Transcript Conducting A CommunityBased Study of Asthma in Baltimore” Patrick Breysse, PhD, CIH Professor & Director Division of Environmental Health Engineering Department of Environmental Health Sciences Director Center.

Conducting A CommunityBased Study
of Asthma in Baltimore”
Patrick Breysse, PhD, CIH
Professor & Director
Division of Environmental Health Engineering
Department of Environmental Health Sciences
Director
Center for Childhood Asthma in the Urban
Environment
Centers for Children’s Environmental Health
Co sponsored by NIEHS, EPA, CDC
Johns Hopkins Center for the
Asthmatic Child in the Urban
Environment (CCAUE)
Director: Peyton A. Eggleston, MD
Associate Director: Patrick Breysse, PhD
Investigators
Tim Buckley, PhD
Gregory Diette, MD, MS
Sukon Kanchanaraska, PhD
Jerry Krishnan, MD
Elizabeth Matsui, MD
Sekhar Reddy, PhD
Arlene Butz, RN, DSc
Cynthia Rand, PhD
Marsha Wills-Karp, PhD
Steve Georas, MD
Why Focus on Asthma?
• In 1999…
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10,488,000 persons with asthma in US (3.8%)
14.5 million work days lost with asthma
3,114,000 children < 14 yrs old with asthma (4.9%)
14 million lost school days
14.6% report activity limited by asthma
10,808,000 physician visits
1,997,000 ER visits for acute asthma
478,000 hospitalizations for asthma
4657 deaths
CDC MMWR March 29, 2002 / 51(SS01);1-13
CCAUE
• Multidisciplinary research center
• Combine basic research and community
based studies
• Long Term Goals
– Understand mechanism by which allergens,
pollutant increases airway inflammation and
asthma morbidity
– Develop effective intervention strategies
Environmental Factors in Urban
Asthma Research Model
IMMUNOLOGIC
SENSITIZATION
ALLERGENS
AIR
POLLUTANTS
CHILDREN LIVING
IN URBAN
ENVIRONMENTS
ASTHMATIC
AIRWAY
OBSTRUCTION
RESPIRATORY
MORBIDITY
SUSCEPTIBILITY FACTORS
ATOPY, INFLAMMATION CONTROL
BRONCHIAL HYPERRESPONSIVENESS
UNDERLYING SOCIAL SUSCEPTIBILITY FACTORS
POVERTY, STRESS, CONFLICTING NEEDS, EDUCATION, ADHERENCE, ACCESS TO CARE
CCAUE Study Components
• Community Based Studies
– Cohort Study of Environmental Asthma
• Longitudinal comparison of environmental exposures and
other risk factors
• Greg Diette et al.
– Asthma Susceptibility to Particulates, Allergens
• Genetic association of environmental exposures and asthma
• Greg Diette et al.
– Asthma Intervention Trial
• Randomized trial to reduced household exposures to
particulate matter and allergens
• Peyton Eggleston et al.
CCAUE – Asthma Intervention
Study
• Randomized Controlled Trial of Home Exposure Control
in Asthma
• Rationale
– Strong epidemiologic evidence that indoor
environmental exposure relates to asthma morbidity
– Effective treatments available for indoor
environmental exposure
• Goal
– Test hypothesis that reduction of allergen and pollutant
exposure in the homes of asthmatic children will reduce
morbidity
STUDY AREA
Air monitoring station
Recruitment Plan
• 100 children recruited from elementary
schools in inner city neighborhoods
• Eligibility:
– 6 – 12 years old
– Doctor-diagnosed asthma
– Current asthma symptoms
– No other lung disease
– Live in catchment area
387 children enrolled in
asthma education program
180 eligible and
interested
Recruitment
125 consented,
questionnaire completed
116 baseline home
evaluation
100 randomized
97 competed
1 year study
Intervention Protocol
INTERVENTION
TREATMENT
BASELINE
TREATMENT
CONTROL
questionnaire
skin test
serum,FEV1
home
environment
telephone
0
3
6
9
12
Intervention
• 3-4 home visits by home health educators
• Roach extermination, sealed plastic
containers
• Allergen-proof bedding encasings
• HEPA air cleaner in child’s bedroom
• Smoking cessation education and support
Leaky Faucet, Dirty Dishes and a …Guest
Kitchen ceiling hole with water damage
Moldy Wall in Basement of Home
Air Cleaner
Environmental Monitoring
• Indoor Air Pollutants were measured over
a 72-hr period in child's bedroom
– Particulate Matter
• PM10
• PM2.5
• Data-logging Nephelometer
– Ozone
– Nitrogen Dioxide
– Airborne nicotine (marker for passive smoking
