Indoor environmental exposures for children with asthma enrolled in the HEAL study, post-Katrina New Orleans

Impact of Hurricane Harvey on Inpatient Asthma Hospitalization Visits Within Southeast Texas, 2016-2019

OBJECTIVE

The aim of the study is to estimate inpatient asthma hospital visit rates among impacted Texans in Public Health Region 6/5S during the year of and after Hurricane Harvey.

METHODS

Asthma inpatient hospitalization discharges were collected from the Texas Health Care Information Collection database (2016-2019).

RESULTS

Females (age-adjusted rates [AARs] = 4.8-5.0) and Black Texans (AARs = 5.0-8.1) experienced significantly higher AARs compared with males and White Texans during the year of and after Harvey. During the year of Hurricane Harvey, females were 1.49 times as likely to have an inpatient asthma visit compared with males, while Black Texans were 2.78 times as likely to have an inpatient asthma hospitalization compared with White Texans.

CONCLUSIONS

Findings from this study may assist public health professionals and local officials to allocate future resources to the most impacted subgroups as well as establish effective processes to mitigate consequences.

Infants exposed in utero to Hurricane Maria have gut microbiomes with reduced diversity and altered metabolic capacity

The gut microbiome is a potentially important mechanism that links prenatal disaster exposures with increased disease risks. However, whether prenatal disaster exposures are associated with alterations in the infant's gut microbiome remains unknown. We established a birth cohort study named Hurricane as the Origin of Later Alterations in Microbiome (HOLA) after Hurricane Maria struck Puerto Rico in 2017. We enrolled vaginally born Latino term infants aged 2 to 6 months, including n = 29 infants who were exposed in utero to Hurricane Maria in Puerto Rico and n = 34 infants who were conceived at least 5 months after the hurricane as controls. Shotgun metagenomic sequencing was performed on infant stool swabs. Infants exposed in utero to Hurricane Maria had a reduced diversity in their gut microbiome compared to the control infants, which was mainly seen in the exclusively formula-fed group (P = 0.02). Four bacterial species, including Bacteroides vulgatus, Clostridium innocuum, Bifidobacterium pseudocatenulatum, and Clostridium neonatale, were depleted in the exposure group compared to the control group. Compositional differences in the microbial community and metabolic genes between the exposure and control groups were significant, which were driven by the formula feeding group (P = 0.02 for the microbial community and P = 0.008 for the metabolic genes). Metabolic modules involved in carbohydrate metabolism were reduced in the exposure group. Prenatal maternal exposure to Hurricane Maria was associated with a reduced gut commensal and an altered microbial composition and metabolic potential in the offspring's gut. Breastfeeding can adjust the composition of the gut microbiomes of exposed infants. IMPORTANCE Climate change is a serious issue that is affecting human health. With more frequent and intense weather disasters due to climate change, there is an urgent need to evaluate and understand the impacts of prenatal disaster exposures on the offspring. The prenatal stage is a particularly vulnerable stage for disease origination. However, the impact of prenatal weather disaster exposures on the offspring's gut microbiome has not been evaluated. Our HOLA study starts to fill this knowledge gap and provides novel insights into the microbiome as a mechanism that links prenatal disaster exposures with elevated disease risks. Our major finding that reduced microbial diversity and altered metabolic capacity are associated with prenatal hurricane exposures warrants further studies to evaluate the impact of weather disasters on the unborn.

Impact of Hurricane Matthew on a Cohort of Adolescents With Asthma in North Carolina

OBJECTIVE

The aim of this study was to look at a cohort of adolescents who were already enrolled in a randomized controlled trial to see (1) how demographics were associated with hurricane impact, and (2) how hurricane impact was associated with reported asthma quality of life.

METHODS

One hundred fifty-one adolescents ages 11-17 and their parents enrolled in a randomized controlled trial at 2 sites in southeastern North Carolina completed questions about asthma quality of life, demographics, and the impact of Hurricane Matthew.

RESULTS

The most common effects of Hurricane Matthew were that the family's home was damaged or flooded (32.5%), the school was damaged or flooded (31.8%), and the home had mold or mildew as a result of flooding or damage (25.8%). Problems with access to care were more common for families whose adolescent was non-White (P = 0.04), on Medicaid (P = 0.05), or if the family spoke Spanish at home (P < 0.001). Being affected by the hurricane was negatively associated with asthma quality of life.

