Mouse and cockroach allergens in the dust and air in northeastern United States inner-city public high schools

Environmental allergen reduction in asthma management: an overview

Asthma is a prevalent non-communicable disease that affects both children and adults. Many patients with severe, uncontrolled asthma could not achieve total control despite using anti-asthmatic drugs. There is increasing evidence that allergy to environmental allergens, including both indoor and outdoor allergens, is associated with asthma symptoms and severe asthma. Frequently reported sensitized allergens were dust mites, cockroaches, grass pollens, molds, pets, and rodents in allergic asthma patients, although the patterns of widespread allergens differed from each country. Allergen avoidance is the cornerstone of asthma management, especially in sensitized subjects. This review summarizes environmental allergen avoidance and clarifies their effects on asthma control. Despite contrasting results about the impact of allergen exposure reduction on asthma control, several studies supported the beneficial effects of reducing asthma-related symptoms or risk of exacerbations as a nondrug therapy. Identifying environmental allergens is helpful for asthma patients, and further studies on clinically effective avoidance methods are required.

Social determinants of health and asthma

PURPOSE OF REVIEW

Social determinants of health play a major role in healthcare utilization and outcomes in patients with asthma. Continuing to understand how these complex and interwoven relationships interact to impact patient care will be crucial to creating innovative programmes that address these disparities.

RECENT FINDINGS

The current literature continues to support the association of substandard housing, urban and rural neighbourhoods, and race/ethnicity with poor asthma outcomes. Targeted interventions with community health workers (CHWs), telemedicine and local environmental rectifications can help improve outcomes.

SUMMARY

The link between social determinants and poor asthma outcomes continues to be supported by recent literature. These factors are both nonmodifiable and consequences of institutionalized racist policies that require innovative ideas, technologic equity and funding for groups most at risk for poorer outcomes.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Aeroallergen sensitization in school-age children with allergic rhinitis: What has changed during the COVID-19 pandemic?

BACKGROUND

Pandemic period may affect aeroallergen sensitization.

OBJECTIVE

The study aimed to investigate changes in allergen sensitivities of skin prick test (SPT) in patients with allergic rhinitis (AR) during pandemic and to evaluate relationship with disease severity.

METHODS

In all, 164 AR patients with or without asthma, aged 6-17 years, who have undergone SPTs prior to the pandemic and after October 1, 2021 (18th month of the pandemic), were evaluated retrospectively. The wheal size of allergens in performed SPTs during and prior to the pandemic were compared. Detected changes in allergen sensitivities via SPT results were compared with changes in the disease severity parameters (AR severity, asthma severity, and the number of asthma exacerbations per year), frequency of upper respiratory tract infections and antibiotic use, laboratory parameters, demographic characteristics, and visual analogue scores (VAS).

RESULTS

House dust mites (HDMs), cat, pollen, Artemisia, and Cupressus sensitization increased in AR patients during the Coronavirus disease 2019 (COVID-19) pandemic. HDM, mold, and pollen wheal diameters increased in SPTs. Proportion of polysensitization increased during the pandemic, compared to pre-pandemic period (9.1% vs 3%; P < 0.001), and number of non-sensitized patients decreased during the pandemic period compared to the pre-pandemic period (7.9% vs 22.6%; P < 0.001). An increase in HDM sensitivity in SPTs was correlated with VAS for nasal blockage, and an increase in cat sensitivity was correlated with VAS for all nasal symptoms.

CONCLUSION

We believe that inhalant allergen sensitization might have been affected by the lifestyle changes of patients during the pandemic. Hence, it is important to evaluate patients for allergen sensitization, especially patients with moderate/severe AR, to revise disease control measurements.

Allergen Management in Children with Type 2-High Asthma

Children exposed to various indoor and outdoor allergens are placed at an increased risk of developing asthma in later life, with sensitization in these individuals being a strong predictor of disease morbidity. In addition, aeroallergen exposure influences asthma outcomes through an interplay with adverse determinants of health. The goal of this review is to provide an introductory overview of factors related to aeroallergen exposure in type 2-high childhood asthma. These include the relevance of exposure in asthma exacerbations and severity, and the evidence-base for avoidance and treatment for sensitization to these allergens. This review will focus on both indoor aeroallergens (house dust mite, pet, cockroach, mold, and rodent) and outdoor aeroallergens (pollens and molds). Treatment of aeroallergen sensitization in children with asthma includes avoidance and removal measures, although there is limited evidence of clinical benefit especially with single-strategy approaches. We will also address the interplay of aeroallergens and climate change, adverse social determinants, and the current COVID-19 pandemic, when we have seen a dramatic reduction in asthma exacerbations and emergency department visits among children. While there are many factors that are hypothesized to contribute to this reduction, among them is a reduced exposure to outdoor seasonal aeroallergens.

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 level of allergens in dust samples collected from selected schools in Shiraz, Iran and its asthma-risk implications

BACKGROUND

Both home and school are important places where children are exposed to various indoor allergens. This study aimed to identify the profile of indoor allergens in schools and its impact on asthma development.

METHODS

A total of 104 classrooms from 52 schools were selected for dust collection during the fall of 2017. The levels of indoor allergens including dust mite (Der f1, Der p1), cat (Fel d1), cockroach (Bla g1) and mouse (Mus m1) were measured by enzyme linked immunosorbent assay (ELISA). The diagnosis of asthma was made in all students of the selected classes by the allergist. The collected data were analyzed using SPSS version 21.0.

RESULTS

Out of 2816 students in the selected classes, 180 students were involved with asthma. Students were mostly exposed to Bla g1 (83.1%), followed by Der f1 (51.5%), Mus m 1 (45.5%), Der p1 (8.9%) and Fel d1 (7.9%) in the dust collected from 101 classrooms. Although levels of all studied allergens in the settled dust of the classrooms were low, there was a relationship between Fel d1 in the classroom dust and development of asthma.

CONCLUSION

This study showed considerable levels of cockroach allergens in schools. Exposure to cat allergen in our schools played an important role in asthma development; further school-based investigations require evaluating the role of classroom allergen on asthma development.