exposure)
In-Home Air Sampling Set-Up
Air Monitoring Station
Reservoir Dust Allergen Samples
• Vacuum samples collected in bedroom,
living room/family room, and kitchen
– Analyzed for
•
•
•
•
•
Cockroach
Dust mite
Cat
Dog
Mouse
Baseline Characteristics
Age (mean)
home ETS (%)
Cockroach (%)
Pos skin test (%)
Mod/severe syx (%)
controller meds (%)
FEV1 (% pred)
ED visit/3 mon (%)
CONTROL
8.3
65
66
65
20
34
94±21
36
TREATMENT
8.5
73
62
75
28
28
101±20
32
Housing Characteristics
Characteristic
%
Characteristic
%
Row House
91
Leaks in bedroom
18
Roof Leaks
24
Food in bedroom
29
Cats
26
Cockroaches in bedroom
8
Dogs
20
Mouse droppings in
bedroom
7
Current smoker
46
Moisture damage in kitchen
22
Cockroaches in kitchen
31
Mouse droppings in kitchen
38
Particulate Concentrations:
% Change
% change from baseline
20
10
0
-10
p=0.08
PM10
PM 2.5
PM 10
PM 2.5
treatment
treatment
control
control
-20
p<0.001
-30
p=0.019
-40
p<0.001
-50
baseline
6 months
12 months
Bedroom Cockroach Allergen
Bla g 1
U/gm
Treatment
Control
10
p=0.07
p=0.001
1
base
6 mon
12 mon
Change in proportion with symptoms
Proportion of children with wheeze, cough,
dyspnea in last 2 weeks
p=<0.001
40
Control group
30
20
p=0.60
p=<0.001
10
p=0.02
0
-10
-20
Treatment group
-30
-40
base
3 mon
6 mon
9 mon
12 mon
Other Health Outcomes
• Other health outcomes not different
between the two groups
– Nighttime symptoms
– ED visits
– Hospitalizations
– FEV1
CCAUE Community Outreach
• Community Advisory Committee
– 9 members representing political organizations,
schools, churches, parents
– 2 principals, pastor, nun, 2 community association
presidents, parent of child with asthma, retired
environmental health professional, social worker
• Meet in neighborhood school
• Advisory Functions
– Protocol feasibility
– Community priorities, concerns
– Translation of results to local community
Community Outreach
Core Values
• Developed in partnership with community advisory
committee and members of the community during a
series of workshops
• Represent a common set of guiding principals or
beliefs
• Establishing core values clarified the basis for the
collaboration and formed the heart of future
discussions
Core Values
• Cultural competence and inclusiveness: investigators
and community members recognize, accept, and
celebrate their differences and value and include
different community perspectives;
• First do no harm: studies should be drafted so that they
are safe and ethical
• Honesty: conversations between the community and
investigators should be frank and honest
• Confidentiality: private information should be kept
confidential
• Productive use of resources: efficiency in time, effort,
and money is important to investigators and community
members
Core Values
Continued
• Effective communication: communications between
investigators and community will be open and continuing
and participants have a right to know study findings
• Commitment to advocacy: investigators and community
should use their information and energy to advocate for
community improvement
• Education/co-learning/sustainability: community and
investigators should learn and share with one another
• Sound science: any community intervention or research
planning must be compatible with sound scientific
principles
Co-Learning
• CAB sponsored “staff development
seminars”
– Purpose is to learn about the community
– Included a half-day guided tour of the
neighborhood
CAB Interactions
• Assisted in hiring field and support staff
– Recruit from the community
• Support approval efforts with School Board, and
Baltimore City Health Department
• Requested help with general environmental
health concerns
– Trash in alleys
– Traffic pollution
– Building Demolition
• Risk Communication
Dust sample
of allergens:
House dust
mite
German and
American
Cockroach
What you need to know:
Health
effects:
Dust levels:
House dust mites are tiny insects from
the spider family. They live in fabric
and can be found in mattresses,
pillows, cloth covered furniture, and
carpeting.
