Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma

Epidemiological study of post-pandemic pediatric common respiratory pathogens using multiplex detection

BACKGROUND

The burden and characteristics of respiratory viral infections in children hospitalized for acute respiratory tract infections (ARTIs) during the post-COVID-19 pandemic era are unclear. We analyzed the epidemiological and clinical characteristics of pediatric patients hospitalized with common respiratory virus infections before and after relaxation of non-pharmaceutical interventions in Hangzhou, China and evaluated the diagnostic value of the six-panel respiratory pathogen detection system.

METHODS

Six types of respiratory viruses were detected in respiratory samples from children with suspected ARTIs by multiplex real-time quantitative polymerase chain reaction (RT-qPCR). Changes in virus detection rates and epidemiological and clinical characteristics, obtained from electronic health records, were analyzed. Binary logistic regression was used to identify respiratory tract infections risk factors. Multiplex RT-qPCR and targeted next-generation sequencing results were compared in random samples.

RESULTS

Among the 11,056 pediatric samples, 3228 tested positive for one or more of six common respiratory pathogens. RSV and PIV-3 detection rates differed significantly across age groups (both P < 0.001), and were more common in younger children. PIV-1 was more common in infants, toddlers, and preschoolers than in school-age children (P < 0.001). FluB was predominantly detected in school-age children (P < 0.001). RSV-, ADV-, and PIV-1-positivity rates were higher in 2022 than in 2023. Seasonal viral patterns differed across years. RSV (OR 9.156. 95% CI 5.905-14.195) and PIV-3 (OR 1.683, 95% CI 1.133-2.501) were risk factors for lower respiratory tract infections. RSV-positivity was associated with severe pneumonia (P = 0.044). PIV-3 (OR 0.391, 95% CI 0.170-0.899), summer season (OR 1.982, 95% CI 1.117-3.519), and younger age (OR 0.938, 95% CI 0.893-0.986) influenced pneumonia severity. Multiplex RT-qPCR showed good diagnostic performance.

CONCLUSION

After changes in COVID-19 prevention and control strategies, six common respiratory viruses in children were prevalent in 2022-2023, with different seasonal epidemic characteristics and age proclivities. RSV and PIV-3 cause lower, and FluA, FluB, and ADV more typically cause upper respiratory tract infections. Infancy and summer season influence severe pneumonia risk. Multiplex RT-qPCR is valuable for accurate and timely detection of respiratory viruses in children, which facilitates management, treatment, and prevention of ARTIs.

The interaction between voice disorders and stress for work ability of teachers

OBJECTIVE

Less attention has been paid to the interaction between voice disorders, stress, and indoor environmental quality for work ability in teachers. Therefore, our aim was to study whether lower work ability associated more strongly when the variables of voice disorders and stress at work were combined as opposed to evaluating these two factors separately.

METHODS

We conducted a questionnaire study including validated self-assessment of work ability and a technical assessment of school buildings utilizing a sample of 1198 and a subsample (n = 538) of Finnish teachers.

RESULTS

When combined, voice disorders and stress at work had a stronger association to decreased work ability than when they were evaluated separately. The occurrence of stress was more prevalent in poor and moderate work ability than the occurrence of voice disorders. Nine out of 10 of the teachers who had neither voice disorders nor stress reported good work ability, while four out of 10 of the teachers who suffered from both voice disorders and stress had poor work ability. As regards the background variables, nearly half of the subjects working in the non-problem buildings have neither stress nor voice disorders.

DISCUSSION

We recommend offering support for reducing stress at work to improve teachers' work performance. The findings also support the maintenance of school buildings and keeping them in good condition. Follow-up studies are needed to investigate the possible effects of voice disorders and the associated variables on work ability.

Exposure to different residential indoor characteristics during childhood and asthma in adolescence: a latent class analysis of the Danish National Birth Cohort

BACKGROUND

Many residential indoor environments may have an impact on children's respiratory health.

OBJECTIVES

The aims of this study were to identify latent classes of children from the Danish National Birth Cohort (DNBC) who share similar patterns of exposure to indoor home characteristics, and to examine the association between membership in the latent classes and asthma in adolescence.

METHODS

We included data on residential indoor characteristics of offspring from the DNBC whose mothers had responded to the child's 11-year follow-up and who had data on asthma from the 18-year follow-up. Number of classes and associations were estimated using latent class analysis. To account for sample selection, we applied inverse probability weighting.

