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Wrona J, Hardy P, Youssef C, Adeleke S, Martin MA, Gerald LB, Pappalardo AA. Stock Inhalers: A Qualitative Data Analysis of Illinois Health Policy Trials and Triumphs. THE JOURNAL OF SCHOOL HEALTH 2024. [PMID: 39098995 DOI: 10.1111/josh.13500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 05/31/2024] [Accepted: 07/13/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Asthma reliever medication access is critical, especially in schools. Policies that "stock" reliever inhalers in schools provide failsafe medication access. This research aims to understand barriers and facilitators to Illinois stock inhaler policy implementation. METHODS We conducted 18 semi-structured interviews in 2021-2022 with key school-based and non-school-based partners (school administrators, nurses, governmental agencies, and advocacy leaders). Through Atlas.ti, code frequencies compared (Fisher's exact test), and a thematic analysis performed. RESULTS Four themes emerged: facilitators, barriers, program rationale, and process considerations. The common facilitators were "Finding a provider," having a "Champion," and "Funding". Barriers included "Not enough school nurses," "Pharmacy refusal to fill prescriptions," and "Feeling overwhelmed." All were supportive of the rationale for stock inhalers. Non-school-based informants (p < .01) were more likely to mention medication donations, while school staff reported having enough nurses as a facilitator (p < .01). School staff reported concerns about children with asthma not having their medication significantly more than other partners (p = .02). IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY Our analysis revealed that school partners recognize the value of stock inhalers. Barrier mitigation to support the funding, prescription access and processing, and training are essential to success of stock inhaler programming. Multilevel collaborative efforts through coalitions could be a potential solution.
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Affiliation(s)
- Jessica Wrona
- School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | - Paige Hardy
- School of Public Health, University of Illinois Chicago, Chicago, IL
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
| | - Caroline Youssef
- Department of Pediatrics, University of Illinois Chicago, Chicago, IL, USA
| | - Semmy Adeleke
- Department of Pediatrics, University of Illinois Chicago, Chicago, IL
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Molly A Martin
- Department of Pediatrics, University of Illinois Chicago, Chicago, IL, USA
| | - Lynn B Gerald
- Department of Medicine, University of Illinois Chicago, at Chicago, Chicago, IL
- Office of Population Health Sciences, University of Illinois, Chicago, IL, USA
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois Chicago, Chicago, IL
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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Adeleke SA, Ongtengco A, Youssef C, Hardy P, Pappalardo AA. Addressing critical barriers for sustainability of asthma stock inhaler policy implementation and resultant programming. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00373-9. [PMID: 38942380 DOI: 10.1016/j.anai.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 05/07/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Asthma is a prevalent health concern among Illinois (IL) children, and management is significantly influenced by social determinants. There were 17 states who have adopted stock inhaler laws, but implementation varies widely. OBJECTIVE To assess critical barriers to implementation and address sustainability of stock inhaler programming in school-based asthma care in IL. METHODS Semistructured interviews were conducted with high asthma burden school districts in IL to assess barriers in implementing stock inhaler policies and resultant programming. Thematic analysis was performed using Atlas.ti (Scientific Software Development GmbH, Berlin, Germany) to identify and code "threats" to future sustainability. Data were synthesized and presented to stakeholders for barrier mitigation. A schematic flowchart outlining steps to support sustainability was created. RESULTS A total of 18 interviews were conducted with key community partners across 8 IL school districts, representing rural, urban, and suburban areas. Analysis revealed 25 barriers, with several identified as "threats" to future sustainability, including liability concerns, follow-up care assurance, funding/resources, pharmacy dispensing practices, district-level readiness to change, and nurse staffing. Stakeholders formed a statewide coalition to address these barriers, increase awareness, plan evaluations, and advise on state funding allocation. A national stock inhaler toolkit tailored to school administrative needs was developed to support sustainability efforts. CONCLUSION Strategic stakeholder and community engagement are vital for establishing and sustaining stock inhaler programs that adhere to policy mandates. Many districts face challenges initiating and maintaining such programs without critical barrier mitigation and support. Collaborative solutions are necessary to ensure effective school-based asthma management and mitigate persistent pediatric asthma health disparities.