CONCLUSIONS

Hurricane Matthew had significant impact on the health of adolescents with asthma in the affected region, especially in the most vulnerable populations. Providers should ensure that families of adolescents with asthma have a hurricane plan to mitigate impact on their children's health.

Impact of Global Climate Change on Pulmonary Health: Susceptible and Vulnerable Populations

As fossil fuel combustion continues to power the global economy, the rate of climate change is accelerating, causing severe respiratory health impacts and large disparities in the degree of human suffering. Hotter and drier climates lead to longer and more severe wildland fire seasons, impairing air quality around the globe. Hotter temperatures lead to higher amounts of ozone and particles, causing the exacerbation of chronic respiratory diseases and premature mortality. Longer pollen seasons and higher pollen concentrations provoke allergic airway diseases. In arid regions, accelerated land degradation and desertification are promoting dust pollution and impairing food production and nutritional content that are essential to respiratory health. Extreme weather events and flooding impede healthcare delivery and can lead to poor indoor air quality due to mold overgrowth. Climate and human activities that harm the environment and ecosystem may also affect the emergence and spread of viral infections, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and associated morbidity and mortality exacerbated by air pollution. Children and elderly individuals are more susceptible to the adverse health effects of climate change. Geographical and socioeconomic circumstances, together with a decreased capacity to adapt, collectively increase vulnerability to the adverse effects of climate change. Successful mitigation of anthropogenic climate change is dependent on the commitment of energy-intensive nations to manage greenhouse gas emissions, as well as societal support and response to aggravating factors. In this review, we focus on the respiratory health impacts of global climate change, with an emphasis on susceptible and vulnerable populations and low- and middle-income countries.

Classifying Building Roof Damage Using High Resolution Imagery for Disaster Recovery

Post-hurricane damage assessments are often costly and time-consuming. Remotely sensed data provides a complementary method of data collection that can be completed comparatively quickly and at relatively low cost. This study focuses on 15 Florida counties impacted by Hurricane Michael (2018), which had category 5 strength winds at landfall. The present study evaluates the ability of aerial imagery collected to cost-effectively measure blue tarps on buildings for disaster impact and recovery. A support vector machine model classified blue tarp, and parcels received a damage indicator based on the model's prediction. The model had an overall accuracy of 85.3% with a sensitivity of 74% and a specificity of 96.7%. The model results indicated approximately 7% of all parcels (27 926 residential and 4431 commercial parcels) in the study area as having blue tarp present. The study results may benefit jurisdictions that lacked financial resources to conduct on-the-ground damage assessments.

Projecting the Impacts of a Changing Climate: Tropical Cyclones and Flooding

PURPOSE OF REVIEW

There is clear evidence that the earth's climate is changing, largely from anthropogenic causes. Flooding and tropical cyclones have clear impacts on human health in the United States at present, and projections of their health impacts in the future will help inform climate policy, yet to date there have been few quantitative climate health impact projections.

RECENT FINDINGS

Despite a wealth of studies characterizing health impacts of floods and tropical cyclones, many are better suited for qualitative, rather than quantitative, projections of climate change health impacts. However, a growing number have features that will facilitate their use in quantitative projections, features we highlight here. Further, while it can be difficult to project how exposures to flood and tropical cyclone hazards will change in the future, climate science continues to advance in its capabilities to capture changes in these exposures, including capturing regional variation. Developments in climate epidemiology and climate science are opening new possibilities in projecting the health impacts of floods and tropical cyclones under a changing climate.

Novel Mouse Models of Fungal Asthma

Alternaria alternata is a ubiquitous fungus and a major allergen associated with the development of asthma. Inhalation of intact spores is the primary cause of human exposure to fungal allergen. However, allergen-rich cultured fungal filtrates are oftentimes used in the current models of fungal sensitization that do not fully reflect real-life exposures. Thus, establishing novel spore exposure models is imperative. In this study, we established novel fungal exposure models of both adult and neonate to live spores. We examined pathophysiological changes in the spore models as compared to the non-exposure controls and also to the conventional filtrate models. While both Alternaria filtrate- and spore-exposed adult BALB/c mice developed elevated airway hyperresponsiveness (AHR), filtrates induced a greater IgE mediated response and higher broncholavage eosinophils than spores. In contrast, the mice exposed to Alternaria spores had higher numbers of neutrophils. Both exposures induced comparable levels of lung tissue inflammation and mucous cell metaplasia (MCM). In the neonatal model, exposure to Alternaria spores resulted in a significant increase of AHR in both adult and neonatal mice. Increased levels of IgE in both neonatal and adult mice exposed to spores was associated with increased eosinophilia in the treatment groups. Adult demonstrated increased numbers of lymphocytes that was paralleled by increased IgG1 production. Both adults and neonates demonstrated similarly increased eosinophilia, IgE, tissue inflammation and MCM.

