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Phipatanakul W, Koutrakis P, Coull BA, Petty CR, Gaffin JM, Sheehan WJ, Lai PS, Bartnikas LM, Kang CM, Wolfson JM, Samnaliev M, Cunningham A, Baxi SN, Permaul P, Hauptman M, Trivedi M, Louisias M, Liang L, Thorne PS, Metwali N, Adamkiewicz G, Israel E, Baccarelli AA, Gold DR. Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma: A Randomized Clinical Trial. JAMA 2021; 326:839-850. [PMID: 34547084 PMCID: PMC8424475 DOI: 10.1001/jama.2021.11559] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE School and classroom allergens and particles are associated with asthma morbidity, but the benefit of environmental remediation is not known. OBJECTIVE To determine whether use of a school-wide integrated pest management (IPM) program or high-efficiency particulate air (HEPA) filter purifiers in the classrooms improve asthma symptoms in students with active asthma. DESIGN, SETTING, AND PARTICIPANTS Factorial randomized clinical trial of a school-wide IPM program and HEPA filter purifiers in the classrooms was conducted from 2015 to 2020 (School Inner-City Asthma Intervention Study). There were 236 students with active asthma attending 41 participating urban elementary schools located in the Northeastern US who were randomized to IPM by school and HEPA filter purifiers by classroom. The date of final follow-up was June 20, 2020. INTERVENTIONS The school-wide IPM program consisted of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for school staff. Infestation was assessed every 3 months, with additional treatments as needed. Control schools received no IPM, cleaning, or education. Classroom portable HEPA filter purifiers were deployed and the filters were changed every 3 months. Control classrooms received sham HEPA filters that looked and sounded like active HEPA filter purifiers. Randomization was done independently (split-plot design), with matching by the number of enrolled students to ensure a nearly exact 1:1 student ratio for each intervention with 118 students randomized to each group. Participants, investigators, and those assessing outcomes were blinded to the interventions. MAIN OUTCOMES AND MEASURES The primary outcome was the number of symptom-days with asthma during a 2-week period. Symptom-days were assessed every 2 months during the 10 months after randomization. RESULTS Among the 236 students who were randomized (mean age, 8.1 [SD, 2.0] years; 113 [48%] female), all completed the trial. At baseline, the 2-week mean was 2.2 (SD, 3.9) symptom-days with asthma and 98% of the classrooms had detectable levels of mouse allergen. The results were pooled because there was no statistically significant difference between the 2 interventions (P = .18 for interaction). During a 2-week period, the mean was 1.5 symptom-days with asthma after use of the school-wide IPM program vs 1.9 symptom-days after no IPM across the school year (incidence rate ratio, 0.71 [95% CI, 0.38-1.33]), which was not statistically significantly different. During a 2-week period, the mean was 1.6 symptom-days with asthma after use of HEPA filter purifiers in the classrooms vs 1.8 symptom-days after use of sham HEPA filter purifiers across the school year (incidence rate ratio, 1.47 [95% CI, 0.79-2.75]), which was not statistically significantly different. There were no intervention-related adverse events. CONCLUSIONS AND RELEVANCE Among children with active asthma, use of a school-wide IPM program or classroom HEPA filter purifiers did not significantly reduce symptom-days with asthma. However, interpretation of the study findings may need to consider allergen levels, particle exposures, and asthma symptoms at baseline. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02291302.
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Affiliation(s)
- Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard University Medical School, Boston, Massachusetts
| | - Petros Koutrakis
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Brent A. Coull
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Carter R. Petty
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Jonathan M. Gaffin
- Harvard University Medical School, Boston, Massachusetts
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - William J. Sheehan
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Peggy S. Lai
- Harvard University Medical School, Boston, Massachusetts
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston
| | - Lisa M. Bartnikas
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard University Medical School, Boston, Massachusetts
| | - Choong-Min Kang
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jack M. Wolfson
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Mihail Samnaliev
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Amparito Cunningham
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
| | - Sachin N. Baxi
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard University Medical School, Boston, Massachusetts
| | - Perdita Permaul
- Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston
- Division of Pediatric Pulmonology, Allergy and Immunology, Department of Pediatrics, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Marissa Hauptman
- Harvard University Medical School, Boston, Massachusetts
- Division of General Pediatrics, Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Michelle Trivedi
- Division of Pediatric Pulmonology and Department of Population and Quantitative Health Sciences, University of Massachusetts Memorial Medical School, Worcester
| | - Margee Louisias
- Division of Allergy and Immunology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Liming Liang
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Peter S. Thorne
- Department of Occupational and Environmental Health, University of Iowa, Iowa City
| | - Nervana Metwali
- Department of Occupational and Environmental Health, University of Iowa, Iowa City
| | - Gary Adamkiewicz
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Elliot Israel
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Divisions of Pulmonary and Critical Care Medicine and Allergy and Immunology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrea A. Baccarelli
- Department of Environmental Health, School of Public Health, Columbia University, New York, New York
| | - Diane R. Gold
- Harvard University Medical School, Boston, Massachusetts
- Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Laboratory Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Jonas JA, Leu CS, Reznik M. A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes. J Asthma 2020; 59:395-406. [PMID: 33148066 DOI: 10.1080/02770903.2020.1846746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma. METHODS In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed. RESULTS At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers. CONCLUSION Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.
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Affiliation(s)
| | - Cheng-Shiun Leu
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Marina Reznik
- Albert Einstein College of Medicine, Bronx, NY, USA.,Children's Hospital at Montefiore, Bronx, NY, USA
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