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Affiliation(s)
- Semmy A Adeleke
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois.
| | - Ana Ongtengco
- College of Medicine, University of Illinois at Rockford, Rockford, Illinois
| | - Caroline Youssef
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Paige Hardy
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Pechter E, Lessin N. Measuring Indoor Air Quality Does Not Prevent COVID-19. New Solut 2023; 33:95-103. [PMID: 37700674 DOI: 10.1177/10482911231196883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Boston Public Schools (BPS) closed for in-person learning in March 2020 due to COVID-19 and didn't fully reopen until the 2021-2022 school year. Due to the age of schools and absent ventilation systems, coupled with decades of disinvestment in the infrastructure, BPS entered the pandemic with serious challenges impacting the health of students and staff. These challenges were magnified by an infectious airborne virus. Instead of using this opportunity to improve ventilation systems, BPS opted to invest in an air quality monitoring system. This system only confirmed what was already known-there is poor ventilation in most school buildings. It did not lead to correction of new or long-standing problems. This failure has harmed the BPS community, which includes primarily low-income Black and Brown families. This article describes Boston's school system, its track record of inadequate attention to infrastructure, and explores pitfalls of focusing on evaluation instead of correction.
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Vesper SJ, Wymer L, Coull BA, Koutrakis P, Cunningham A, Petty CR, Metwali N, Sheehan WJ, Gaffin JM, Permaul P, Lai PS, Bartnikas LM, Hauptman M, Gold DR, Baxi SN, Phipatanakul W. HEPA filtration intervention in classrooms may improve some students' asthma. J Asthma 2023; 60:479-486. [PMID: 35341426 PMCID: PMC9548522 DOI: 10.1080/02770903.2022.2059672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The School Inner-City Asthma Intervention Study 2 (SICAS 2) tested interventions to reduce exposures in classrooms of students with asthma. The objective of this post-hoc analysis was limited to evaluating the effect of high-efficiency particulate (HEPA) filtration interventions on mold levels as quantified using the Environmental Relative Moldiness Index (ERMI) and the possible improvement in the students' asthma, as quantified by spirometry testing. METHODS Pre-intervention dust samples were collected at the beginning of the school year from classrooms and corresponding homes of students with asthma (n = 150). Follow-up dust samples were collected in the classrooms at the end of the HEPA or Sham intervention. For each dust sample, ERMI values and the Group 1 and Group 2 mold levels (components of the ERMI metric) were quantified. In addition, each student's lung function was evaluated by spirometry testing, specifically the percentage predicted forced expiratory volume at 1 sec (FEV1%), before and at the end of the intervention. RESULTS For those students with a higher Group 1 mold level in their pre-intervention classroom than home (n = 94), the FEV1% results for those students was significantly (p < 0.05) inversely correlated with the Group 1 level in their classrooms. After the HEPA intervention, the average Group 1 and ERMI values were significantly lowered, and the average FEV1% test results significantly increased by an average of 4.22% for students in HEPA compared to Sham classrooms. CONCLUSIONS HEPA intervention in classrooms reduced Group 1 and ERMI values, which corresponded to improvements in the students' FEV1% test results.
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Affiliation(s)
- Stephen J. Vesper
- US Environmental Protection Agency, Center for Environmental Measurement and Modeling, Cincinnati, OH, USA
| | - Larry Wymer
- US Environmental Protection Agency, Center for Environmental Measurement and Modeling, Cincinnati, OH, USA
| | - Brent A. Coull
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Petros Koutrakis
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Amparito Cunningham
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Carter R. Petty
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
| | - Nervana Metwali
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - William J. Sheehan
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jonathan M. Gaffin
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Perdita Permaul
- Division of Pediatric Pulmonology, Allergy and Immunology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Peggy S. Lai
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa M. Bartnikas
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Marissa Hauptman
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
| | - Diane R. Gold
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sachin N. Baxi
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wanda Phipatanakul