Impact of Hurricanes on Children With Asthma: A Systematic Literature Review

Following hurricanes, there can be increases in exacerbations of chronic diseases, such as asthma. Asthma is common among children, and many asthma exacerbations can be prevented. This systematic literature review assessed literature describing the impact of hurricanes on children with asthma in the United States. Medline, Embase, Global Health, PubMed, and Scopus databases were searched for peer-reviewed, English-language articles published January 1990 to June 2019 that described the effect of a hurricane on children with asthma. This search identified 212 articles; 8 met inclusion criteria. All 8 were related to Hurricane Katrina, but research questions and study design varied. Articles included information on asthma after hurricanes from cross-sectional surveys, retrospective chart review, and objective clinical testing. Four articles described discontinuity in health insurance, asthma-related health care, or asthma medication use; and 3 articles examined the relationship between mold exposure and asthma symptoms and reported varying results. The eighth study quantified the burden of asthma among people visiting mobile medical units but did not describe factors associated with asthma symptoms. These results highlight opportunities for future research (eg, on more recent hurricanes) and disaster preparedness planning (eg, strategies to prevent health-care discontinuity among children with asthma).

A Community-Based Participatory Research Approach to Hurricane Katrina: When Disasters, Environmental Health Threats, and Disparities Collide

In 2005, Hurricane Katrina resulted in long-term flooding of 80% of New Orleans, Louisiana. Mold-infested homes gave rise to concerns about increased childhood asthma. To address these concerns, a diverse community-academic partnership used a community-based participatory research (CBPR) approach to implement the Head-off Environmental Asthma in Louisiana (HEAL) study in 2007.The study examined the relationship between post-Katrina mold and other environmental exposures and asthma morbidity, while testing an asthma counselor (AC) intervention. Both the AC intervention and the CBPR approach were effectively implemented in the postdisaster setting. However, homes had lower levels of mold and other allergens than expected, possibly because of the timing of environmental sampling. Also, HEAL illustrated the vulnerability of the study community, especially to the interconnected threats of health disparities, environmental health stressors, and disasters.We examine the implications of these threats for public health science, policy, and practice, not only through the lens of Hurricane Katrina but also for future disasters faced by communities in the Gulf Coast and nationally.

Elemental Contamination in Indoor Floor Dust and Its Correlation with PAHs, Fungi, and Gram+/- Bacteria

In this study, we performed elemental analysis for floor dust samples collected in Jordanian microenvironments (dwellings and educational building). We performed intercorrelation and cluster analysis between the elemental, polyaromatic hydrocarbon (PAH), and microorganism concentrations. In general, the educational building workshops had the highest elemental contamination. The age of the dwelling and its occupancy played a role on the elemental contamination level: older and more occupied dwellingshad greater contamination. The elemental contamination at a dwelling entrance was observed to be higher than in the living room. We found exceptionally high concentrations for Fe and Mn in the educational workshop and additionally, Hg, Cr, and Pb concentrations exceeded the limits set by the Canadian Council of Ministers of the Environment. According to the cluster analysis, we found three major groups based on location and contamination. According to the enrichment factor (EF) assessment, Al, Co, Mn, Ti, and Ba had EF < 2 (i.e., minimal enrichment) whereas P, S, Pb, Sb, Mo, Zn, Hg, and Cu had EF > 40 (i.e., extremely enriched). In contrast, Ca and P were geogenically enriched. Furthermore, significant Spearman correlations indicated nine subgroups of elemental contamination combined with PAHs and microbes.