RESULTS

Our final model included five latent classes. The probability of current asthma at 18 years was highest among individuals in class one with higher clustering on household dampness (9, 95%CI 0.06-0.13). Individuals in class four (with higher clustering on pets ownership and living in a farm) had a lower risk of current asthma at age 18 compared to individuals in class one (with higher clustering on household dampness) (OR 0.53 (95%CI 0.32-0.88), p = .01).

CONCLUSION

Our findings suggest that, in a high-income country such as Denmark, groups of adolescents growing up in homes with mold and moisture during mid-childhood might be at increased risk of current asthma at age 18. Adolescents who grew-up in a farmhouse and who were exposed to pets seem less likely to suffer from asthma by age 18.

Overcrowding and Hazardous Dwelling Condition Characteristics: A Systematic Search and Scoping Review of Relevance for Health

Crowding in dwellings is an important public health issue. We hypothesize that overcrowding may cause indirect health effects by adversely affecting the dwelling itself, for example, by increasing dampness leading to mold. We therefore performed a systematic search and a scoping review on overcrowding leading to dwelling condition characteristics of relevance for health. A literature search was performed using the PubMed and Scopus databases up to 5 March 2021. The search yielded 100 records with relevant information. We found that overcrowding is defined in numerous ways and often address "socially deprived" populations. Six studies report associations of overcrowding with at least one dwelling condition characteristic, namely lead, cadmium, microorganism distribution, dust mite and cockroach allergens in dust, cockroach infestation, peeling paint, and mold. One of the studies reports associations between several characteristics, e.g., association of mold with cleanliness and rodent infestation, and points out the common use of pesticides. Additional characteristics were extracted from the remaining 94 records, without data on statistical associations with overcrowding. Our review suggests that multiple potentially hazardous dwelling condition characteristics often coincide in overcrowded dwellings. The epidemiological attribution of health effects to any characteristic is therefore difficult. Causal relationships are even more difficult to establish, as overcrowding is also associated with a range of social and other circumstances that may affect health. The complexity should be considered by scientists and practitioners dealing with overcrowding in dwellings.

Patient perceptions of vulnerability to recurrent respiratory tract infections and prevention strategies: a qualitative study

OBJECTIVES

Respiratory tract infections (RTIs) are extremely common, usually self-limiting, but responsible for considerable work sickness absence, reduced quality of life, inappropriate antibiotic prescribing and healthcare costs. Patients who experience recurrent RTIs and those with certain comorbid conditions have higher personal impact and healthcare costs and may be more likely to suffer disease exacerbations, hospitalisation and death. We explored how these patients experience and perceive their RTIs to understand how best to engage them in prevention behaviours.

DESIGN

A qualitative interview study.

SETTING

Primary care, UK.

METHODS

23 participants who reported recurrent RTIs and/or had relevant comorbid health conditions were interviewed about their experiences of RTIs. Interviews took place as the COVID-19 pandemic began. Data were analysed using inductive thematic analysis.

RESULTS

Three themes were developed: Understanding causes and vulnerability, Attempting to prevent RTIs, Uncertainty and ambivalence about prevention, along with an overarching theme; Changing experiences because of COVID-19. Participants' understandings of their susceptibility to RTIs were multifactorial and included both transmission via others and personal vulnerabilities. They engaged in various approaches to try to prevent infections or alter their progression yet perceived they had limited personal control. The COVID-19 pandemic had improved their understanding of transmission, heightened their concern and motivation to avoid RTIs and extended their repertoire of protective behaviours.

CONCLUSIONS

Patients who experience frequent or severe RTIs are likely to welcome and benefit from advice and support regarding RTI prevention. To engage people effectively, those developing interventions or delivering health services must consider their beliefs and concerns about susceptibility and prevention.

Home environmental interventions for prevention of respiratory tract infections: a systematic review and meta-analysis

OBJECTIVES

Poor housing conditions have been associated with increased risks of respiratory infections. This review aims to determine whether modifying the physical environment of the home has benefits in reducing respiratory infections.

CONTENT

We performed a systematic review and meta-analysis of the effectiveness of home environmental interventions for preventing respiratory tract infections. Ten electronic databases were searched to identify randomized controlled trials published from inception to July 31, 2020. Random-effects meta-analyses were used to assess the study outcomes. Our search identified 14 eligible studies across 12 countries, which comprised 87,428 households in total. The type of interventions on home environment included kitchen appliance and design, water supply and sanitation, house insulation, and home heating. Meta-analysis indicated a potential benefit of home environmental interventions in preventing overall respiratory tract infections (Absolute RR=0.89, 95% CI=0.78-1.01, p=0.07; Pooled adjusted RR=0.72, 95% CI=0.63-0.84, p<0.0001). Subgroup analyses depicted that home environmental interventions had no significant impact on lower respiratory tract infections, pneumonia, and severe pneumonia. A protective effect against respiratory infections was observed in high income country setting (RR=0.82, 95% CI=0.78-0.87, p<0.00001).

