1. Conducting A Community- Based 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

2. "Protection of Children from Environmental Health Risks and Safety Risks" –Charges agencies to consider special environmental risks to children A high priority to identify and assess environmental health risks to children –National Institute for Environmental Health Sciences (NIEHS) and Environmental Protection Agency (EPA) Fund research centers Executive Order April, 1997

3. Centers for Children’s Environmental Health Co sponsored by NIEHS, EPA, CDC

4. Johns Hopkins Center for the Asthmatic Child in the Urban Environment (CCAUE) Director: Peyton A. Eggleston, MD Associate Director: Patrick Breysse, PhD 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 Investigators

5. Why Focus on Asthma? In 1999… –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

6. 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

7. Environmental Factors in Urban Asthma Research Model RESPIRATORY MORBIDITY SUSCEPTIBILITY FACTORS ATOPY, INFLAMMATION CONTROL BRONCHIAL HYPERRESPONSIVENESS ASTHMATIC AIRWAY OBSTRUCTION AIR POLLUTANTS ALLERGENS CHILDREN LIVING IN URBAN ENVIRONMENTS UNDERLYING SOCIAL SUSCEPTIBILITY FACTORS POVERTY, STRESS, CONFLICTING NEEDS, EDUCATION, ADHERENCE, ACCESS TO CARE IMMUNOLOGIC SENSITIZATION

8. 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.

9. 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

10. STUDY AREA Air monitoring station

12. 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

13. Recruitment 387 children enrolled in asthma education program 180 eligible and interested 125 consented, questionnaire completed 116 baseline home evaluation 100 randomized 97 competed 1 year study

14. Intervention Protocol questionnaire skin test serum,FEV 1 home environment telephone 0 3 6 9 12 BASELINE CONTROL TREATMENT INTERVENTION

15. 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

16. Leaky Faucet, Dirty Dishes and a …Guest

17. Kitchen ceiling hole with water damage

18. Moldy Wall in Basement of Home

19. Air Cleaner

20. Environmental Monitoring Indoor Air Pollutants were measured over a 72-hr period in child's bedroom –Particulate Matter PM 10 PM 2.5 Data-logging Nephelometer –Ozone –Nitrogen Dioxide –Airborne nicotine (marker for passive smoking exposure)

21. In-Home Air Sampling Set-Up

22. Air Monitoring Station

23. Reservoir Dust Allergen Samples Vacuum samples collected in bedroom, living room/family room, and kitchen –Analyzed for Cockroach Dust mite Cat Dog Mouse

24. Baseline Characteristics CONTROLTREATMENT Age (mean)8.38.5 home ETS (%)6573 Cockroach (%)6662 Pos skin test (%)6575 Mod/severe syx (%)2028 controller meds (%)3428 FEV1 (% pred)94±21101±20 ED visit/3 mon (%)3632

25. Housing Characteristics Characteristic% % Row House91Leaks in bedroom18 Roof Leaks24Food in bedroom29 Cats26Cockroaches in bedroom8 Dogs20Mouse droppings in bedroom 7 Current smoker46 Moisture damage in kitchen22 Cockroaches in kitchen31 Mouse droppings in kitchen38

26. PM 10 treatment PM 2.5 treatment PM 10 control PM 2.5 control p<0.001 p=0.08 p=0.019 Particulate Concentrations: % Change PM 10 treatment PM 2.5 treatment PM 10 control PM 2.5 control

27. Bedroom Cockroach Allergen Bla g 1 U/gm p=0.07 p=0.001 Treatment Control

28. Proportion of children with wheeze, cough, dyspnea in last 2 weeks Change in proportion with symptoms Treatment group Control group p=<0.001 p=0.60 p=<0.001 p=0.02

29. Other Health Outcomes Other health outcomes not different between the two groups –Nighttime symptoms –ED visits –Hospitalizations –FEV 1

30. 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

31. 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

32. 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

33. 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

34. Co-Learning CAB sponsored “staff development seminars” –Purpose is to learn about the community –Included a half-day guided tour of the neighborhood

35. 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

36. House dust mite German and American Cockroach  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. Cockroach allergen levels above 8 units/g may be unhealthy. The cockroach allergen level in your home is: «blag1» units/g This level is: X High OK Roaches can be a big problem in the inner cities. Cockroach allergens can cause problems with allergies and asthma.  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.  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. Dust mite allergen levels above 2,000 ng/g may be unhealthy. The dust mite allergen level in your home is: «CombDust» ng/g This level is: High X OK 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  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. If it is high, you should:Dust levels: Health effects: What you need to know: Dust sample of allergens:

37. Mice  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. 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 Mice urine and dander can cause allergies. Mice allergens can cause problems with asthma.  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. 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  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 1- 2 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. Cat allergen levels above 8,000 ng/g may be unhealthy. The cat allergen level in your home is: «Feld1» ng/g This level is: X High OK 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.  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. If it is high, you should:Dust levels:Health effects:What you need to know: Dust Sample of allergens: Pets: Cats and Dogs

38. Ozone Nitrogen dioxide  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. 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 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.  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.  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. The level in your home was: High X OK The average level for the 3 days of monitoring was: «Ozone_f» ppb *A level above 80 ppb is not healthy Ozone can cause breathing problems, a stuffy nose, and make eyes red and burn. Ozone also makes asthma worse.  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. To reduce your exposure, you should: Your level:Health effectsWhere it comes from:Air Pollutants

39. Large Particles Environmental Tobacco Smoke  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 Environmental tobacco smoke X Was Was Not found in your home. Second hand smoke irritates the lungs and can cause an asthma attack, lung cancer, and breathing problems.  Cigarettes, pipes, cigars  Exposure from anyone smoking nearby  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. The level in your home was: High X OK The average level for the 3 days of monitoring was: « PM10_f»  g/m 3 *A level above 150  g/m 3 is not healthy 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.  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.  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. The level in your home was: High X OK The average level for the 3 days of monitoring was: « PM25_f»  g/m 3 *A level above 65  g/m 3 is not healthy 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.  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. Small Particles If it is high, you should:Your level:Health effects: Where it comes from: Air Pollutants