Proximity to major roadways and asthma symptoms in the School Inner-City Asthma Study

BACKGROUND

Traffic proximity has been associated with adverse respiratory health outcomes. Less is known about the combined impact of residential and school exposures on pediatric asthma.

OBJECTIVE

We sought to use spatial analysis methodology to analyze residential and school proximity to major roadways and pediatric asthma morbidity.

METHODS

The School Inner-City Asthma Study (n = 350) recruited school-aged children with asthma. Each participant's school and home addresses were geocoded, and distances from major roadways were measured to calculate a composite measure accounting for both home and school traffic exposure. Generalized estimating equation models were clustered by subject and adjusted for age, race/ethnicity, sex, income, environmental tobacco smoke, controller medication, upper respiratory tract infections, and seasonality.

RESULTS

The majority of participants (62%) attended schools within 100 m from major roadways, and 40% also resided within 100 m of major roadways. In multivariate analyses major roadway proximity was independently associated with increased asthma symptom days. At greater than the threshold of 100 m, children had 29% less odds of a symptom day over the past 2 weeks for each 100-m increase in distance from a major roadway (odds ratio, 0.71; 95% CI, 0.58-0.87; P < .01). Children farther from a major roadway also had significantly less reported health care use (odds ratio, 0.63; 95% CI, 0.47-0.85; P < .01) and were significantly less likely to have poor asthma control (odds ratio, 0.80; 95% CI, 0.69-0.94; P < .01). There was not a meaningful association between distance to a major roadway and lung function outcomes.

CONCLUSIONS

Proximity to a major roadway, a composite measure of home and school exposure but primarily driven by home exposure, was associated with greater asthma morbidity. More studies are needed to evaluate the independent effect of school distance to a roadway on asthma morbidity.

Update in Pediatric Asthma: Selected Issues

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.

Time for Allergists to Consider the Role of Mouse Allergy in Non-Inner City Children with Asthma

Mouse allergen is endemic in the inner cities of the United States, with research predominantly in the Northeastern United States. A recent practice parameter notes the effect of mouse exposure in asthma in inner cities. However, studies are emerging that find a role of mouse allergen in non-inner cities as well. Mouse sensitization is associated with mouse allergen exposure and has been linked with adverse asthma outcomes including increased asthma symptoms, poorer lung function, and increased risk of exacerbations. There are commercially available extracts for testing for mouse sensitization although they are not standardized. Pest management studies have had varying results, but with decreased allergen exposure, there is a trend toward improved asthma outcomes. Physicians should be aware of the potential for rodent exposure and sensitization and consider screening for mouse allergy in asthmatic children, especially if they are located in the inner city, have poorly controlled asthma, or have a history of mouse infestation in their location. Evidence is emerging that this allergen should be considered in non-inner-city asthmatics as well. Finally, advocacy efforts are necessary to ensure that removal of this allergen is accomplished, when possible, in the environments of asthmatic children sensitized to mouse.

School exposure and asthma

OBJECTIVE

To provide a comprehensive overview of common school exposures and the association between school exposures and pediatric asthma morbidity.

DATA SOURCES

A comprehensive literature review was performed using PubMed.

STUDY SELECTIONS

Full-length, peer-reviewed studies published in English were considered for review. In vivo, in vitro, and animal studies were excluded. Studies of school exposure to cockroach, mouse, dust mite, dog, cat, molds, pollution, and endotoxin associated with asthma and asthma morbidity were considered.

RESULTS

The current literature establishes an association between school exposure and pediatric asthma morbidity. There is a need for ongoing research to evaluate the effects of school-based environmental interventions on asthma morbidity.

CONCLUSION

It is evident that the indoor school environment is a significant reservoir of allergens, molds, pollutants, and endotoxin and that there is an association between school exposure and pediatric asthma morbidity. School-based interventions have the potential for substantial individual, community, and public health benefit. It is important that researchers continue to study the health effects associated with school exposures and assess cost-effectiveness of multifaceted school-based interventions.

Perceived Versus Actual Aeroallergen Sensitization in Urban Children

BACKGROUND

Individuals often report allergy to specific aeroallergens, but allergy testing can reveal disparate sensitization.

OBJECTIVE

To characterize the agreement between perceived and actual sensitization to individual aeroallergens in an urban pediatric population.

METHODS

A total of 253 children were enrolled from pediatric clinics in New York, NY. Detailed questionnaires regarding perceived sensitization and serum specific IgE measurements to 10 common aeroallergens were completed. Agreement between perceived and actual sensitization (sIgE ≥ 0.35 kU_A/L) to individual aeroallergens was assessed by Cohen's kappa. Multivariable logistic regression models adjusted for potential confounders were used to test for associations between perceived and actual sensitization.

RESULTS

A total of 161 (63.6%) of 253 children reported perceived sensitization to 1 or more aeroallergen, and 203 (80.2%) were actually sensitized to 1 or more aeroallergen. Agreement between perceived and actual aeroallergen sensitization was fair for most aeroallergens, with greatest agreement for cat dander (κ, 0.42; 95% CI, 0.32-0.53) and dust (κ, 0.32; 95% CI, 0.20-0.44). Models adjusted for potential confounders showed nearly 6-fold odds of sensitization to cat dander given perceived cat allergy (adjusted odds ratio, 5.82; 95% CI, 2.91-11.64), and over 2-fold odds of sensitization to Dermatophagoides pteronyssinus, Dermatophagoides farinae, dog dander, or grass pollen given perceived sensitization to their respective allergens. Among children with no perceived sensitization, actual sensitization ranged from 5.4% to 30.4%, and was more common for indoor versus outdoor allergens, including cockroach.

CONCLUSIONS

Children who perceive allergen sensitization to cat, dog, dust, or grass are likely to demonstrate actual sensitization to these individual allergens. Children with no perceived sensitization to allergens are nonetheless frequently sensitized.

Taming Asthma in School-Aged Children: A Comprehensive Review

Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.

School Environmental Intervention Programs

Exposure to indoor allergens and pollutants plays a significant part in the development of asthma and its associated morbidity. Inner-city children with asthma are disproportionately affected by these exposures with increased asthma morbidity. Although years of previous research have linked exposures in the urban home environment with significant childhood asthma disease, many of these allergens are also present in inner-city school environments. Therefore, evaluation of the school environment of patients with asthma is also essential. School-based environmental interventions may offer benefit for this problem and has the potential to help many children with asthma at once in a cost-effective manner. It is important that environmental health researchers continue to assess which interventions are most practical and result in the greatest measurable improvements.