SUMMARY AND OUTLOOK

Home environmental interventions have the potential to reduce morbidity of respiratory tract infections. The lack of significant impact from stand-alone housing interventions suggests that multicomponent interventions should be implemented in tandem with high-quality health systems.

Detection of Candida albicans-Specific CD4+ and CD8+ T Cells in the Blood and Nasal Mucosa of Patients with Chronic Rhinosinusitis

Candida albicans is ubiquitously present, and colonization in the nose and oral cavity is common. In healthy patients, it usually does not act as a pathogen, but in some cases can cause diseases. The influence of C. albicans as a trigger of T cell activation on the pathogenesis of chronic rhinosinusitis (CRS) is controversial, and its exact role is not clear to date. The aim of the present study was to detect and characterize C. albicans-specific CD4+ and CD8+ T cells in patients with CRS, with and without nasal polyps. Tissue and blood samples were collected from patients suffering from chronic rhinosinusitis with (CRSwNP) and without nasal polyps (CRSsNP), and from healthy controls. A peptide pool derived from C. albicans antigen was added to tissue and blood samples. After 6 days, lymphocytes were analyzed by multicolor flow cytometry. Activation was assessed by the intracellular marker Ki-67, and the cytokine secretion was measured. Tissue CD8+ T cells of CRSsNP patients showed a significantly higher proportion of Ki-67+ cells after activation with C. albicans antigen compared to peripheral blood CD8+ T cells. Cytokine secretion in response to C. albicans antigen was similar for all study groups. In this study, C. albicans-specific CD4+ and CD8+ T cells were detected in peripheral blood and mucosal tissue in all study groups. In patients suffering from CRSsNP, C. albicans-specific CD8+ T cells were relatively enriched in the nasal mucosa, suggesting that they might play a role in the pathogenesis of CRSsNP.

Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART)

OBJECT

To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients.

METHODS

The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article.

RESULTS

A detailed guideline about all aspects of allergic rhinitis was created.

CONCLUSION

The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.

Skin sensitivity to capsaicin, perceived stress and burn out among patients with building-related symptoms

Objective

The mechanisms behind building-related symptoms have remained unknown despite many years of research. It is known that environmental and psychosocial factors are of importance. Some receptors in the Transient Receptor Potential family elicit the same symptoms when stimulated, as reported by those suffering from building-related symptoms. The aim of this study was to compare capsaicin sensitivity between people with and without skin symptoms. A second aim was to investigate perceived stress among individuals with different levels of capsaicin sensitivity.

Methods

People referred to an occupational health care unit and judged to have building-related symptoms by a physician answered a questionnaire regarding their symptoms. Solutions with different capsaicin concentrations were applied to participants’ nasolabial folds. Self-reported stress and burnout were assessed using two questionnaires: the Perceived Stress Scale (PSS) and the Shirom-Melamed Burnout Questionnaire (SMBQ).

Results

We found that people who reported facial erythema or itching, stinging, tight or burning facial skin were more sensitive than those without symptoms and similarities with Sensitive Skin are discussed. We also found that participants who reacted to the lowest capsaicin concentrations scored significantly higher on scales for stress and burnout.

Conclusions

We found associations between sensitivity to capsaicin and skin symptoms among people with building-related symptoms, as well as associations between capsaicin sensitivity and perceived stress/burnout.

Asthma and Allergies in the School Environment

The school is a complex microenvironment of indoor allergens, pollutants, and other exposures. The school represents an occupational model for children and exposures in this environment have a significant health effect. Current research establishes an association between school exposure and asthma morbidity in children. This review will focus on common school environmental exposures (cockroach, rodents, cat, dog, classroom pets, dust mite, fungus, and pollution) and their impact on children with allergies and asthma. Understanding and evaluation of school-based environments is needed to help guide school-based interventions. School-based interventions have the potential for substantial benefit to the individual, school, community, and public health. However, there is a paucity data on school-based environmental interventions and health outcomes. The studies performed to date are small and cross-sectional with no control for home exposures. Randomized controlled school-based environmental intervention trials are needed to assess health outcomes and the cost-effectiveness of these interventions. The School Inner-City Asthma Intervention Study (SICAS 2), a NIH/NIAID randomized controlled clinical trial using environmental interventions modeled from successful home-based interventions, is currently underway with health outcome results pending. If efficacious, these interventions could potentially help further guide school-based interventions potentially with policy implications. In the meanwhile, the allergist/immunologist can continue to play a vital role in improving the quality of life in children with allergies and asthma at school through the use of the ADA policy and Section 504 of the Rehabilitation Act as well as encouraging adoption of toolkits to build successful school-based asthma programs and asthma-friendly schools.