Environmental health effects attributed to toxic and infectious agents following hurricanes, cyclones, flash floods and major hydrometeorological events

Extreme hydrometeorological events such as hurricanes and cyclones are increasing in frequency and intensity due to climate change and often associated with flash floods in coastal, urbanized and industrial areas. Preparedness and response measures need to concentrate on toxicological and infectious hazards, the potential impact on environmental health, and threat to human lives. The recognition of the danger of flood water after hurricanes is critical. Effective health management needs to consider the likelihood and specific risks of toxic agents present in waters contaminated by chemical spills, bio-toxins, waste, sewage, and water-borne pathogens. Despite significant progress in the ability to rapidly detect and test water for a wide range of chemicals and pathogens, there has been a lack of implementation to adapt toxicity measurements in the context of flash and hurricane-induced flooding. The aim of this review was to highlight the need to collect and analyze data on toxicity of flood waters to understand the risks and prepare vulnerable communities and first responders. It is proposed that new and routinely used technologies be employed during disaster response to rapidly assess toxicity and infectious disease threats, and subsequently take necessary remedial actions.

Impact of weather and climate change with indoor and outdoor air quality in asthma: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee

Weather and climate change are constant and ever-changing processes that affect allergy and asthma. The purpose of this report is to provide information since the last climate change review with a focus on asthmatic disease. PubMed and Internet searches for topics included climate and weather change, air pollution, particulates, greenhouse gasses, traffic, insect habitat, and mitigation in addition to references contributed by the individual authors. Changes in patterns of outdoor aeroallergens caused by increasing temperatures and amounts of carbon dioxide in the atmosphere are major factors linked to increased duration of pollen seasons, increased pollen production, and possibly increased allergenicity of pollen. Indoor air pollution threats anticipated from climate changes include microbial and mold growth secondary to flooding, resulting in displacement of persons and need for respiratory protection of exposed workers. Air pollution from indoor burning of mosquito repellants is a potential anticipatory result of an increase in habitat regions. Air pollution from fossil fuel burning and traffic-related emissions can alter respiratory defense mechanisms and work synergistically with specific allergens to enhance immunogenicity to worsen asthma in susceptible subjects. Community efforts can significantly reduce air pollution, thereby reducing greenhouse gas emission and improving air quality. The allergist's approach to weather pattern changes should be integrated and anticipatory to protect at-risk patients.

Flooding: what is the impact on pregnancy and child health?

Floods are the most common type of natural disaster in both developed and developing countries and have led to extensive morbidity and mortality throughout the world. Worldwide, over the past 30 years, flooding has claimed the lives of more than 200,000 people and affected more than 2.8 billion others. The impact of flooding on health varies among populations and depends primarily on vulnerability and the kind of event experienced. It severely disrupts livelihoods and has a significant impact on the health of pregnant women and children. In addition, it may exacerbate a range of negative psychological and physiological child and reproductive health outcomes. Awareness-raising, education, and the issuing of warnings appear to be key initiatives to mitigate or prevent flood morbidity and mortality, especially among people living in low- and middle-income countries. Agencies responding to emergencies also need to be more cognisant of the dangers, specifically those engaged in healthcare, nutrition, and water safety programmes.

Using community-based, ethnographic methods to examine risk perceptions and actions of low-income, first-time mothers in a post-spill environment

Following the 2010 Gulf Oil Spill, area pregnant women were thought to be at-risk for poor health outcomes from the stress of managing health actions in this post-disaster environment. Research directed by an ongoing community- academic partnership sought to explore the specific role of culture in environmental risk protection actions among low-income pregnant women. As a part of the first-phase of a mixed-methods cultural study, community health workers (CHWs) used freelisting methods to survey low-income, first-time mother (n = 20) for the threats in the environment and relevant protective actions. Then, a separate pile sort activity (n = 31) was used to further investigate these cultural topics. Results elicited a diverse range of threats, protective actions, and sources of support across socio-demographic groups. Results also showed a culturally tailored conceptualization of threats in the environment. Exploring beliefs among a diverse population helps to uncover cultural differences in a population. Results will aid in developing culturally tailored policies and interventions, and increase the relevance of such interventions to address community concerns. Moreover, incorporating CHWs into the research process enhanced researcher literacy, and fostered mutual trust between the community and researchers.