Effect of an Integrated Pest Management Intervention on Asthma Symptoms Among Mouse-Sensitized Children and Adolescents With Asthma: A Randomized Clinical Trial

IMPORTANCE

Professionally delivered integrated pest management (IPM) interventions can reduce home mouse allergen concentrations, but whether they reduce asthma morbidity among mouse-sensitized and exposed children and adolescents is unknown.

OBJECTIVE

To determine the effect of an IPM intervention on asthma morbidity among mouse-sensitized and exposed children and adolescents with asthma.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted in Baltimore, Maryland, and Boston, Massachusetts. Participants were mouse-sensitized and exposed children and adolescents (aged 5-17 years) with asthma randomized to receive professionally delivered IPM plus pest management education or pest management education alone. Enrollment occurred between May 2010 and August 2014; the final follow-up visit occurred on September 25, 2015.

INTERVENTIONS

Integrated pest management consisted of application of rodenticide, sealing of holes that could serve as entry points for mice, trap placement, targeted cleaning, allergen-proof mattress and pillow encasements, and portable air purifiers. Infestation was assessed every 3 months, and if infestation persisted or recurred, additional treatments were delivered. All participants received pest management education, which consisted of written material and demonstration of the materials needed to set traps and seal holes.

MAIN OUTCOMES AND MEASURES

The primary outcome was maximal symptom days defined as the highest number of days of symptoms in the previous 2 weeks among 3 types of symptoms (days of slowed activity due to asthma; number of nights of waking with asthma symptoms; and days of coughing, wheezing, or chest tightness) across 6, 9, and 12 months.

RESULTS

Of 361 children and adolescents who were randomized (mean [SD] age, 9.8 [3.2] years; 38% female; 181 in IPM plus pest management education group and 180 in pest management education alone group), 334 were included in the primary analysis. For the primary outcome, there was no statistically significant between-group difference for maximal symptom days across 6, 9, and 12 months with a median of 2.0 (interquartile range, 0.7-4.7) maximal symptom days in the IPM plus pest management education group and 2.7 (interquartile range, 1.3-5.0) maximal symptom days in the pest management education alone group (P = .16) and a ratio of symptom frequencies of 0.86 (95% CI, 0.69-1.06).

CONCLUSIONS AND RELEVANCE

Among mouse-sensitized and exposed children and adolescents with asthma, an intensive year-long integrated pest management intervention plus pest management education vs pest management education alone resulted in no significant difference in maximal symptom days from 6 to 12 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01251224.

Association Between Allergen Exposure in Inner-City Schools and Asthma Morbidity Among Students

IMPORTANCE

Home aeroallergen exposure is associated with increased asthma morbidity in children, yet little is known about the contribution of school aeroallergen exposures to such morbidity.

OBJECTIVE

To evaluate the effect of school-specific aeroallergen exposures on asthma morbidity among students, adjusting for home exposures.

DESIGN, SETTING, AND PARTICIPANTS

The School Inner-City Asthma Study was a prospective cohort study evaluating 284 students aged 4 to 13 years with asthma who were enrolled from 37 inner-city elementary schools in the northeastern United States between March 1, 2008, and August 31, 2013. Enrolled students underwent baseline clinical evaluations before the school year started and were then observed clinically for 1 year. During that same school year, classroom and home dust samples linked to the students were collected and analyzed for common indoor aeroallergens. Associations between school aeroallergen exposure and asthma outcomes during the school year were assessed, adjusting for home exposures.

EXPOSURES

Indoor aeroallergens, including rat, mouse, cockroach, cat, dog, and dust mites, measured in dust samples collected from inner-city schools.

MAIN OUTCOMES AND MEASURES

The primary outcome was maximum days in the past 2 weeks with asthma symptoms. Secondary outcomes included well-established markers of asthma morbidity, including asthma-associated health care use and lung function, measured by forced expiratory volume in 1 second.

RESULTS

Among 284 students (median age, 8 years [interquartile range, 6-9 years]; 148 boys and 136 girls), exposure to mouse allergen was detected in 441 (99.5%) of 443 school dust samples, cat allergen in 420 samples (94.8%), and dog allergen in 366 samples (82.6%). Levels of mouse allergen in schools were significantly higher than in students' homes (median settled dust level, 0.90 vs 0.14 µg/g; P < .001). Exposure to higher levels of mouse allergen in school (comparing 75th with 25th percentile) was associated with increased odds of having an asthma symptom day (odds ratio, 1.27; 95% CI, 1.05-1.54; P = .02) and 4.0 percentage points lower predicted forced expiratory volume in 1 second (95% CI, -6.6 to -1.5; P = .002). This effect was independent of allergic sensitization. None of the other indoor aeroallergens were associated with worsening asthma outcomes.

CONCLUSIONS AND RELEVANCE

In this study of inner-city students with asthma, exposure to mouse allergen in schools was associated with increased asthma symptoms and decreased lung function. These findings demonstrate that the school environment is an important contributor to childhood asthma morbidity. Future school-based environmental interventions may be beneficial for this important public health problem.

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.

Inner-city asthma: special considerations for management

PURPOSE OF REVIEW

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.

RECENT FINDINGS

Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.

SUMMARY

Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

The school environment and asthma in childhood

In this article, we discuss the relationship between environmental exposures within the school environment and pediatric asthma morbidity. This article will conclude by reviewing novel school based asthma education and therapeutic programs and environmental interventions designed to help mitigate pediatric asthma morbidity.