The Role of Home Environments in Allergic Disease

Allergic diseases are surprisingly common, chronic health conditions. The primary location where the vast majority of people are exposed to allergens and other substances is in their home. This means it is important to understand home environments and how a home's systems function and interact-and that how we occupy these spaces plays a crucial role in both environmental exposure and management of allergic disease. This review provides an overview of what is understood about home environmental exposure and its impact on our health, and proposes a systematic process for using a patient's environmental history to develop individualized, manageable and cost-effective recommendations. Once occupant-related information has been gathered, a home environmental exposure assessment should be performed focused on identifying the relationships between any identified sources of contaminants and the housing systems, and conditions that may be contributing to exposure. The results and recommendations from this assessment can then be used to guide exposure-reduction efforts by patients and/or their caregivers in an effort to improve disease management. In this review, we'll discuss three different types of home interventions-active, which must be routinely performed by the patient and/or caregiver, passive, which are interventions that work without routine, direct interaction from the homeowner, and behavioral changes in how the home environment is cleaned and maintained for long-term reduction of allergens. In this review, and others evaluated for this discussion, a significant number of home environmental assessment and intervention programs were shown to be cost effective, with the majority of programs showing a net positive return on investment. It is important to recognize that to be cost effective, the level and intensity of services offered through home visit programs need be stratified, based on the estimated health risks of the patient, in order to tailor the assessment and target the interventions to a patient's needs while maximizing cost effectiveness.

Associations between indoor environmental quality in schools and symptom reporting in pupil-administered questionnaires

BACKGROUND

The associations between indoor environmental quality (IEQ) in homes and symptom reporting of children have been extensively studied, but only few large-scale studies have been done in schools. We examined associations between expert-assessed IEQ in schools and pupils' reporting of different symptoms, and whether associations were stronger if participants relate symptoms to the school environment.

METHODS

The questionnaire survey was done in all primary and secondary schools in two areas of Helsinki, Finland. Primary school pupils (grade 3-6, n = 8775, 99 school-buildings) and secondary school pupils (grade 7-9, n = 3410, 30 school-buildings) reported their symptoms. Symptoms were combined into respiratory, lower respiratory, eye, skin, and general symptom groups. Surveys were also done among the parents of the primary school pupils (grade 1-6, n = 3540, 88 school buildings), but results are reported only in the supplement due to the low response rate (20% in 2017 and 13% in 2018). The associations between IEQ and symptoms were analyzed using multilevel logistic regression analysis.

RESULTS

Several of the IEQ indicators were highly correlated and indicators were therefore mainly analyzed by combining them into a summary score and into latent classes. Dose-response associations were found between IEQ problems and higher reporting of respiratory and general symptoms among both primary and secondary school pupils. Some associations were also observed with lower respiratory and skin symptoms, but not with eye symptoms. The associations were somewhat stronger with symptoms related to the school environment compared to symptoms reported without such relation: for a unit change in IEQ summary score and respiratory symptoms in primary schools, odds ratios were 1.07 (95% CI 1.02-1.06) and 1.04 (95% CI 1.04-1.10), and in secondary schools 1.09 (95% CI 1.01-1.09) and 1.05 (95% CI 1.02-1.17), respectively.

CONCLUSIONS

Expert-assessed IEQ problems in schools were associated with increased reporting of especially respiratory and general symptoms. The associations were only somewhat stronger in magnitude for symptoms reported in relation to the school environment compared to symptoms reported without such relation.

Indoor Environmental Interventions for Furry Pet Allergens, Pest Allergens, and Mold: Looking to the Future

Over the last 2 to 3 decades, significant advances have been made in understanding the role that indoor allergen exposures play with regard to respiratory health. Multiple studies have confirmed that sensitization and exposure to indoor allergens can be a risk factor for asthma morbidity. Environmental interventions targeting key indoor allergens have been evaluated with the aims of examining their causal effects on asthma-related outcomes and identifying clinically efficacious interventions to incorporate into treatment recommendations. Historically, it appeared that the most successful intervention, as performed in the Inner-City Asthma Study, was individually tailored, targeting multiple allergens in a predominantly low-income, minority, and urban pediatric population. Recent studies suggest that single-allergen interventions may be efficacious when targeting the most clinically relevant allergen for a population. In this article, we review recent literature on home environmental interventions and their effects on specific indoor allergen levels and asthma-related outcomes.