Dust mites live off dead skin scales
and need humidity to grow.
The allergen is what makes you sick.
Dust mite allergens come from their
body parts and feces.
The allergen is very small. When
breathed in, can start allergy and
asthma problems.
The allergen in the mattress and
pillow is very close to the face while
sleeping.
Dust mite
allergens can
cause breathing
problems, a stuffy
nose, and
sneezing.
Dust mite
allergens can
make asthma
symptoms worse
during the night or
early in the
morning
Dust mite allergen
levels above 2,000
ng/g may be
unhealthy.
The dust mite
allergen level in
your home is:
German and American roaches are
the most common type of roaches in
Baltimore.
Roaches live in small cracks and near
sources of food and water.
Allergens are found in both dead and
living roaches. Allergens make
allergies and asthma worse.
It is hard to get rid of roaches because
each female roach can have another
300 babies.
The allergen is found in their feces,
stomach juices and dead body parts.
Roaches can be a
big problem in the
inner cities.
Cockroach
allergens can
cause problems
with allergies and
asthma.
Cockroach
allergen levels
above 8 units/g
may be unhealthy.
The cockroach
allergen level in
your home is:
«CombDust»
ng/g
This level is:
If it is high, you should:
Put allergen-proof mattress and
pillow covers on your child’s bed.
Wash all bedding in hot water
every 1-2 week.
Remove carpeting and replace
with tile, vinyl, or linoleum.
Keep stuffed toys to a minimum.
Never keep stuffed toys on your
child’s bed.
Keep humidity low by using an air
conditioner or a dehumidifier.
High
X OK
«blag1» units/g
This level is:
X High
OK
Exterminate. A professional can
use much stronger, yet safe
chemicals. Baits and traps are
helpful. Never use roach sprays.
Take trash out daily.
Keep floor, counter tops and
appliances clean by sweeping and
mopping often.
Put exposed food in tightly sealed
containers such as sugar, snacks,
pasta boxes, breads and cereals.
Clean grease from the stove and
walls after cooking.
Dust Sample
of allergens:
Pets:
Cats
and
Dogs
What you need to know:
Health effects:
Dust levels:
If it is high, you should:
 People can be allergic to any furry
pets. The most common pet allergies
are to cats and dogs.
 The allergen from pets comes from
dander or skin scales, and saliva.
 The length of hair or fur does not
matter because the allergen comes
from the skin under the fur.
 Pet allergens easily travel all over the
house.
 It takes months of lots of cleaning to
remove pet allergens.
Pet allergens can
cause sneezing,
coughing and
wheezing.
The allergen is
very small so
easily gets in the
lungs.
Reactions to pets
may not start for
hours after
exposure.
Cat allergen levels
above
8,000 ng/g may be
unhealthy.
The cat allergen
level in your home
is:
 Finding the pet a new home is
best.
 If pet removal is not an option,
keep it outside at all times. Never
let the pet in the bedroom.
 Use allergen-proof mattress and
pillow covers on your child’s bed
and wash all the bedding every 12 week.
 Use an air cleaner to help remove
the small allergens from the air.
 Use filters on the furnace, air
conditioner and vents.
 If you are near a pet, shower and
change clothes to help remove the
sticky allergen.
«Feld1» ng/g
This level is:
X High
OK
Dog allergen levels
above 8,000 ng/g
may be unhealthy.
The dog allergen
level in your home
is:
«Canf1» ng/g
This level is:
High
X OK
Mice
 Mice spread their allergens through
urine and dander of skin scales.
 They enter homes through holes in
walls and doors and live in nests in
dark places. They come inside went it
gets cold outside
 Mice travel inside the home through
holes in the walls or up and down gas
and water pipes.
 Mice live near food and water sources.
They can live inside the oven, behind
walls and in the ceiling.
Mice urine and
dander can cause
allergies.
Mice allergens
can cause
problems with
asthma.
Mouse allergen
levels above 8,000
ng/gm may be
unhealthy.
The mouse
allergen level in
your home is:
«DustMUP»
ng/gm
This level is:
High
X OK
 Exterminate mice by using
mousetraps and poisons.
 Clean up floors, countertops and
stoves after meals.
 Keep exposed food in tightly
sealed containers and take trash
out everyday.
 Fill holes and around pipes with
steel wool to keep mice out.