Building-related health symptoms and classroom indoor air quality: a survey of school teachers in New York State

Most previous research on indoor environments and health has studied school children or occupants in non-school settings. This investigation assessed building-related health symptoms and classroom characteristics via telephone survey of New York State school teachers. Participants were asked about 14 building-related symptoms and 23 classroom characteristics potentially related to poor indoor air quality (IAQ). Poisson regression analysis was used to assess the relationship between these symptoms and each classroom characteristic, controlling for potential confounders. About 500 teachers completed the survey. The most frequently reported classroom characteristics included open shelving (70.7%), food eaten in class (65.5%), dust (59.1%), and carpeting (46.9%). The most commonly reported symptoms included sinus problems (16.8%), headache (15.0%), allergies/congestion (14.8%), and throat irritation (14.6%). Experiencing one or more symptoms was associated most strongly with reported dust (relative risk (RR) = 3.67; 95% confidence interval (CI): 2.62-5.13), dust reservoirs (RR = 2.13; 95% CI: 1.72-2.65), paint odors (RR = 1.73; 95% CI: 1.40-2.13), mold (RR = 1.71; 95% CI: 1.39-2.11), and moldy odors (RR = 1.65 95% CI: 1.30-2.10). Stronger associations were found with increasing numbers of reported IAQ-related classroom characteristics. Similar results were found with having any building-related allergic/respiratory symptom. This research adds to the body of evidence underscoring the importance to occupant health of school IAQ.

PRACTICAL IMPLICATIONS

Teachers play an important role in educating children, and teacher well-being is important to this role. Health symptoms among New York teachers while at work are common and appear to be associated with numerous characteristics related to poor classroom IAQ. Improving school Indoor Air Quality may reduce sickness and absenteeism and improve teacher performance.

[Cockroaches and co. The role of health pests as allergen source]

In most of the cases health pests are carriers of pathogens or parasites which have a negative impact on human health or affect the health of other mammals. What is lesser known is that they can also act as allergens. Most of the health pests in this sense belong to the arthropods, such as cockroaches (Blattaria), mosquitos (Culiciformia), lice (Pediculus humanus corporis), fleas (Siphonaptera) and ticks (Argasidae). In the group of vertebrates rats (Rattus norvegicus and Rattus rattus), house mice (Mus musculus) and pigeons (Columba livia domestica) are also classified as health pests. Also storage pests which are not carriers of pathogens can induce secondary infestation with hygiene pests or molds and have an underestimated impact on human health. In this article selected examples of health pests and also storage pests as an allergen source are described, taking into account the sensitization prevalence and identified single allergens.

Introducing an environmental assessment and intervention program in inner-city schools

Home-based environmental interventions have demonstrated clinical benefit for children with asthma. Although much is known about school-based exposures, few studies have comprehensively examined the role the school environment plays in asthma and how effectively changing the environment might reduce morbidity when adjusting for exposures in the home. This review summarizes the importance and common challenges of school-based environmental assessment and intervention studies linked to health effects. We focus on the key components of study development and the challenges and benefits to implementation.

Animal allergens and their presence in the environment

Exposure to animal allergens is a major risk factor for sensitization and allergic diseases. Besides mites and cockroaches, the most important animal allergens are derived from mammals. Cat and dog allergies affect the general population; whereas, allergies to rodents or cattle is an occupational problem. Exposure to animal allergens is not limited to direct contact to animals. Based on their aerodynamic properties, mammalian allergens easily become airborne, attach to clothing and hair, and can be spread from one environment to another. For example, the major cat allergen Fel d 1 was frequently found in homes without pets and in public buildings, including schools, day-care centers, and hospitals. Allergen concentrations in a particular environment showed high variability depending on numerous factors. Assessment of allergen exposure levels is a stepwise process that involves dust collection, allergen quantification, and data analysis. Whereas a number of different dust sampling strategies are used, ELISA assays have prevailed in the last years as the standard technique for quantification of allergen concentrations. This review focuses on allergens arising from domestic, farm, and laboratory animals and describes the ubiquity of mammalian allergens in the human environment. It includes an overview of exposure assessment studies carried out in different indoor settings (homes, schools, workplaces) using numerous sampling and analytical methods and summarizes significant factors influencing exposure levels. However, methodological differences among studies have contributed to the variability of the findings and make comparisons between studies difficult. Therefore, a general standardization of methods is needed and recommended.

Animal allergens and their presence in the environment

Exposure to animal allergens is a major risk factor for sensitization and allergic diseases. Besides mites and cockroaches, the most important animal allergens are derived from mammals. Cat and dog allergies affect the general population; whereas, allergies to rodents or cattle is an occupational problem. Exposure to animal allergens is not limited to direct contact to animals. Based on their aerodynamic properties, mammalian allergens easily become airborne, attach to clothing and hair, and can be spread from one environment to another. For example, the major cat allergen Fel d 1 was frequently found in homes without pets and in public buildings, including schools, day-care centers, and hospitals. Allergen concentrations in a particular environment showed high variability depending on numerous factors. Assessment of allergen exposure levels is a stepwise process that involves dust collection, allergen quantification, and data analysis. Whereas a number of different dust sampling strategies are used, ELISA assays have prevailed in the last years as the standard technique for quantification of allergen concentrations. This review focuses on allergens arising from domestic, farm, and laboratory animals and describes the ubiquity of mammalian allergens in the human environment. It includes an overview of exposure assessment studies carried out in different indoor settings (homes, schools, workplaces) using numerous sampling and analytical methods and summarizes significant factors influencing exposure levels. However, methodological differences among studies have contributed to the variability of the findings and make comparisons between studies difficult. Therefore, a general standardization of methods is needed and recommended.

Environmental control for asthma: recent evidence

PURPOSE OF REVIEW

To review and interpret recent literature related to the role of environmental control in prevention and treatment of asthma.

RECENT FINDINGS

Environmental control has a clearly established role in the management of asthma, but its role as a primary prevention tool is not supported by recent clinical trials. Although some of the interventions tested in these trials reduced the risk of asthma, the interventions often included dietary modification and those trials intervening only on environmental exposures were largely negative. Environmental interventions that target multiple asthma triggers, such as a laminar airflow device and relocation to high altitude, continue to demonstrate efficacy in asthma. Several studies highlight the efficacy of portable HEPA purifiers in reduction of indoor particulate matter and improving asthma outcomes. Several recently published practice parameters provide evidence-based recommendations for environmental control practices targeting furry pet, rodent, and cockroach allergens. Emerging work highlights the potential impact of spatial-temporal aspects of exposure and the shape of the dose-response relationships on the indoor allergen exposure-asthma relationship.