Knowledge gaps in the construction of rural healthy homes: A research agenda for improved low-cost housing in hot-humid Africa

Lorenz von Seidlein and colleagues discuss improving house designs in rural Africa to benefit health.

Probability of Abnormal Indoor Air Exposure Categories Compared with Occupants’ Symptoms, Health Information, and Psychosocial Work Environment

Indoor air problems are complicated and need to be approached from many perspectives. In this research, we studied the association of four-level categorisation of the probability of abnormal indoor air (IA) exposure with the work environment-related symptoms, group-level health information and psychosocial work environment of employees. We also evaluated the multiprofessional IA group assessment of the current indoor air quality (IAQ) of the hospital premises. We found no statistical association between the four-level categorisation of the probability of abnormal IA exposure and the employees’ perceived symptoms, health information, and perceived psychosocial work environment. However, the results showed a statistical association between perceived symptoms and man-made vitreous fibre sources in ventilation. Furthermore, extensive impurity sources in the premises increased the employees’ contact with health services and their perceived symptoms. The employees perceived stress and symptoms in all categories of abnormal IA exposure, which may be related to IAQ or other factors affecting human experience. Prolonged process management may influence users’ experiences of IAQ. The results suggest that an extensive impurity source in premises does not always associate with the prevalence of perceived symptoms. We conclude that indoor air questionnaires alone cannot determine the urgency of the measures required.

Bedroom Allergen Exposure Beyond House Dust Mites

PURPOSE OF REVIEW

The review provides insight into recent findings on bedroom allergen exposures, primarily focusing on pet, pest, and fungal exposures.

RECENT FINDINGS

Large-scale studies and improved exposure assessment technologies, including measurement of airborne allergens and of multiple allergens simultaneously, have extended our understanding of indoor allergen exposures and their impact on allergic disease. Practical, streamlined methods for exposure reduction have shown promise in some settings, and potential protective effects of early-life exposures have been further elucidated through the investigation of specific bacterial taxa. Advances in molecular allergology have yielded novel data on sensitization profiles and cross-reactivity. The role of indoor allergen exposures in allergic disease is complex and remains incompletely understood. Advancing our knowledge of various co-exposures, including the environmental and host microbiome, that interact with allergens in early life will be crucial for the development of efficacious interventions to reduce the substantial economic and social burden of allergic diseases including asthma.

An Official American Thoracic Society Workshop Report: Presentations and Discussion of the Sixth Jack Pepys Workshop on Asthma in the Workplace

The Sixth Jack Pepys Workshop on Asthma in the Workplace focused on six key themes regarding the recognition and assessment of work-related asthma and airway diseases: (1) cleaning agents and disinfectants (including in swimming pools) as irritants and sensitizers: how to evaluate types of bronchial reactions and reduce risks; (2) population-based studies of occupational obstructive diseases: use of databanks, advantages and pitfalls, what strategies to deal with biases and confounding?; (3) damp environments, dilapidated buildings, recycling processes, and molds, an increasing problem: mechanisms, how to assess causality and diagnosis; (4) diagnosis of occupational asthma and rhinitis: how useful are recombinant allergens (component-resolved diagnosis), metabolomics, and other new tests?; (5) how does exposure to gas, dust, and fumes enhance sensitization and asthma?; and (6) how to determine probability of occupational causality in chronic obstructive pulmonary disease: epidemiological and clinical, confirmation, and compensation aspects. A summary of the presentations and discussion is provided in this proceedings document. Increased knowledge has been gained in each topic over the past few years, but there remain aspects of controversy and uncertainty requiring further research.

Indoor mould exposure, asthma and rhinitis: findings from systematic reviews and recent longitudinal studies

Starting from the Institute of Medicine (IOM) and World Health Organization (WHO) reports, this review provides an overview of the literature published from 2006 to 2017 on the associations between indoor mould exposure and asthma and rhinitis separately in children and adults with a focus on longitudinal epidemiological studies.A systematic search of peer-reviewed literature was performed, including systematic reviews and meta-analyses, longitudinal, incident case-control and panel studies. 61 publications were identified reporting visible mould or mould odour or quantitative assessment of culturable fungi or mould species.In children, visible mould and mould odour were associated with the development and exacerbations of asthma, providing sufficient evidence of a causal relationship. Results from population-based studies in adults were too few and divergent to conclude at more than a limited level of evidence. Exposure to mould in a work building was associated with the incidence and exacerbations of occupational asthma, and we concluded at a sufficient evidence for an association. Systematic reviews, meta-analyses and longitudinal studies on the relationships between mould exposure and allergic rhinitis provide sufficient evidence of an association.This review extended the conclusions of the IOM and WHO reports, and highlighted the need for further longitudinal studies on asthma in adults, and on rhinitis.

