Improved childhood asthma control after exposure reduction interventions for desert dust and anthropogenic air pollution: the MEDEA randomised controlled trial

INTRODUCTION

Elevated particulate matter (PM) concentrations of anthropogenic and/or desert dust origin are associated with increased morbidity among children with asthma.

OBJECTIVE

The Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches randomised controlled trial assessed the impact of exposure reduction recommendations, including indoor air filtration, on childhood asthma control during high desert dust storms (DDS) season in Cyprus and Greece.

DESIGN, PARTICIPANTS, INTERVENTIONS AND SETTING

Primary school children with asthma were randomised into three parallel groups: (a) no intervention (controls); (b) outdoor intervention (early alerts notifications, recommendations to stay indoors and limit outdoor physical activity during DDS) and (c) combined intervention (same as (b) combined with indoor air purification with high efficiency particulate air filters in children's homes and school classrooms. Asthma symptom control was assessed using the childhood Asthma Control Test (c-ACT), spirometry (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)) and fractional exhaled nitric oxide (FeNO).

RESULTS

In total, 182 children with asthma (age; mean=9.5, SD=1.63) were evaluated during 2019 and 2021. After three follow-up months, the combined intervention group demonstrated a significant improvement in c-ACT in comparison to controls (β=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (β=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (β=4.26, 95% CI 0.54 to 7.99, p=0.025), the need for any asthma medication and unscheduled clinician visits, but not FVC% and FeNO, were significantly improved in the combined intervention compared with controls.

CONCLUSION

Recommendations to reduce exposure and use of indoor air filtration in areas with high PM pollution may improve symptom control and lung function in children with asthma.

TRIAL REGISTRATION NUMBER

NCT03503812.

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study

BACKGROUND

Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition.

METHODS

The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression.

RESULTS

A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25).

CONCLUSIONS

The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Improved indoor air quality during desert dust storms: The impact of the MEDEA exposure-reduction strategies

Desert dust storms (DDS) are natural events that impact not only populations close to the emission sources but also populations many kilometers away. Countries located across the main dust sources, including countries in the Eastern Mediterranean, are highly affected by DDS. In addition, climate change is expanding arid areas exacerbating DDS events. Currently, there are no intervention measures with proven, quantified exposure reduction to desert dust particles. As part of the wider "MEDEA" project, co-funded by LIFE 2016 Programme, we examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation during DDS events and continuous use of air purifier during DDS and non-DDS days) across homes and/or classrooms of schoolchildren with asthma and adults with atrial fibrillation in Cyprus and Crete-Greece. Participants were randomized to a control or intervention groups, including an indoor intervention group with exposure reduction measures and the use of air purifiers. Particle sampling, PM₁₀ and PM_2.5, was conducted in participants' homes and/or classrooms, between 2019 and 2022, during DDS-free weeks and during DDS days for as long as the event lasted. In indoor and outdoor PM₁₀ and PM_2.5 samples, mass and content in main and trace elements was determined. Indoor PM_2.5 and PM₁₀ mass concentrations, adjusting for premise type and dust conditions, were significantly lower in the indoor intervention group compared to the control group (PM_{2.5-intervention}/PM_2.5-control = 0.57, 95% CI: 0.47, 0.70; PM_{10-intervention}/PM_10-control = 0.59, 95% CI: 0.49, 0.71). In addition, the PM_2.5 and PM₁₀ particles of outdoor origin were significantly lower in the intervention vs. the control group (PM_2.5 infiltration intervention-to-control ratio: 0.49, 95% CI: 0.42, 0.58; PM₁₀ infiltration intervention-to-control ratio: 0.68, 95% CI: 0.52, 0.89). Our findings suggest that the use of air purifiers alongside decreased ventilation measures is an effective protective measure that reduces significantly indoor exposure to particles during DDS and non-DDS in high-risk population groups.