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Hwa Jung K, Pitkowsky Z, Argenio K, Quinn JW, Bruzzese JM, Miller RL, Chillrud SN, Perzanowski M, Stingone JA, Lovinsky-Desir S. The effects of the historical practice of residential redlining in the United States on recent temporal trends of air pollution near New York City schools. ENVIRONMENT INTERNATIONAL 2022; 169:107551. [PMID: 36183489 PMCID: PMC9616211 DOI: 10.1016/j.envint.2022.107551] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND In the 1930's the United States (US) sponsored Home Owners' Loan Corporation (HOLC) created maps that determined risk for mortgage lending based on the racial and ethnic composition of neighborhoods leading to disinvestment in "redlined" or highest risk neighborhoods. This historical practice has perpetuated racial and economic segregation, and health disparities, that persist today. Interventions near schools where children spend large portions of the day, could impact large groups of children but schools are an often-overlooked environment for exposure. Despite a declining trend of ambient pollution in New York City (NYC) between 1998 and 2012, little is known about differences in air quality improvement near schools by historical redlining neighborhood status. Our objective was to examine if recent temporal trends of air pollution near NYC public schools differed in historically redlined neighborhoods. METHODS We examined annual average street-level concentrations of combustion-related air pollutants (black carbon (BC), particulate matter (PM2.5), nitrogen dioxide (NO2), and nitric oxide (NO)), within a 250-m radius around schools using NYC Community Air Survey land-use regression models (n = 1,462). Year of monitoring, historical redlining (binary), and summer ozone were included in multivariable linear regression using generalized estimating equation models. Average annual percent change (APC) in pollutant concentration was calculated. Models were further stratified by historical redlining and a multiplicative interaction term (year of monitoring × historical redlining) was used to assess effect modification. RESULTS Overall, there was a decreasing trend of BC (APC = -4.40%), PM2.5 (-3.92%), NO2 (-2.76%), and NO (-6.20%) during the 10-year period. A smaller reduction of BC, PM2.5 and NO was observed in redlined neighborhoods (n = 722), compared to others (n = 740): BC (APC: -4.11% vs -4.69%; Pinteraction < 0.01), PM2.5 (-3.82% vs -4.11%; Pinteraction < 0.01), and NO (-5.73% vs -6.67%; Pinteraction < 0.01). Temporal trends of NO2 did not differ by historical redlining (Pinteraction = 0.60). CONCLUSIONS Despite significant reductions in annual average pollution concentrations across NYC, schools in historically redlined neighborhoods, compared to others, experienced smaller decrease in pollution, highlighting a potential ongoing ramification of the discriminatory practice.
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Affiliation(s)
- Kyung Hwa Jung
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, 3959 Broadway CHC-745, New York, NY 10032, United States.
| | - Zachary Pitkowsky
- Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, United States.
| | - Kira Argenio
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, 3959 Broadway CHC-745, New York, NY 10032, United States.
| | - James W Quinn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W. 168 St., New York, NY 10032, United States.
| | - Jean-Marie Bruzzese
- Columbia University School of Nursing, 560 W. 168 St., New York, NY 10032, United States.
| | - Rachel L Miller
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, New York 10029, United States.
| | - Steven N Chillrud
- Lamont-Doherty Earth Observatory of Columbia University, 61 Rt 9W, Palisades, NY 10964, United States.
| | - Matthew Perzanowski
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, 722 W. 168 St., New York, NY 10032, United States.
| | - Jeanette A Stingone
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W. 168 St., New York, NY 10032, United States.
| | - Stephanie Lovinsky-Desir
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, 3959 Broadway CHC-745, New York, NY 10032, United States.
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Mortelliti CL, Banzon TM, Phipatanakul W, Vieira CZ. Environmental Exposures Impact Pediatric Asthma Within the School Environment. Immunol Allergy Clin North Am 2022; 42:743-760. [DOI: 10.1016/j.iac.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bartnikas LM, Dupuis R, Wang J, Phipatanakul W. Food Allergies in Inner-City Schools: Addressing Disparities and Improving Management. Ann Allergy Asthma Immunol 2022; 129:430-439. [PMID: 35568300 DOI: 10.1016/j.anai.2022.04.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Food allergy (FA) affects approximately 8% of children in the United States. Management comprises both preventing and treating allergic reactions, which poses unique challenges in the inner-city school setting. In this article, we review the epidemiology of FA in school-aged children and management challenges and opportunities specific to the inner-city population. DATA SOURCES A literature search of the PubMed database was performed to identify published literature on FA epidemiology, FA management, school policies, disparities, inner-city, race, ethnicity, and socioeconomic status. STUDY SELECTIONS Relevant articles on FA management best practices and challenges in schools, with a particular emphasis on inner-city schools and populations and socioeconomic, racial, and ethnic disparities, were reviewed in detail. RESULTS Disparities in FA prevalence, management, and treatment exist. Additional research is needed to better characterize these disparities and elucidate the mechanisms leading to them. There is a lack of evidence-based interventions for the prevention and treatment of food allergic reactions in schools and specifically in inner-city schools, in which a greater proportion of students may rely on school food. CONCLUSION There are opportunities for partnership among health care providers, schools, and communities to address unmet needs in FA management and disparities in the inner-city school setting.