SUMMARY

Environmental interventions likely have no effect on the risk of developing atopic disease, but multifaceted interventions are generally of benefit in the management of asthma, particularly in children.

Performance of the halogen immunoassay to assess airborne mouse allergen-containing particles in a laboratory animal facility

Airborne mouse allergen is a risk factor for respiratory diseases. Conventional assessment techniques provide mass-based exposure estimates that may not capture completely the inhalation risk of airborne allergen particles. In contrast to mass-based estimates, the halogen immunoassay (HIA) combines immunoblotting and microscopy to directly assess allergen-containing particles. We evaluated the HIA for the assessment of airborne mouse allergen and compared the results to the enzyme linked immunosorbent assay (ELISA). Particulate matter (PM)(10) and PM(2.5) samples (30 min, 4 l/m) were collected in a mouse facility before, during, and after disturbance of soiled bedding. Concentrations of Mus m 1-positive particles (haloed particles (HPs)) and intensities of the haloes were determined with the HIA. Although HPs/m(3) were positively correlated with mass concentration (statistically significant only with Mus m 1 concentration on PM(10)), replicates of mass concentration showed higher variability than HPs/m(3). After disturbance, most of the HPs were in the PM(2.5) fraction. Mean haloes intensities were similar before, during, and after disturbance. The HIA was able to measure allergen-containing particles with less variability than the ELISA, detected the shift of HPs to smaller particles after disturbance, and may suggests similar halo intensity by particles detected during and after disturbance. Our findings suggest that the HIA can be used to assess indoor concentrations of mouse allergen particles and their morphological characteristics.

Sensitization to rodents (mouse/rat) in urban atopic populations without occupational exposure living in Campania district (Southern Italy): a multicenter study

BACKGROUND

Up to now very few data on allergic sensitization to rodent allergens in Western Europe and Italy are available, and there are no information at district level.The aim of this report was to investigate clinical significance and characteristics of allergic sensitization to mouse/rat (M/Rt) allergens in atopic subjects living in Campania district (Southern Italy).

METHODS

Allergists from the whole Campania district were required to report the results of skin prick tests of at least 100 consecutive subjects. In 1,477 consecutive outpatients, we selected all subjects with an immediate skin reaction to M/Rt dander. Clinical history including a careful evaluation of the modality of exposure and the results of skin-prick tests (SPTs) were recorded.

RESULTS

Fifty seven patients were sensitized to M/Rt dander (5.78%). Two patients were mono-sensitized. Fourteen patients reported indoor conditions suggesting presence of rodents allergens at home. All patients exhibited low-moderate degree of SPT positivity to M/Rt. High frequency of concomitant allergic sensitization to dust mites was found.

CONCLUSIONS

Our results suggest that the role of allergic sensitization to rodents is not negligible in atopic subjects without occupational exposure living in Campania district area; these values are higher in comparison to those previously found in Naples area. Highly atopic individuals should be tested by SPTs/evaluation of serum specific IgE to rodents in the case they should begin an occupational exposure to M/Rt or keep these animals as pets.

Assessment of environmental cockroach allergen exposure

In the past, cockroach allergen exposure assessment mainly focused on settled dust in homes in low-income urban cities in the United States. That choice was not wrong; without measureable levels of cockroach allergen, it is difficult to show associations with any home characteristics, much less with health outcomes (e.g., allergy, asthma). However, recent studies in other suburban areas, schools, and other countries have elucidated the importance of cockroach allergen in these environments too. In addition, characterizing the underlying factors that give rise to cockroach allergen exposure (or protect against it) can lead to more targeted public health interventions. This review discusses different approaches to sampling indoor environments, interprets recent asthma and allergy studies, compares cockroach allergen levels from past studies with those of recent studies, and describes strategies for decreasing exposures.

Early-life cockroach allergen and polycyclic aromatic hydrocarbon exposures predict cockroach sensitization among inner-city children

BACKGROUND

Sensitization to cockroach is one of the strongest identified risk factors for greater asthma morbidity in low-income urban communities; however, the timing of exposures relevant to the development of sensitization has not been elucidated fully. Furthermore, exposure to combustion byproducts, including polycyclic aromatic hydrocarbons (PAHs), can augment the development of allergic sensitization.

OBJECTIVE

We sought to test the hypotheses that domestic cockroach allergen measured prenatally would predict cockroach sensitization in early childhood and that this association would be greater for children exposed to higher PAH concentrations.

METHODS

Dominican and African American pregnant women living in New York City were enrolled. In the third trimester expectant mothers wore personal air samplers for measurement of 8 nonvolatile PAHs and the semivolatile PAH pyrene, and dust was collected from homes for allergen measurement. Glutathione-S-transferase μ 1 (GSTM1) gene polymorphisms were measured in children. Allergen-specific IgE levels were measured from the children at ages 2, 3, 5, and 7 years.

RESULTS

Bla g 2 in prenatal kitchen dust predicted cockroach sensitization at the ages of 5 to 7 years (adjusted relative risk [RR], 1.15; P = .001; n = 349). The association was observed only among children with greater than (RR, 1.22; P = .001) but not less than (RR, 1.07; P = .24) the median sum of 8 nonvolatile PAH levels. The association was most pronounced among children with higher PAH levels and null for the GSTM1 gene (RR, 1.54; P = .001).

CONCLUSIONS

Prenatal exposure to cockroach allergen was associated with a greater risk of allergic sensitization. This risk was increased by exposure to nonvolatile PAHs, with children null for the GSTM1 mutation particularly vulnerable.

Assessment of indoor air pollution in homes with infants

Infants spend most of their indoor time at home; however, residential air quality is poorly understood. We investigated the air quality of infants’ homes in the New England area of the U.S. Participants (N = 53) were parents of infants (0–6 months) who completed telephone surveys to identify potential pollutant sources in their residence. Carbon monoxide (CO), carbon dioxide (CO₂), particulate matter with aerodynamic diameter ≤0.5 µm (PM_0.5), and total volatile organic compounds (TVOCs) were measured in 10 homes over 4–7 days, and levels were compared with health-based guidelines. Pollutant levels varied substantially across homes and within homes with overall levels for some homes up to 20 times higher than for other homes. Average levels were 0.85 ppm, 663.2 ppm, 18.7 µg/m³, and 1626 µg/m³ for CO, CO₂, PM_0.5, and TVOCs, respectively. CO₂, TVOCs, and PM_0.5 levels exceeded health-based indoor air quality guidelines. Survey results suggest that nursery renovations and related potential pollutant sources may be associated with differences in urbanicity, income, and presence of older children with respiratory ailments, which could potentially confound health studies. While there are no standards for indoor residential air quality, our findings suggest that additional research is needed to assess indoor pollution exposure for infants, which may be a vulnerable population.

