home, and any stove, heater, lantern, or lamp that burns gas or oil fuel releases carbon monoxide (CO) into the air. Carbon monoxide is colorless, tasteless, and odorless, and it can kill you. You can breathe it in while sleeping or while talking to a friend or family member without realizing that you’re being poisoned, and it only takes a few minutes of exposure to be affected. If you’re awake, you may feel light-headed or weak, eventually experience flu-like symptoms, such as weakness, vertigo or dizziness, stomach upset or vomiting, or chest pain. If you’re asleep (or even inebriated, for that matter), you may not even notice these symptoms at all; you simply don’t wake up the next morning for work or school. Or anything ever again. Just like that.

Unfortunately, Rodney Todd’s story is not an isolated incident. On February 21 of last year, Leonard and Heather Quasarano and their four children, ranging in age from 23 months to 11 years, perished inside their two-story home in Fenton Township, Michigan. Their power went out, so the Quasaranos set up his gas-powered generator in the basement to keep the family comfortable as they slept, a fatal mistake. Said Genesee County Sheriff Robert Pickell, "It's very difficult just talking to the undersheriff who was in the house and saw all the bodies in the different rooms," he said. "No matter how long, how many investigations we conduct, seeing young children, an entire family wiped out, is just a very, very sad thing."

According to the U.S. Centers for Disease Control and Prevention (CDC), unintentional CO poisoning (non-fire-related) results in 20,000 emergency room visits, 4,000 hospitalizations, and roughly 300 fatalities every year in the U.S. The U.S. Consumer Product Safety Commission’s estimate (200 non-fire-related fatalities yearly) is more conservative but still tragic, especially when it happens to someone you know.

But you don’t have to die from CO poisoning to be affected by it. Even what some might describe as a “low-level,” nonfatal CO exposure may still result in permanent organ or brain damage. You may also suffer other side effects, such as headaches, amnesia, loss of muscle control, incontinence, and personality changes. These are usually short-term problems for most victims, but they can be permanent in some cases.

So how do you defend yourself and your family against a villain who can’t be seen, heard, smelled, or touched? What extra steps could Rodney Todd have taken to protect himself and the seven children who occupied that small house on Antioch Avenue? Are you making the same mistakes? How long before your luck runs out?

While there are many things you can do to reduce the likelihood of CO poisoning, let's focus on two solutions that might’ve saved Mr. Todd and his family.

First, avoid running any kind of combustion device inside your home. Read the instructions and heed the warning labels. If you must use a combustion device indoors, make sure that you have adequate ventilation. “Adequate ventilation” means that there must be some source of fresh air nearby, usually an open window or door. The window can be open only a few inches, but you must provide a way for fresh air to enter your home so that oxygen binds with the CO molecules, which creates carbon dioxide (CO2) instead.

Second, install CO alarms (also “monitor” or “detector”) in your home, if they aren’t there already. According to NCHH's National Healthy Housing Standard, a CO alarm is “an electronic device that measures the level of carbon monoxide gas… [and] … activates an audible alarm when an amount … above the device’s threshold level accumulates in the area in which the alarm is located.” The alarms look very much like a smoke detector and work similarly. The International Fire Code requires (and the Consumer Product Safety Commission also recommends) smoke and CO alarm models that include a voice notification system. There should be one CO alarm on each floor and outside each sleeping area, near the bedroom. NCHH is promoting CO alarm requirements as a safety provision in the National Healthy Housing Standard. Maryland (where NCHH is located) requires that homes constructed after January 1, 2008, have a hardwired CO alarm; some states have similar laws. Last year, NCHH proposed an amendment before the International Code Council that would require CO alarms in all properties governed under the International Property Maintenance Code (IPMC). ICC codes currently require only that CO alarms be installed in new structures and in existing properties where a building permit has been requested for renovations. Such an amendment would result in CO alarms being as prevalent in properties as smoke detectors, which we feel is extremely important for public safety.

Since most older homes have no CO alarms, that’s where you come in. If your budget is tight, you can buy a CO alarm for under $20; units with more bells and whistles, such as models that also detect smoke or explosive gases, cost more but are still affordable; and they’re a small price to pay for peace of mind. You can even buy a “travel alarm,” which is not a bad thing to have with you on a trip, because you’ll never know when you’ll need one.

If your CO detector runs on batteries, be sure to replace them twice per year. You should install new batteries when you change the time on your clocks each spring and fall, just as you do with your smoke alarms. You were already doing that, right?

Great, you've installed the CO detector! That's your best tool for protecting your family and yourself, although there are several other ways to minimize the threat of CO poisoning. For example, when shopping for appliances or equipment, be sure to look for products that have been approved by a nationally recognized testing lab, such as UL or NSF International. Make sure that any gas appliances are vented properly, with horizontal vent pipes angling slightly upward. Have a qualified service technician inspect your heating system and combustion appliances annually, and, if you have a fireplace, get your chimney checked for blockages every year. Also, don't burn charcoal or use a portable gas camp stove or inside.

Now, let’s say your power's on, your furnace works just fine, and you don’t have a gas generator in your kitchen or living room. Are you still at risk for CO poisoning?

Yes, you may still be in danger. Here's another story: It was two days after Christmas when Melissa and Jorge were killed. They left their home in New Jersey on a frosty night to celebrate their anniversary at a charming little bed and breakfast in Stroudsburg, Pennsylvania, laughing and joking flirtatiously. The happy couple pulled off the road and parked for a moment in front of a strip of storage garages. Melissa had a key. Should they or shouldn't they? Melissa opened the door to garage 55. They backed in, and Jorge shut the door. They needed a little privacy, just for a few minutes; then they'd be back on the road. But they never saw the killer that entered the garage with them...

Most CO exposures occur inside the home, but there are far too many incidences of accidental exposures and deaths relating to car exhaust fumes wafting into the living areas of homes and poisoning families. Some are unusual, such as the case of the man who committed suicide in his garage but inadvertently killed his wife and two daughters as they tried to rescue him, that tale of the amorous New Jersey couple who lingered in their car too long, or the tale of heroic father who realized that his car had been idling and opened the garage door, preventing the deaths of his family and their neighbors but not his own—he collapsed and died before he could shut off the car’s ignition, a shocking reminder of how quickly carbon monoxide can overcome a person; but most of the stories are just sad. And all of these tragedies could have been avoided if only the victims had known that about the silent killer that is carbon monoxide.

Now that you know what to do and what not to do, be safe and sleep peacefully.

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