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Affiliation(s)
- Lisa M Bartnikas
- Department of Medicine, Division of Immunology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, Massachusetts
| | - Roxanne Dupuis
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wanda Phipatanakul
- Department of Medicine, Division of Immunology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, Massachusetts.
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Indoor Air Quality Prior to and Following School Building Renovation in a Mid-Atlantic School District. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212149. [PMID: 34831903 PMCID: PMC8624555 DOI: 10.3390/ijerph182212149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022]
Abstract
Children spend the majority of their time indoors, and a substantial portion of this time in the school environment. Air pollution has been shown to adversely impact lung development and has effects that extend beyond respiratory health. The goal of this study was to evaluate the indoor environment in public schools in the context of an ongoing urban renovation program to investigate the impact of school building renovation and replacement on indoor air quality. Indoor air quality (CO2, PM2.5, CO, and temperature) was assessed for two weeks during fall, winter, and spring seasons in 29 urban public schools between December 2015 and March 2020. Seven schools had pre- and post-renovation data available. Linear mixed models were used to examine changes in air quality outcomes by renovation status in the seven schools with pre- and post-renovation data. Prior to renovation, indoor CO measurements were within World Health Organization (WHO) guidelines, and indoor PM2.5 measurements rarely exceeded them. Within the seven schools with pre- and post-renovation data, over 30% of indoor CO2 measurements and over 50% of indoor temperatures exceeded recommended guidelines from the American Society of Heating, Refrigerating, and Air Conditioning Engineers. Following renovation, 10% of indoor CO2 measurements and 28% of indoor temperatures fell outside of the recommended ranges. Linear mixed models showed significant improvement in CO2, indoor PM2.5, and CO following school renovation. Even among schools that generally met recommendations on key guidelines, school renovation improved the indoor air quality. Our findings suggest that school renovation may benefit communities of children, particularly those in low-income areas with aging school infrastructure, through improvements in the indoor environment.
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Abstract
Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.
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Affiliation(s)
- Divya Seth
- Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, 4th Floor, Pediatric Specialty Building, Detroit, MI 48201, USA.
| | - Shweta Saini
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pavadee Poowuttikul
- Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
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Paciência I, Cavaleiro Rufo J, Mendes F, Farraia M, Cunha P, Silva D, Delgado L, Padrão P, Moreira P, Moreira A. A cross-sectional study of the impact of school neighbourhood on children obesity and body composition. Eur J Pediatr 2021; 180:535-545. [PMID: 32910211 DOI: 10.1007/s00431-020-03798-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
Schools' neighbourhoods provide an important environmental context that may influence the risk of obesity among children. The aim of this study was to assess the effect of neighbourhood surrounding schools on obesity and body composition in schoolchildren. Data on 845 children aged 7 to 12 years old from 20 primary schools were considered. Anthropometric measurements and bioelectrical impedance analysis were performed to assess body mass index (BMI) and characterize body composition. Land use characteristics were quantified within a 500-m buffer zone around schools. Mixed-effect models measured the effects of school neighbourhood on obesity and body composition. The results showed a tendency between green urban areas around schools and lower values of BMI and better body composition parameters compared with built areas, being BMI z-scores CDC, and body fat percentage significantly higher in-built than in green urban areas (β = 0.48, 95% CI 0.05; 0.90, and β = 2.56, 95% CI 0.39; 4.73, respectively).Conclusion: Our findings suggest that the school neighbourhood has an effect on BMI and body fat percentage in schoolchildren. These results may contribute to the creation of healthier cities and help reduce health expenses by focusing on prevention programmes towards the expansion of green spaces. What is Known: • Living in greener areas has been associated with healthy weight outcomes and to the lower impact of obesogenic urban environments. • The school environment may be especially important for youth health outcomes. What is New: • Neighbourhoods around schools may affect child health, specifically the development of obesity. • The presence of urban green areas around school may promote a framework of lifestyle or behaviours conducive to achieving a healthy weight.