Quantitative measurement of airborne cockroach allergen in New York City apartments

We designed and tested a sampling and analysis system for quantitative measurement of airborne cockroach allergen with sufficient sensitivity for residential exposure assessment. Integrated 1-week airborne particle samples were collected at 10-15 LPM in 19 New York City apartments in which an asthmatic child who was allergic to cockroach allergen resided. Four simultaneous air samples were collected in each home: at heights of 0.3 and 1 m in the child's bedroom and in the kitchen. Extracts of air samples were analyzed by ELISA for the cockroach allergen Bla g2, modified by amplifying the colorimetric signal generated via use of AMPLI-Q detection system (DAKO Corporation, Carpinteria, CA, USA). Settled dust samples were quantified by conventional ELISA. Of the homes where cockroach allergen was detected in settled dust, Bla g2 also was detected in 87% and 93% of air samples in the bedroom and kitchen, respectively. Airborne Bla g2 levels were highly correlated within and between the bedroom and kitchen locations (P < 0.001). Expressed as picogram per cubic meter, the room average geometric mean for Bla g2 concentrations was 1.9 pg/m³ (95% CI 0.63, 4.57) and 3.8 pg/m³ (95% CI 1.35, 9.25) in bedrooms and kitchens, respectively. This method offers an attractive supplement to settled dust sampling for cockroach allergen exposure health studies.

PRACTICAL IMPLICATIONS

Until now, cockroach allergen exposures have usually been assessed by collection and analysis of settled dust, on the assumption that airborne cockroach allergen cannot be reliably measured. In this study, a sensitive and quantitative method for measuring indoor airborne exposures to cockroach allergens involving a 7-day integrated total suspended particulate (TSP) sample collected at approximately 10-15 l/min was developed. Investigators are now empowered with an alternative exposure assessment method to supplement their studies and the understanding of allergen aerodynamics in the homes of children with asthma. We report airborne cockroach allergen in apartments, suggesting an ongoing burden of inhalation exposure.

The school inner-city asthma study: design, methods, and lessons learned

BACKGROUND

Children spend a significant amount of time in school. Little is known about the role of allergen exposure in school environments and asthma morbidity.

OBJECTIVES

The School Inner-City Asthma Study (SICAS) is a National Institutes of Health (NIH)-funded prospective study evaluating the school/classroom-specific risk factors and asthma morbidity among urban children.

METHODS/RESULTS

This article describes the design, methods, and important lessons learned from this extensive investigation. A single center is recruiting 500 elementary school-aged children, all of whom attend inner-city metropolitan schools. The primary hypothesis is that exposure to common indoor allergens in the classroom will increase the risk of asthma morbidity in children with asthma, even after controlling for home allergen exposures. The protocol includes screening surveys of entire schools and baseline eligibility assessments obtained in the spring prior to the academic year. Extensive baseline clinical visits are being conducted among eligible children with asthma during the summer prior to the academic school year. Environmental classroom/school assessments including settled dust and air sampling for allergen, mold, air pollution, and inspection data are collected twice during the academic school year and one home dust sample linked to the enrolled student. Clinical outcomes are measured every 3 months during the academic school year.

CONCLUSION

The overall goal of SICAS is to complete the first study of its kind to better understand school-specific urban environmental factors on childhood asthma morbidity. We also discuss the unique challenges related to school-based urban research and lessons being learned from recruiting such a cohort.

Asthma and the achievement gap among urban minority youth

OBJECTIVES

To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems.

METHODS

Literature review.

RESULTS

Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts.

CONCLUSIONS

Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.

Indoor air quality in elementary schools of Lisbon in spring

Analysis of indoor air quality (IAQ) in schools usually reveals higher levels of pollutants than in outdoor environments. The aims of this study are to measure indoor and outdoor concentrations of NO(2), speciated volatile organic compounds (VOCs) and carbonyls at 14 elementary schools in Lisbon, Portugal. The investigation was carried out in May-June 2009. Three of the schools were selected to also measure comfort parameters, such as temperature and relative humidity, carbon dioxide (CO(2)), carbon monoxide (CO), total VOCs, and bacterial and fungal colony-forming units per cubic metre. Indoor concentrations of CO(2) in the three main schools indicated inadequate classroom air exchange rates. The indoor/outdoor (I/O) NO(2) ratio ranged between 0.36 and 0.95. At the three main schools, the total bacterial and fungal colony-forming units (CFU) in both indoor and outdoor air were above the advised maximum value of 500 CFU/m(3) defined by Portuguese legislation. The aromatic compounds benzene, toluene, ethylbenzene and xylenes, followed by ethers, alcohols and terpenes, were usually the most abundant classes of VOCs. In general, the indoor total VOC concentrations were markedly higher than those observed outdoors. At all locations, indoor aldehyde levels were higher than those observed outdoors, particularly for formaldehyde. The inadequate ventilation observed likely favours accumulation of pollutants with additional indoor sources.

[Indoor air quality in schools]

Indoor air quality in schools has received particular attention over the past several years. Children are considered as one of the most sensitive groups to atmospheric pollution because their bodies are actively growing and they breathe higher volumes of air relative to their body weights than adults do. They also spend more time in school or group structures (preschools, day nurseries) than in any indoor environments other than the home. The analysis of children's exposure to air pollution at school requires the identification of the main pollutant sources present in these educational institutions. Both a strong contribution of outdoor pollution and a very specific pollution bound to school activities such as the use of paints, markers, glues, and manufactured ink eraser pens, exist. The ventilation in school buildings also plays an important role in air quality. A higher air exchange may improve thermal comfort and air quality. The cause of indoor air pollution is a combinatory effect of physical, chemical, and biological factors, and the adequacy of ventilation in the environment. Several pollutants have been reported to exist in classrooms such as bacteria, molds, volatile organic compounds, persistent organic pollutants and microparticles. There is a correlation between the concentrations of the pollutants and onset of health problems in schoolchildren. We observe predominantly respiratory symptoms as well as a prevalence of respiratory diseases such as asthma and allergies. This study shows that poor indoor air quality affects children's health.