Association between Four-Level Categorisation of Indoor Exposure and Perceived Indoor Air Quality

The aim of this study was to develop and test a tool for assessing urgency of indoor air quality (IAQ) measures. The condition of the 27 buildings were investigated and results were categorized. Statistical test studied the differences between the categories and the employees&rsquo; complaints about their work environment. To study the employees&rsquo; experiences of the work premises, a validated indoor air (IA) questionnaire was used. This study reveals a multifaceted problem: many factors affecting IAQ may also affect perceived IAQ, making it difficult to separate the impurity sources and ventilation system deficiencies affecting to employee experiences. An examination of the relationship between the categories and perceived IAQ revealed an association between the mould odour perceived by employees and mould detected by the researcher. A weak link was also found between the assessed categories and environmental complaints. However, we cannot make far-reaching conclusions regarding the assessed probability of abnormal IA exposure in the building on the basis of employee experiences. According to the results, categorising tool can partly support the assessment of the urgency for repairs when several factors that affect IAQ are taken into account.

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

Indoor Environmental Interventions and their Effect on Asthma Outcomes

PURPOSE OF REVIEW

The use of environmental interventions to improve outcomes in asthmatics has long been an elusive goal. While numerous interventions have been studied, the results of clinical trials have been mixed. This review aims to identify combinations of interventions that have been proven to be effective and to propose a model for using them in a clinical setting.

RECENT FINDINGS

An NIH workshop emphasized a need for research to identify effective interventions for reducing indoor exposures and improving asthma outcomes. A number of innovative measures were described, though evidence supporting their use was lacking. A recent systematic review described various interventions for which evidence is available. The greatest challenge for this approach is the same as that for the medical approach to treatment: nonadherence. Given evidence for effective interventions, control of environmental exposures should lead to improved asthma outcomes. Methods to improve adherence need to be identified.

Monitoring biodiversity in libraries: a pilot study and perspectives for indoor air quality

Indoor Air Quality (IAQ) in libraries is influenced by the presence of specific factors which can impact on both paper storage as well as people health. Microclimatic conditions induce and support a biodiversity pattern involving environmental and anthropic microorganisms. We used a multidisciplinary monitoring model to characterize microflora biodiversity by Next Generation Sequencing (NGS). Biodiversity indexes were adapted to evaluate anthropic vs environmental pollution by combining Shannon mean index (H), species representativeness (E_H), human/environmental pollution ratio (SA) to better characterize the NGS output and acquire synthetic information on Indoor Air Microbial Biodiversity (IAMB). Results indicate a frequently low microbial load (IGCM/m³ < 1000) characterized by different species (n = 102), including several cellulose metabolizing bacteria. Workers and visitors appeared a relevant source of microbial contamination. Air biodiversity assayed by NGS seems a promising marker for studying IAQ.

Predictors of emergency department use in children with persistent asthma in metropolitan Atlanta, Georgia

BACKGROUND

Racial disparities are evident among children with asthma in the United States, with non-Hispanic black children at particularly high risk for poor asthma outcomes, including frequent emergency department (ED) use for asthma exacerbations.

OBJECTIVE

To compare asthma features in non-Hispanic black vs white children in Atlanta, Georgia, and determine what clinical features predict future ED use for asthma.

METHODS

Self-reported black and white children 6 to 17 years of age with persistent asthma treated with controller medications completed medical history questionnaires, lung function testing, aeroallergen sensitization testing, and venipuncture. Medical records were reviewed for asthma-related ED visits for 12 months after the initial study visit.

RESULTS

A total of 276 children were enrolled. Black children, compared with white children, resided in more disadvantaged zip code areas and were more likely to have public insurance. Black children also had more features of asthma severity and more ED visits during the study period. Predictors of ED use, aside from a previous ED visit, differed by race. After adjustment for socioeconomic status, predictors of ED use in white children included an ED visit in the previous year and sensitization to pets and dust; in black children, predictors included ED use in the previous year, the number of asthma controller medications, forced expiratory volume in 1 second less than 80% predicted, blood eosinophil count greater than 4%, and mold sensitization.

CONCLUSION

Asthma features and ED use differ between black and white children in metropolitan Atlanta. Strategies to eliminate allergen exposure in the home and improve asthma control in these children may require tailoring for different racial groups.