 Remove clutter and keep clothes
and papers picked up to keep
mice from nesting in these soft
areas.
Air Pollutants
Ozone
Nitrogen
dioxide
Where it comes from:
Health effects
Your level:
The ozone we measured is
a type of air pollution. It is
different from the ozone
layer around the earth.
Ozone is highest on hot,
sunny days when it is humid
outside (summer).
It is formed from pollutants
that mostly come from car
exhaust.
Ozone is the main thing in
smog and gets inside when
windows and doors are
opened.
Ozone can cause breathing
problems, a stuffy nose,
and make eyes red and
burn.
Ozone also makes asthma
worse.
The level in
your home was:
Nitrogen dioxide is a
chemical found in smog and
can be found both inside
and outside the home.
It comes from burning fuel
such as oil, kerosene, coal,
natural gas, tobacco smoke,
and gasoline.
Indoor sources are cooking
with gas, using a gas stove
for heat or using a kerosene
heater.
Nitrogen dioxide causes
lung irritation and can make
asthma worse.
Nitrogen dioxide may also
cause eye irritation.
It can increase the risk of
getting a lung infection.
High
X OK
The average
level for the 3
days of
monitoring was:
To reduce your
exposure, you should:
On Ozone Action Days or on
hot, sunny, summer days stay
inside and keep the windows
and doors closed.
Keep cool by using an air
conditioner or by keeping
blinds or shades down
Stay in the lower level of your
home.
«Ozone_f»
ppb
*A level above
80 ppb
is not healthy
The level in
your home was:
High
X OK
The average
level for the 3
days of
monitoring was:
«NO2_f»
ppb
*A level above
53 ppb
is not healthy
Use electric sources of
cooking and heating.
If you use a gas stove, it is
helpful to open the windows or
use the exhaust fan when
cooking.
Never use a gas stove as a
source of heating your home.
If you need additional heat,
consider electric space heaters
instead of kerosene. Kerosene
gives off pollution that can
trigger an asthma attack.
Don’t allow smoking inside
your home.
Air Pollutants
Small Particles
Where it comes
from:
 It is in the main source
of outdoor haze.
 It is formed from
burning fuel such as
incineration, home
heating, car exhaust,
and gas cooking.
 Small particles are
also formed by
burning candles or
incense, tobacco
smoke, allergens, and
by using a fireplace.
Health effects:
Your level:
Small particles get
deep into the lungs.
They can irritate the
lungs and make
asthma worse.
Small particles also
cause eye, nose,
and throat irritation.
They increase the
risk of getting an
infection in the
lungs.
The level in your
home was:
High
X OK
Large particles can
cause shortness of
breath and asthma
by irritating the
lungs.
They can also
increase the risk of
getting an infection
in the lungs.
The level in your
home was:
High
X OK
The average level for
the 3 days of
monitoring was:
«PM25_f» g/m3
If it is high, you should:
 Do not burn candles or incense in
your home.
 Avoid using heating sources that
are not vented, such as a gas stove
or kerosene heater.
 Use an air cleaner to help remove
small particles from the air.
 Do not allow smoking inside your
home.
*A level above
65 g/m3
is not healthy

Large
Particles
Environmental
Tobacco Smoke
 Large particles are
formed from soot and
road dust being stirred
up, especially on
unpaved roads.
 Large particles come
from dust and
allergens inside the
home.
 Burning fuels are also
a source of large
particles.
 Cigarettes, pipes,
cigars
 Exposure from
anyone smoking
nearby
Second hand
smoke irritates the
lungs and can
cause an asthma
attack, lung cancer,
and breathing
problems.
The average level for
the 3 days of
monitoring was:


«PM10_f» g/m3

*A level above
150 g/m3

is not healthy

Environmental
tobacco smoke
X Was
Was Not
found in your home.
Keep windows and doors closed
especially on windy days if you
live near the road or have a lot of
loose dirt in your yard.
Wet mop the floors often to pick
up particles.
Vacuum at least weekly, use a
HEPA filter and open windows
while vacuuming
Change furnace filters every 3
months
Use an air cleaner to help remove
large particles from the air.
Use air conditioning instead of
opening windows if possible.
 Do not smoke around your child
inside the house or car.
 Try to smoke outside only
 Ask friends and family not to
smoke inside your home
 Consider quitting