Neighborhood differences in exposure and sensitization to cockroach, mouse, dust mite, cat, and dog allergens in New York City

BACKGROUND

Asthma prevalence varies widely among neighborhoods within New York City. Exposure to mouse and cockroach allergens has been suggested as a cause.

OBJECTIVE

To test the hypotheses that children living in high asthma prevalence neighborhoods (HAPNs) would have higher concentrations of cockroach and mouse allergens in their homes than children in low asthma prevalence neighborhoods (LAPNs), and that these exposures would be related to sensitization and asthma.

METHODS

In the New York City Neighborhood Asthma and Allergy Study, a case-control study of asthma, children 7 to 8 years old from HAPNs (n = 120) and LAPNs (n = 119) were recruited through the same middle-income health insurance plan. Children were classified as asthma cases (n = 128) or controls without asthma (n = 111) on the basis of reported symptoms or medication use. Allergens were measured in bed dust.

RESULTS

HAPN homes had higher Bla g 2 (P = .001), Mus m 1 (P = .003), and Fel d 1 (P = .003) and lower Der f 1 (P = .001) than LAPN homes. Sensitization to indoor allergens was associated with asthma, but relevant allergens differed between LAPNs and HAPNs. Sensitization to cockroach was more common among HAPN than LAPN children (23.7% vs 10.8%; P = .011). Increasing allergen exposure was associated with increased probability of sensitization (IgE) to cockroach (P < .001), dust mite (P = .009), and cat (P = .001), but not mouse (P = .58) or dog (P = .85).

CONCLUSION

These findings further demonstrate the relevance of exposure and sensitization to cockroach and mouse in an urban community and suggest that cockroach allergen exposure could contribute to the higher asthma prevalence observed in some compared with other New York City neighborhoods.

Are building-level characteristics associated with indoor allergens in the household?

Building-level characteristics are structural factors largely beyond the control of those who live in them. We explored whether building-level characteristics and indoor allergens in the household are related. We examined the relationship between building-level characteristics and indoor allergens: dust mite, cat, cockroach, and mouse. Building-level characteristics measured were presence of pests (seeing cockroaches and rodents), building type (public housing, buildings zoned commercially and residentially, and building size), and building condition (building age and violations). Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 μg/g; cat: >1 μg/g; cockroach: >1 U/g; mouse: >1.6 μg/g. In fully adjusted linear analyses, neither dust mite nor cat allergen were statistically significantly associated with any building-level characteristics. Cockroach allergen was associated with the presence of cockroaches (2.07; 95% CI, 1.23, 3.49) and living in public housing (2.14; 95% CI, 1.07, 4.31). Mouse allergen was associated with the presence of rodents (1.70; 95% CI, 1.29, 2.23), and building size: living in a low-rise (<8 floors; 0.60; 95% CI, 0.42, 0.87) or high-rise (8 + floors; 0.50; 95% CI, 0.29, 0.88; compared with house/duplex). In fully adjusted logistic analyses, cat allergen was statistically significantly associated with living in a high-rise (6.29; 95% CI, 1.51, 26.21; compared with a house/duplex). Mouse allergen was associated with living in public housing (6.20; 95% CI, 1.01, 37.95) and building size: living in a low-rise (0.16; 95% CI, 0.05, 0.52) or high-rise (0.06; 95% CI, 0.01, 0.50; compared with a house/duplex). Issues concerning building size and public housing may be particularly critical factors in reducing asthma morbidity. We suggest that future research explore the possible improvement of these factors through changes to building code and violations adherence, design standards, and incentives for landlords.

Allergy to rodents: an update

Allergy to rodents in the workplace is an important occupational health problem affecting research, pharmaceutical and toxicological sectors and can have a serious impact on employees working in this area. Despite measures to reduce aeroallergen exposures to rodents in the workplace, there are few signs that this occupational health problem is declining. Rodent allergens are well characterized and exposure-response relationships have been demonstrated to be complex. More recently, the importance of rodent allergens outside of the workplace has been demonstrated in several studies of individuals with asthma. This review focuses on rodent allergy both in the workplace and in the home and examines the complex exposure-response relationships between allergen exposure and sensitization and asthma. Risk factors for rodent allergy and mechanisms of tolerance to rodent allergens are discussed.

The impact of school building conditions on student absenteeism in Upstate New York

OBJECTIVES

We investigated Upstate New York school building conditions and examined the associations between school absenteeism and building condition problems.

METHODS

We merged data from the 2005 Building Condition Survey of Upstate New York schools with 2005 New York State Education Department student absenteeism data at the individual school level and evaluated associations between building conditions and absenteeism at or above the 90th percentile.

RESULTS

After adjustment for confounders, student absenteeism was associated with visible mold (odds ratio [OR]=2.22; 95% confidence interval [CI]=1.34, 3.68), humidity (OR=3.07; 95% CI=1.37, 6.89), poor ventilation (OR=3.10; 95% CI=1.79, 5.37), vermin (OR=2.23; 95% CI=1.32, 3.76), 6 or more individual building condition problems (OR=2.97; 95% CI=1.84, 4.79), and building system or structural problems related to these conditions. Schools in lower socioeconomic districts and schools attended by younger students showed the strongest associations between poor building conditions and absenteeism.

CONCLUSIONS

We found associations between student absenteeism and adverse school building conditions. Future studies should confirm these findings and prioritize strategies for school condition improvements.

Pest and allergen exposure and abatement in inner-city asthma: a work group report of the American Academy of Allergy, Asthma & Immunology Indoor Allergy/Air Pollution Committee

Our work group report details the importance of pest allergen exposure in inner-city asthma. We will focus specifically on mouse and cockroach exposure. We will discuss how exposure to these pests is common in the inner city and what conditions exist in urban areas that might lead to increased exposure. We will discuss how exposure is associated with allergen sensitization and asthma morbidity. Finally, we will discuss different methods of intervention and the effectiveness of these tactics.