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Affiliation(s)
- Inês Paciência
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
| | - João Cavaleiro Rufo
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Francisca Mendes
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Mariana Farraia
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Pedro Cunha
- Faculdade de Ciências da Nutrição e Alimentação, da Universidade do Porto, Porto, Portugal
| | - Diana Silva
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Luís Delgado
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Patrícia Padrão
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação, da Universidade do Porto, Porto, Portugal
| | - Pedro Moreira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação, da Universidade do Porto, Porto, Portugal
| | - André Moreira
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação, da Universidade do Porto, Porto, Portugal
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal
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Howard EJ, Vesper SJ, Guthrie BJ, Petty CR, Ramdin VA, Sheehan WJ, Gaffin JM, Permaul P, Lai PS, Bartnikas LM, Cunningham A, Hauptman M, Gold DR, Baxi SN, Phipatanakul W. Asthma Prevalence and Mold Levels in US Northeastern Schools. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1312-1318. [PMID: 33091637 DOI: 10.1016/j.jaip.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Asthma is among the most common chronic diseases of children in the United States (US). Mold exposures have been linked to asthma development and exacerbation. In homes, mold exposures have been quantified using the Environmental Relative Moldiness Index (ERMI), and higher home ERMI values have been linked to occupant asthma. OBJECTIVE In this analysis of the School Inner-City Asthma Study (SICAS), we aimed to evaluate the ERMI's applicability to measuring mold in schools compared with homes and to examine the prevalence of asthma in relationship to students' demographics and the physical characteristics of school buildings. METHODS Northeastern US schools (n = 32) and homes (n = 33) were selected, and the 36 ERMI molds were quantified in a dust sample from each classroom (n = 114) or home. School building characteristics data were collected from SICAS. Asthma prevalence and student demographics data were obtained from government websites. Linear regression and mixed models were fit to assess the association of the current asthma prevalence and physical characteristics of the school, make-up of the student body, and the ERMI metric. RESULTS Levels of outdoor group 2 molds were significantly (P < .01) greater in schools compared with homes. The presence of air-conditioning in school buildings correlated significantly (P = .02) with lower asthma prevalence. CONCLUSION The prevalence of asthma in student bodies is associated with many factors in schools and homes.
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Affiliation(s)
- Evin J Howard
- Bouvé College of Health Sciences, School of Nursing, Northeastern University, Boston, Mass
| | - Stephen J Vesper
- US Environmental Protection Agency, Center for Environmental Measurement and Modeling, Cincinnati, Ohio
| | - Barbara J Guthrie
- Bouvé College of Health Sciences, School of Nursing, Northeastern University, Boston, Mass
| | - Carter R Petty
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Mass
| | - Valeria A Ramdin
- Bouvé College of Health Sciences, School of Nursing, Northeastern University, Boston, Mass
| | - William J Sheehan
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jonathan M Gaffin
- Harvard Medical School, Boston, Mass; Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Mass
| | - Perdita Permaul
- Division of Pediatric Pulmonology, Allergy and Immunology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Peggy S Lai
- Harvard Medical School, Boston, Mass; Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Mass
| | - Lisa M Bartnikas
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Amparito Cunningham
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass
| | - Marissa Hauptman
- Harvard Medical School, Boston, Mass; Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Mass
| | - Diane R Gold
- Harvard Medical School, Boston, Mass; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Sachin N Baxi
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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12
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Bowman AF, Copeland DJ, Miller KS. Asthma Health Policies in Schools: Implications for Nurse Practitioners. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Urban-level environmental factors related to pediatric asthma. Porto Biomed J 2020; 5:e57. [PMID: 33299939 PMCID: PMC7722407 DOI: 10.1097/j.pbj.0000000000000057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/06/2020] [Indexed: 01/22/2023] Open
Abstract
During the 20th century, urbanization has increasing and represented a major demographic and environmental change in developed countries. This ever-changing urban environment has an impact on disease patterns and prevalence, namely on noncommunicable diseases, such as asthma and allergy, and poses many challenges to understand the relationship between the changing urban environment and the children health. The complex interaction between human beings and urbanization is dependent not only on individual determinants such as sex, age, social or economic resources, and lifestyles and behaviors, but also on environment, including air pollution, indoors and outdoors, land use, biodiversity, and handiness of green areas. Therefore, the assessment and identification of the impact of urban environment on children's health have become a priority and many recent studies have been conducted with the goal of better understanding the impacts related to urbanization, characterizing indoor air exposure, identifying types of neighborhoods, or characteristics of neighborhoods that promote health benefits. Thus, this review focuses on the role of urban environmental factors on pediatric asthma.