SBS symptoms in relation to dampness and ventilation in inspected single-family houses in Sweden

Purpose

To investigate the relationships between symptoms compatible with the sick building syndrome (SBS) in adults and building dampness and ventilation in single-family houses.

Methods

Within the Swedish BETSI study, a national sample of single-family houses were inspected by professional building experts, and adults living in the houses answered a questionnaire on SBS. Relationships between building factors and SBS were analysed using logistic regression.

Results

Of the respondents, 23% reported having had weekly SBS symptoms during the last three months. A large proportion of houses exhibited building or construction problems. In total, 40% of houses had dampness problems in the foundation, and this was related to a higher prevalence of both mucous and dermal symptoms, and any SBS symptoms. Furthermore, high air humidity was related to more symptoms, with the relationship with absolute humidity being stronger than that with relative humidity or moisture load. Symptoms were also more prevalent in houses with a high U value, reflecting a poor thermal insulation. Compared to natural ventilation, living in a house with mechanical supply and exhaust ventilation was related to a lower prevalence of general symptoms and any SBS symptoms, but there were only weak associations between measured air exchange rate and symptoms.

Conclusions

A large proportion of single-family houses have dampness problems in the foundation, and pollutants may enter the living space of the house and affect the health of the occupants. Furthermore, absolute air humidity should be measured more often in indoor air studies.

Recent advances in environmental controls outside the home setting

PURPOSE OF REVIEW

It has been well studied that aeroallergen, mold, and airborne pollutant exposure in the inner-city home environment is associated with significant childhood asthma morbidity. Although the home environment has been extensively studied, the school environment is less well understood.

RECENT FINDINGS

In this article, we discuss the relationship between environmental exposures within the school and daycare environment and pediatric asthma morbidity and novel environmental interventions designed to help mitigate pediatric asthma morbidity.

SUMMARY

Studies assessing environmental exposures outside the home environment and interventions to mitigate these exposures have the potential to reduce pediatric asthma morbidity. Further study in this area should focus on the complex cost benefit analyses of environmental interventions outside the home setting, while controlling for the home environment.

Comparing cognitive-behavioural psychotherapy and psychoeducation for non-specific symptoms associated with indoor air: a randomised control trial protocol

INTRODUCTION

Indoor air-related conditions share similarities with other conditions that are characterised by medically unexplained symptoms (MUS)-a combination of non-specific symptoms that cannot be fully explained by structural bodily pathology. In cases of indoor air-related conditions, these symptoms are not fully explained by either medical conditions or the immunological-toxicological effects of environmental factors. The condition may be disabling, including a non-adaptive health behaviour. In this multifaceted phenomenon, psychosocial factors influence the experienced symptoms. Currently, there is no evidence of clinical management of symptoms, which are associated with the indoor environment and cannot be resolved by removing the triggering environmental factors. The aim of this study is to compare the effect of treatment-as-usual (TAU) and two psychosocial interventions on the quality of life, and the work ability of employees with non-specific indoor air-related symptomatology.

METHODS AND ANALYSES

The aim of this ongoing randomised controlled trial is to recruit 60 participants, in collaboration with 5 occupational health service units. The main inclusion criterion is the presence of indoor air-related recurrent symptoms in ≥2 organ systems, which have no pathophysiological explanation. After baseline clinical investigations, participants are randomised into interventions, which all include TAU: cognitive-behavioural psychotherapy, psychoeducation and TAU (control condition). Health-related quality of life, measured using the 15D-scale, is the primary outcome. Secondary outcomes include somatic and psychiatric symptoms, occupational factors, and related underlying mechanisms (ie, cognitive functioning). Questionnaires are completed at baseline, at 3, 6 and 12-month follow-ups. Data collection will continue until 2017. The study will provide new information on the individual factors related to indoor air-associated symptoms, and on ways in which to support work ability.

ETHICS AND DISSEMINATION

The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02069002; Pre-results.