Floor dust bacteria and fungi and their coexistence with PAHs in Jordanian indoor environments

Floor dust samples were collected from Jordanian indoor environments (eight dwellings and an educational building) in Amman. Quantitative PCR (qPCR) analyses of selected fungal and bacterial groups were performed. The bacterial and fungal concentrations were also correlated with PAHs concentrations, which were previously measured in the same samples by using GC-MS. The bacterial and fungal concentrations varied significantly among and within the tested indoor environments. Based on the collected samples in the entrance area of the dwellings, the largest variation was found in Gram-negative bacteria and total fungi concentration. The lowest bacterial and fungal concentrations were found in the dwelling that was least occupied and the most recently built. At the educational building, the Gram-positive bacteria concentrations were lower than those observed in the dwellings. Unlike for bacteria, we observed significant negative correlation with some polycyclic aromatic hydrocarbons (PAHs). This calls for further studies investigating biodegradation of PAHs in house dust and presence of potentially health hazardous PAH metabolites. Since biocontamination in floor dust has been given relatively little to no attention in the MENA region we recommend that more extensive measurements be conducted in the future with chemical and biological analysis of floor dust contaminants and their exposure indoors.

From Design to Dissemination: Implementing Community-Based Participatory Research in Postdisaster Communities

OBJECTIVES

To review how disasters introduce unique challenges to conducting population-based research and community-based participatory research (CBPR).

METHODS

From 2007-2009, we conducted the Head-off Environmental Asthma in Louisiana (HEAL) Study in the aftermath of Hurricane Katrina in a Gulf Coast community facing an unprecedented triple burden: Katrina's and other disasters' impact on the environment and health, historic health disparities, and persistent environmental health threats.

RESULTS

The unique triple burden influenced every research component; still, most existing CBPR principles were applicable, even though full adherence was not always feasible and additional tailored principles govern postdisaster settings.

CONCLUSIONS

Even in the most challenging postdisaster conditions, CBPR can be successfully designed, implemented, and disseminated while adhering to scientific rigor.

Environmental mold and mycotoxin exposures elicit specific cytokine and chemokine responses

Background

Molds can cause respiratory symptoms and asthma. We sought to use isolated peripheral blood mononuclear cells (PBMCs) to understand changes in cytokine and chemokine levels in response to mold and mycotoxin exposures and to link these levels with respiratory symptoms in humans. We did this by utilizing an ex vivo assay approach to differentiate mold-exposed patients and unexposed controls. While circulating plasma chemokine and cytokine levels from these two groups might be similar, we hypothesized that by challenging their isolated white blood cells with mold or mold extracts, we would see a differential chemokine and cytokine release.

Methods and Findings

Peripheral blood mononuclear cells (PBMCs) were isolated from blood from 33 patients with a history of mold exposures and from 17 controls. Cultured PBMCs were incubated with the most prominent Stachybotrys chartarum mycotoxin, satratoxin G, or with aqueous mold extract, ionomycin, or media, each with or without PMA. Additional PBMCs were exposed to spores of Aspergillus niger, Cladosporium herbarum and Penicillium chrysogenum. After 18 hours, cytokines and chemokines released into the culture medium were measured by multiplex assay. Clinical histories, physical examinations and pulmonary function tests were also conducted. After ex vivo PBMC exposures to molds or mycotoxins, the chemokine and cytokine profiles from patients with a history of mold exposure were significantly different from those of unexposed controls. In contrast, biomarker profiles from cells exposed to media alone showed no difference between the patients and controls.

Conclusions

These findings demonstrate that chronic mold exposures induced changes in inflammatory and immune system responses to specific mold and mycotoxin challenges. These responses can differentiate mold-exposed patients from unexposed controls. This strategy may be a powerful approach to document immune system responsiveness to molds and other inflammation-inducing environmental agents.

Comparison of Single-Point and Continuous Sampling Methods for Estimating Residential Indoor Temperature and Humidity