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14
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Abstract
Severe asthma is broadly defined as asthma requiring a high level of therapy, usually high doses of inhaled corticosteroids, to bring under control. Children who remain symptomatic despite such treatment are a heterogeneous population, and bear a high burden of disease and require high resource utilization. Children with severe asthma require a comprehensive evaluation, careful consideration of alternative diagnoses and comorbid conditions, assessment of medication adherence and environmental conditions, and frequent disease monitoring.
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15
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Paciência I, Rufo JC, Silva D, Martins C, Mendes F, Rama T, Rodolfo A, Madureira J, Delgado L, de Oliveira Fernandes E, Padrão P, Moreira P, Severo M, Pina MF, Teixeira JP, Barros H, Ruokolainen L, Haahtela T, Moreira A. School environment associates with lung function and autonomic nervous system activity in children: a cross-sectional study. Sci Rep 2019; 9:15156. [PMID: 31641175 PMCID: PMC6805928 DOI: 10.1038/s41598-019-51659-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 07/04/2019] [Indexed: 01/10/2023] Open
Abstract
Children are in contact with local environments, which may affect respiratory symptoms and allergic sensitization. We aimed to assess the effect of the environment and the walkability surrounding schools on lung function, airway inflammation and autonomic nervous system activity. Data on 701 children from 20 primary schools were analysed. Lung function, airway inflammation and pH from exhaled breath condensate were measured. Pupillometry was performed to evaluate autonomic activity. Land use composition and walkability index were quantified within a 500 m buffer zone around schools. The proportion of effects explained by the school environment was measured by mixed-effect models. We found that green school areas tended to be associated with higher lung volumes (FVC, FEV1 and FEF25-75%) compared with built areas. FVC was significantly lower in-built than in green areas. After adjustment, the school environment explained 23%, 34% and 99.9% of the school effect on FVC, FEV1, and FEF25-75%, respectively. The walkability of school neighbourhoods was negatively associated with both pupil constriction amplitude and redilatation time, explaining -16% to 18% of parasympathetic and 8% to 29% of sympathetic activity. Our findings suggest that the environment surrounding schools has an effect on the lung function of its students. This effect may be partially mediated by the autonomic nervous system.
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Affiliation(s)
- Inês Paciência
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal.
- Institute of Science and Innovation in Mechanical Engineering and Industrial Management (INEGI), Porto, Portugal.
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
| | - João Cavaleiro Rufo
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
- Institute of Science and Innovation in Mechanical Engineering and Industrial Management (INEGI), Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Diana Silva
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | - Carla Martins
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | - Francisca Mendes
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | - Tiago Rama
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | - Ana Rodolfo
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | - Joana Madureira
- Institute of Science and Innovation in Mechanical Engineering and Industrial Management (INEGI), Porto, Portugal
| | - Luís Delgado
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
| | | | - Patrícia Padrão
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Pedro Moreira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Milton Severo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Maria Fátima Pina
- Instituto de Investigação e Inovação em Saúde (I3S), Universidade do Porto, Porto, Portugal
- Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Porto, Portugal
- Health Communication and Information Institute, Fundação Oswaldo Cruz (ICICT/FIOCRUZ), Rio de Janeiro, Brazil
| | - João Paulo Teixeira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Environmental Health Department, Portuguese National Institute of Health, Porto, Portugal
| | - Henrique Barros
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Lasse Ruokolainen
- Department of Biosciences, University of Helsinki, Helsinki, Finland
| | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - André Moreira
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal & Centro Hospitalar São João, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
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16
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Abstract
Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.
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Affiliation(s)
- Divya Seth
- Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, 4th Floor, Pediatric Specialty Building, Detroit, MI 48201, USA.
| | - Shweta Saini
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pavadee Poowuttikul
- Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
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17
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Hauptman M, Peden D, Phipatanakul W. Environmental Control: The First Tenet of Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:36-37. [PMID: 29310767 DOI: 10.1016/j.jaip.2017.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/24/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Marissa Hauptman
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass; Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Mass
| | - David Peden
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Wanda Phipatanakul
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Division of Immunology, Boston Children's Hospital, Boston, Mass.