Asthma knowledge and asthma management behavior in urban elementary school teachers

BACKGROUND

Although schools are an important setting for asthma care in youth, teachers' asthma knowledge and symptom management is poor. This study investigated the knowledge, prevention and management behaviors, and communication regarding asthma of teachers of low-income, ethnic minority students. It was hypothesized that relative to colleagues whose students did not have active asthma (i.e., did not have symptoms during the day), teachers of students with active asthma would have better asthma knowledge and that more would take asthma prevention steps and communicate with parents and school nurses.

METHODS

Drawing from 25 elementary schools in New York City, 320 pre-Kindergarten through 5th grade classroom teachers with at least one student with asthma completed measures assessing their asthma knowledge, steps taken to manage asthma, communication with the school nurse or parents, information they received about asthma, and whether or not they had at least one student in their class experience asthma symptoms. t test and chi-square were used to test hypotheses.

RESULTS

Asthma knowledge varied among teachers. Most could identify potential triggers, yet few knew that medication taken prior to exercise could prevent symptoms and that students with asthma need not avoid exercise. Communication between teachers and school nurses and between teachers and parents was lacking. Relative to colleagues whose students did not have active asthma, teachers whose students had active asthma had better asthma knowledge, more took steps to prevent students from having asthma symptoms, communicated with parents, and more initiated communication with the nurse.

CONCLUSIONS

Teachers' knowledge about asthma and asthma management is limited, especially among those whose students did not have active asthma. Teachers respond reactively to students who have symptoms in class by increasing prevention steps and communications with parents and the school nurse. A more proactive approach to managing asthma in schools is warranted.

Housing and allergens: a pooled analysis of nine US studies

BACKGROUND

Housing conditions can contribute to allergen exposures that are linked to asthma, but little is known about which of those conditions are most likely to predict high levels of allergens in settled house dust.

METHODS

We pooled allergen, housing condition, occupant behavior, demographic, and other data from nine asthma studies (n=950 homes in 6 US cities). Dust mite (Der f 1 or Der p 1), cockroach (Bla g 1 or Bla g 2), mouse (Mus m 1), cat (Fel d 1) and dog (Can f 1) allergens were measured in settled dust from kitchens or bedrooms, and concentrations were categorized according to previously published asthma symptom thresholds. We calculated odds ratios (OR) using logistic regression to identify those housing conditions and occupant behaviors that were associated with clinically significant allergen levels, after adjusting for numerous confounding variables.

RESULTS

The adjusted results show that high cockroach allergen was associated with cracks or holes in walls (OR=2.1), high dust mite allergen was associated with mold odor (OR=2.5), housing built before 1951 (OR=2.1), and single-family home with slab on grade (OR=1.9); and mouse allergen was associated with rodent control or signs of rodents (OR=3.62) and inversely associated with presence of a cat (OR=0.20). Water leaks and below average housekeeping had unadjusted high odds ratios for high cockroach allergen.

CONCLUSION

We have identified a number of housing conditions that are consistently associated with increased allergen dust concentrations. This study indicates that screening for housing-based asthma triggers should include presence of cats, dogs, cockroaches, or rodents; water leaks; mold or mold odor; holes or cracks in walls; and below average housekeeping. Single family houses that have basements or crawl spaces or are built before 1951 are also important predictors for increased allergens in housing.

School variation in asthma: compositional or contextual?

Background

Childhood asthma prevalence and morbidity have been shown to vary by neighborhood. Less is known about between-school variation in asthma prevalence and whether it exists beyond what one might expect due to students at higher risk of asthma clustering within different schools. Our objective was to determine whether between-school variation in asthma prevalence exists and if so, if it is related to the differential distribution of individual risk factors for and correlates of asthma or to contextual influences of schools.

Methods

Cross-sectional analysis of 16,640 teens in grades 7–12 in Wave 1 (data collected in 1994–5) of the National Longitudinal Study of Adolescent Health. Outcome was current diagnosis of asthma as reported by respondents' parents. Two-level random effects models were used to assess the contribution of schools to the variance in asthma prevalence before and after controlling for individual attributes.

Results

The highest quartile schools had mean asthma prevalence of 21.9% compared to the lowest quartile schools with mean asthma prevalence of 7.1%. In our null model, the school contributed significantly to the variance in asthma ( = 0.27, CI: 0.20, 0.35). Controlling for individual, school and neighborhood attributes reduced the between-school variance modestly ( = 0.19 CI: 0.13–0.29).

Conclusion

Significant between-school variation in current asthma prevalence exists even after controlling for the individual, school and neighborhood factors. This provides evidence for school level contextual influences on asthma. Further research is needed to determine potential mechanisms through which schools may influence asthma outcomes.

Role of mouse allergens in allergic disease

Mouse allergen has long been recognized as an important cause of occupational allergy and asthma, but only recently has it been implicated in asthma and allergic diseases in community settings. Recent studies have established that mouse allergen is detectable in most US homes, with strikingly high levels in some inner cities. Inner city homes in major northeastern and midwestern US urban centers have levels as much as 100-fold higher than those found in other geographic regions. In addition, about 25% of inner city children with asthma have evidence of IgE sensitization to mouse. Several studies have shown that the combination of sensitization and exposure to higher levels of mouse allergen is associated with substantial asthma morbidity, including hospitalizations. Integrated pest management is efficacious in reducing mouse allergen levels and is recommended for sensitized patients with asthma. However, its impact on clinical outcomes has not yet been proven.

Indoor allergens in school and day care environments

Most studies that have examined exposure to indoor allergens have focused on home environments. However, allergen exposures can be encountered in environments other than the home. For example, many children spend a large part of their time in schools and day care facilities. Over the past 2 decades, a large number of studies have been conducted in school and day care environments. However, the role of indoor exposures in allergy and asthma development or morbidity in these settings is not well characterized. The purpose of this review is to evaluate the importance of indoor allergen exposures in school and day care settings. We summarize the key findings from recent scientific literature, describe exposure characteristics, discuss the role of these exposures in relation to asthma and allergy symptoms, and provide information on the effectiveness of published interventions.