Residential temperature and humidity are associated with multiple health effects. Studies commonly use single-point measures to estimate indoor temperature and humidity exposures, but there is little evidence to support this sampling strategy. This study evaluated the relationship between single-point and continuous monitoring of air temperature, apparent temperature, relative humidity, and absolute humidity over four exposure intervals (5-min, 30-min, 24-hr, and 12-days) in 9 northern Utah homes, from March-June 2012. Three homes were sampled twice, for a total of 12 observation periods. Continuous data-logged sampling was conducted in homes for 2-3 wks, and simultaneous single-point measures (n = 114) were collected using handheld thermo-hygrometers. Time-centered single-point measures were moderately correlated with short-term (30-min) data logger mean air temperature (r = 0.76, β = 0.74), apparent temperature (r = 0.79, β = 0.79), relative humidity (r = 0.70, β = 0.63), and absolute humidity (r = 0.80, β = 0.80). Data logger 12-day means were also moderately correlated with single-point air temperature (r = 0.64, β = 0.43) and apparent temperature (r = 0.64, β = 0.44), but were weakly correlated with single-point relative humidity (r = 0.53, β = 0.35) and absolute humidity (r = 0.52, β = 0.39). Of the single-point RH measures, 59 (51.8%) deviated more than ±5%, 21 (18.4%) deviated more than ±10%, and 6 (5.3%) deviated more than ±15% from data logger 12-day means. Where continuous indoor monitoring is not feasible, single-point sampling strategies should include multiple measures collected at prescribed time points based on local conditions.

Environmental remediation in the treatment of allergy and asthma: latest updates

In the modern era, the prevalence of asthma and allergies are increasing. It has been speculated that environmental exposures are contributing to this rise. Several studies demonstrate that common indoor allergen exposures exacerbate asthma. Minimizing exposure to allergens and remediating the environment play a critical role in the treatment of asthma and allergies. The most effective environmental control measures are tailored multifaceted interventions which include education, thorough cleaning, using high-efficiency particulate air (HEPA) filters, integrated pest management, and maintenance of these practices.

Indoor water and dampness and the health effects on children: a review

Exposure to dampness and mold in indoor environments has received significant attention in recent research. This review focuses on studies looking at the impact of dampness, moisture and microbial agents on children's health. We then look more broadly at how research studies have tried to describe dampness and exposure to moisture. Papers published from 2010 onwards were reviewed and are briefly summarized. Most of the papers using dampness as a proxy for microbial exposure focused on respiratory tract infections, especially asthma. This review highlights new findings and also discusses the variety of approaches used to assess dampness in indoor environments.

Decreased pulmonary function measured in children exposed to high environmental relative moldiness index homes

BACKGROUND

Exposures to water-damaged homes/buildings has been linked to deficits in respiratory health. However, accurately quantifying this linkage has been difficult because of the methods used to assess water damage and respiratory health.

PURPOSE

The goal of this analysis was to determine the correlation between the water-damage, as defined by the Environmental Relative Moldiness Index (ERMI) value in an asthmatic child's home, and the child's pulmonary function measured by spirometry, "forced expiratory volume in one second, percent predicted" or FEV1%.

METHODS

This analysis utilized data obtained from the "Heads-off Environmental Asthma in Louisiana" (HEAL) study. The children (n= 109), 6 to 12 years of age, who had completed at least one spirometry evaluation and a dust sample collected for ERMI analysis from the home at approximately the same time as the spirometry testing, were included in the analysis. Statistical evaluation of the correlation between ERMI values and FEV1% was performed using the Spearman's Rank Correlation analysis. The relationship between ERMI values and FEV1% was performed using B-spline regression.

RESULTS

The average ERMI value in the HEAL study homes was 7.3. For homes with ERMI values between 2.5 and 15, there was a significant inverse correlation with the child's lung function or FEV1% measurement (Spearman's rho -0.23; p= 0.03), i.e. as the ERMI value increased, the FEV1% value decreased.

CONCLUSIONS

Measures of water-damage (the ERMI) and clinical assessments of lung function (FEV1%) provided a quantitative assessment of the impact of water-damaged home exposures on children's respiratory health.

Few Associations Found between Mold and Other Allergen Concentrations in the Home versus Skin Sensitivity from Children with Asthma after Hurricane Katrina in the Head-Off Environmental Asthma in Louisiana Study