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18
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Azmeh R, Greydanus DE, Agana MG, Dickson CA, Patel DR, Ischander MM, Lloyd RD. Update in Pediatric Asthma: Selected Issues. Dis Mon 2019; 66:100886. [PMID: 31570159 DOI: 10.1016/j.disamonth.2019.100886] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.
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Affiliation(s)
- Roua Azmeh
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States
| | - Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States.
| | - Marisha G Agana
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States
| | - Cheryl A Dickson
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States; Health Equity and Community Affairs, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Dilip R Patel
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States
| | - Mariam M Ischander
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, United States
| | - Robert D Lloyd
- Pacific Northwest University of Health Sciences College of Osteopathic Medicine, Yakima, Washington, United States
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19
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Abstract
Asthma in inner-city children is often severe and difficult to control. Residence in poor and urban areas confers increased asthma morbidity even after adjusting for ethnicity, age, and gender. Higher exposure to household pests, such as cockroaches and mice, pollutants and tobacco smoke exposure, poverty, material hardship, poor-quality housing, differences in health care quality, medication compliance, and heath care access also contribute to increased asthma morbidity in this population. Since 1991, the National Institutes of Allergy and Infectious Diseases established research networks: the National Cooperative Inner-City Asthma Study (NCICAS), the Inner-City Asthma Study (ICAS), and the Inner-City Asthma Consortium (ICAC), to improve care for this at risk population. The most striking finding of the NCICAS is the link between asthma morbidity and the high incidence of allergen sensitization and exposure, particularly cockroach. The follow-up ICAS confirmed that reductions in household cockroach and dust mite were associated with reduction in the inner-city asthma morbidity. The ICAC studies have identified that omalizumab lowered fall inner-city asthma exacerbation rate; however, the relationship between inner-city asthma vs immune system dysfunction, respiratory tract infections, prenatal environment, and inner-city environment is still being investigated. Although challenging, certain interventions for inner-city asthma children have shown promising results. These interventions include family-based interventions such as partnering families with asthma-trained social workers, providing guidelines driven asthma care as well as assured access to controller medication, home-based interventions aim at elimination of indoor allergens and tobacco smoke exposure, school-based asthma programs, and computer/web-based asthma programs.
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20
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Pham MN, Wang J. Management of food allergies and asthma in schools. Ann Allergy Asthma Immunol 2019; 121:391-399. [PMID: 30290894 DOI: 10.1016/j.anai.2018.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Michele N Pham
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, New York
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, New York.
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21
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Agache I, Miller R, Gern JE, Hellings PW, Jutel M, Muraro A, Phipatanakul W, Quirce S, Peden D. Emerging concepts and challenges in implementing the exposome paradigm in allergic diseases and asthma: a Practall document. Allergy 2019; 74:449-463. [PMID: 30515837 DOI: 10.1111/all.13690] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022]
Abstract
Exposome research can improve the understanding of the mechanistic connections between exposures and health to help mitigate adverse health outcomes across the life span. The exposomic approach provides a risk profile instead of single predictors and thus is particularly applicable to allergic diseases and asthma. Under the PRACTALL collaboration between the European Academy of Allergy and Clinical Immunology (EAACI) and the American Academy of Allergy, Asthma, and Immunology (AAAAI), we evaluated the current concepts and the unmet needs on the role of the exposome in allergic diseases and asthma.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine; Transylvania University; Brasov Romania
| | - Rachel Miller
- Columbia University Medical Center; New York New York
| | - James E. Gern
- School of Medicine and Public Health; University of Wisconsin; Madison Wisconsin
| | - Peter W. Hellings
- Department of Otorhinolaryngology; University Hospitals Leuven; Leuven Belgium
- Department of Otorhinolaryngology; Academic Medical Center; Amsterdam The Netherlands
| | - Marek Jutel
- Wroclaw Medical University; Wrocław Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - Antonella Muraro
- Food Allergy Referral Centre; Department of Woman and Child Health; Padua University hospital; Padua Italy
| | - Wanda Phipatanakul
- Harvard Medical School; Boston Children's Hospital; Boston Massachusetts
| | - Santiago Quirce
- Department of Allergy; Hospital La Paz Institute for Health Research and CIBER of Respiratory Diseases (CIBERES); Madrid Spain
| | - David Peden
- UNC School of Medicine; Chapel Hill North Carolina
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