Toward a microbial Neolithic revolution in buildings

The Neolithic revolution--the transition of our species from hunter and gatherer to cultivator--began approximately 14,000 years ago and is essentially complete for macroscopic food. Humans remain largely pre-Neolithic in our relationship with microbes but starting with the gut we continue our hundred-year project of approaching the ability to assess and cultivate benign microbiomes in our bodies. Buildings are analogous to the body and it is time to ask what it means to cultivate benign microbiomes in our built environment. A critical distinction is that we have not found, or invented, niches in buildings where healthful microbial metabolism occurs and/or could be cultivated. Key events affecting the health and healthfulness of buildings such as a hurricane leading to a flood or a burst pipe occur only rarely and unpredictably. The cause may be transient but the effects can be long lasting and, e.g., for moisture damage, cumulative. Non-invasive "building tomography" could find moisture and "sentinel microbes" could record the integral of transient growth. "Seed" microbes are metabolically inert cells able to grow when conditions allow. All microbes and their residue present actinic molecules including immunological epitopes (molecular shapes). The fascinating hygiene and microbial biodiversity hypotheses propose that a healthy immune system requires exposure to a set of microbial epitopes that is rich in diversity. A particular conjecture is that measures of the richness of diversity derived from microbiome next-generation sequencing (NGS) can be mechanistically coupled to--rather than merely correlated with some measures of--human health. These hypotheses and conjectures inspire workers and funders but an alternative is also consequent to the first Neolithic revolution: That the genetic uniformity of contemporary foods may also decrease human exposure to molecular biodiversity in a heath-relevant manner. Understanding the consequences--including the unintended consequences of the first Neolithic revolution--will inform and help us benignly implement the second--the microbial--Neolithic revolution.

Exposure and Health Effects of Fungi on Humans

Fungi are ubiquitous microorganisms that are present in outdoor and indoor environments. Previous research has found relationships between environmental fungal exposures and human health effects. We reviewed recent articles focused on fungal exposure and dampness as risk factors for respiratory disease development, symptoms, and hypersensitivity. In particular, we reviewed the evidence suggesting that early exposure to dampness or fungi is associated with the development of asthma and increased asthma morbidity. Although outdoor exposure to high concentrations of spores can cause health effects such as asthma attacks in association with thunderstorms, most people appear to be relatively unaffected unless they are sensitized to specific genera. Indoor exposure and dampness, however, appears to be associated with an increased risk of developing asthma in young children and asthma morbidity in individuals who have asthma. These are important issues because they provide a rationale for interventions that might be considered for homes and buildings in which there is increased fungal exposure. In addition to rhinitis and asthma, fungus exposure is associated with a number of other illnesses including allergic bronchopulmonary mycoses, allergic fungal sinusitis, and hypersensitivity pneumonitis. Additional research is necessary to establish causality and evaluate interventions for fungal- and dampness-related health effects.

Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma

BACKGROUND

Dampness and mould in buildings have been associated with adverse respiratory symptoms, asthma and respiratory infections of inhabitants. Moisture damage is a very common problem in private houses, workplaces and public buildings such as schools.

OBJECTIVES

To determine the effectiveness of repairing buildings damaged by dampness and mould in order to reduce or prevent respiratory tract symptoms, infections and symptoms of asthma.

SEARCH METHODS

We searched CENTRAL (2014, Issue 10), MEDLINE (1951 to November week 1, 2014), EMBASE (1974 to November 2014), CINAHL (1982 to November 2014), Science Citation Index (1973 to November 2014), Biosis Previews (1989 to June 2011), NIOSHTIC (1930 to March 2014) and CISDOC (1974 to March 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs (cRCTs), interrupted time series studies and controlled before-after (CBA) studies of the effects of remediating dampness and mould in a building on respiratory symptoms, infections and asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the included studies.

MAIN RESULTS

We included 12 studies (8028 participants): two RCTs (294 participants), one cRCT (4407 participants) and nine CBA studies (3327 participants). The interventions varied from thorough renovation to cleaning only.Repairing houses decreased asthma-related symptoms in adults (among others, wheezing (odds ratio (OR) 0.64; 95% confidence interval (CI) 0.55 to 0.75) and respiratory infections (among others, rhinitis (OR 0.57; 95% CI 0.49 to 0.66), two studies, moderate-quality evidence). For children, we did not find a difference between repaired houses and receiving information only, in the number of asthma days or emergency department visits because of asthma (one study, moderate-quality evidence).One CBA study showed very low-quality evidence that after repairing a mould-damaged office building, asthma-related and other respiratory symptoms decreased. In another CBA study, there was no difference in symptoms between full or partial repair of houses.For children in schools, the evidence of an effect of mould remediation on respiratory symptoms was inconsistent and out of many symptom measures only respiratory infections might have decreased after the intervention. For staff in schools, there was very low-quality evidence that asthma-related and other respiratory symptoms in mould-damaged schools were similar to those of staff in non-damaged schools, both before and after intervention.

AUTHORS' CONCLUSIONS

We found moderate to very low-quality evidence that repairing mould-damaged houses and offices decreases asthma-related symptoms and respiratory infections compared to no intervention in adults. There is very low-quality evidence that although repairing schools did not significantly change respiratory symptoms in staff, pupils' visits to physicians due to a common cold were less frequent after remediation of the school. Better research, preferably with a cRCT design and with more validated outcome measures, is needed.