Mold and other allergen exposures exacerbate asthma symptoms in sensitized individuals. We evaluated allergen concentrations, skin test sensitivities, and asthma morbidity for 182 children, aged 4–12 years, with moderate to severe asthma, enrolled 18 months after Katrina, from the city of New Orleans and the surrounding parishes that were impacted by the storm, into the Head-off Environmental Asthma in Louisiana (HEAL) observational study. Dust (indoor) and air (indoor and outdoor) samples were collected at baseline of 6 and 12 months. Dust samples were evaluated for dust mite, cockroach, mouse, and Alternaria by immunoassay. Air samples were evaluated for airborne mold spore concentrations. Overall, 89% of the children tested positive to ≥1 indoor allergen, with allergen-specific sensitivities ranging from 18% to 67%. Allergen concentration was associated with skin sensitivity for 1 of 10 environmental triggers analyzed (cat). Asthma symptom days did not differ with skin test sensitivity, and surprisingly, increased symptoms were observed in children whose baseline indoor airborne mold concentrations were below median levels. This association was not observed in follow-up assessments. The lack of relationship among allergen levels (including mold), sensitivities, and asthma symptoms points to the complexity of attempting to assess these associations during rapidly changing social and environmental conditions.

The Head-off Environmental Asthma in Louisiana (HEAL) study--methods and study population

BACKGROUND

In the city of New Orleans, Louisiana, and surrounding parishes (NOLA), children with asthma were perilously impacted by Hurricane Katrina as a result of disrupted health care, high home mold and allergen levels, and high stress.

OBJECTIVES

The Head-off Environmental Asthma in Louisiana (HEAL) study was conducted to examine relationships between the post-Katrina environment and childhood asthma in NOLA and assess a novel asthma counselor intervention that provided case management and guidance for reducing home mold and allergen levels.

METHODS

Children (4-12 years old) with moderate-to-severe asthma were recruited from NOLA schools. Over 1 year, they received two clinical evaluations, three home environmental evaluations, and the asthma intervention. Quarterly end points included symptom days, medication use, and unscheduled emergency department or clinic visits. A community advisory group was assembled and informed HEAL at all phases.

RESULTS

Of the children (n = 182) enrolled in HEAL, 67% were African American, and 25% came from households with annual incomes < $15,000. HEAL children were symptomatic, averaging 6.6 symptom days in the 2 weeks before baseline, and had frequent unscheduled visits to clinics or emergency departments (76% had at least one unscheduled visit in the preceding 3 months). In this report, we describe study design and baseline characteristics of HEAL children.

CONCLUSIONS

Despite numerous challenges faced by investigators, study staff, and participants, including destroyed infrastructure, disrupted lives, and lost jobs, HEAL was successful in terms of recruitment and retention, the high quality of data collected that will provide insight into asthma-allergen relationships, and the asthma intervention. This success was attributable to using an adaptive approach and refining processes as needed.

Implementation of evidence-based asthma interventions in post-Katrina New Orleans: the Head-off Environmental Asthma in Louisiana (HEAL) study

BACKGROUND

Childhood asthma morbidity and mortality in New Orleans, Louisiana, is among the highest in the nation. In August 2005, Hurricane Katrina created an environmental disaster that led to high levels of mold and other allergens and disrupted health care for children with asthma.

OBJECTIVES

We implemented a unique hybrid asthma counselor and environmental intervention based on successful National Institutes of Health asthma interventions from the National Cooperative Inner City Asthma (NCICAS) and Inner-City Asthma (ICAS) Studies with the goal of reducing asthma symptoms in New Orleans children after Hurricane Katrina.

METHODS

Children (4-12 years old) with moderate-to-severe asthma (n = 182) received asthma counseling and environmental intervention for approximately 1 year. HEAL was evaluated employing several analytical approaches including a pre-post evaluation of symptom changes over the entire year, an analysis of symptoms according to the timing of asthma counselor contact, and a comparison to previous evidence-based interventions.

RESULTS

Asthma symptoms during the previous 2 weeks decreased from 6.5 days at enrollment to 3.6 days at the 12-month symptom assessment (a 45% reduction, p < 0.001), consistent with changes observed after NCICAS and ICAS interventions (35% and 62% reductions in symptom days, respectively). Children whose families had contact with a HEAL asthma counselor by 6 months showed a 4.09-day decrease [95% confidence interval (CI): 3.25 to 4.94-day decrease] in symptom days, compared with a 1.79-day decrease (95% CI: 0.90, 2.67) among those who had not yet seen an asthma counselor (p < 0.001).

CONCLUSIONS

The novel combination of evidence-based asthma interventions was associated with improved asthma symptoms among children in post-Katrina New Orleans. Post-intervention changes in symptoms were consistent with previous randomized trials of NCICAS and ICAS interventions.