Responses of schoolchildren with asthma to recommendations to reduce desert dust exposure: Results from the LIFE-MEDEA intervention project using wearable technology

Current public health recommendations for desert dust storms (DDS) events focus on vulnerable population groups, such as children with asthma, and include advice to stay indoors and limit outdoor physical activity. To date, no scientific evidence exists on the efficacy of these recommendations in reducing DDS exposure. We aimed to objectively assess the behavioral responses of children with asthma to recommendations for reduction of DDS exposure. In two heavily affected by DDS Mediterranean regions (Cyprus & Crete, Greece), schoolchildren with asthma (6-11 years) were recruited from primary schools and were randomized to control (business as usual scenario) and intervention groups. All children were equipped with pedometer and GPS sensors embedded in smartwatches for objective real-time data collection from inside and outside their classroom and household settings. Interventions included the timely communication of personal DDS alerts accompanied by exposure reduction recommendations to both the parents and school-teachers of children in the intervention group. A mixed effect model was used to assess changes in daily levels of time spent, and steps performed outside classrooms and households, between non-DDS and DDS days across the study groups. The change in the time spent outside classrooms and homes, between non-DDS and DDS days, was 37.2 min (p_value = 0.098) in the control group and -62.4 min (p_value < 0.001) in the intervention group. The difference in the effects between the two groups was statistically significant (interaction p_value < 0.001). The change in daily steps performed outside classrooms and homes, was -495.1 steps (p_value = 0.350) in the control group and -1039.5 (p_value = 0.003) in the intervention group (interaction p_value = 0.575). The effects on both the time and steps performed outside were more profound during after-school hours. To summarize, among children with asthma, we demonstrated that timely personal DDS alerts and detailed recommendations lead to significant behavioral changes in contrast to the usual public health recommendations.

Impact of the MEDEA exposure-reduction strategies on indoor air quality during desert dust storms

Background

Desert dust storms (DDS) impact the Mediterranean basin heavily, particularly in the context of climate change, reduced precipitation and increasing desertification. There is a pressing need to develop policies protecting EU citizens’ health from DDS. While Public Health authorities in affected regions commonly issue warnings, the effectiveness of recommendations to reduce exposure has not been documented.

Methods

This work is part of the wider “MEDEA” intervention studies, co-funded by LIFE 2016 Programme. Among other outcomes, the studies examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation and use of air cleaners) across homes of asthmatic schoolchildren and individuals with atrial fibrillation in Cyprus. Participants were randomized to either a control or indoor intervention group. The assessment took place in a sample of participants’ homes, during 2019 and 2021, with the collection of indoor and outdoor PM10 and PM2.5 samples, which were analyzed for mass and elemental concentrations.

Results

Indoor PM2.5 and PM10 mass and elements concentrations were significantly lower in the indoor intervention group compared to the control group, both during days with no dust (e.g., 55% and 48% reduction for PM2.5 and PM10, respectively) and days with desert dust (PM2.5: 47% and PM10: 40% reduction). In addition, the infiltration of PM2.5 and PM10 particles from the outdoor to the indoor air was significantly lower in the intervention vs. the control group (PM2.5: -55%, 95% CI: -42%, -65%; PM10: -41%, 95% CI: -61%, -12%).

Conclusions

The study assessed a realistic exposure-reduction strategy and provided first-time evidence that closing doors and windows along with air cleaners can reduce indoor exposure to DDS particles. This evidence can further inform decision-making and strategic planning for population-level mitigation of DDS health effects in Mediterranean Europe.

Key messages

Mitigating effects of desert dust storms in asthmatic children: health visitors’ perceptions, Cyprus

Background

Countries of the Mediterranean basin such as Cyprus are experiencing frequent desert dust storm (DDS) events that adversely impact children with asthma. As school health visitors (SHVs) have important role in asthma management, we examined SHVs practices and perceptions on asthma management and their level of engagement in school-based interventions to mitigate DDS- health effects.

Methods

A descriptive cross-sectional survey was conducted among SHVs across state schools in Cyprus via an anonymous questionnaire, which rated the importance of asthma management measures (10-point scale), current implementation of these practices (1=never - 5=always), and regulatory authorities’ preparedness to respond to DDS events (1-5 Likert scale).

Results

Responses from 78 of the 93 SHVs (84%), with an average work experience of 13.5 years (SD 7.3), revealed discordance between high perception of the importance of asthma management measures and their actual implementation, with poor scoring especially in assessment of asthma control (M = 2.4, SD = 1.5), tracking school absenteeism (M = 2.1, SD = 1.0) and monitoring of asthma triggers (M = 1.9, SD = 1.4). Any DDS-related measures (e.g. air quality real-time monitoring, warnings, recommendations, awareness campaigns, etc) were implemented very infrequently. Ratings of authorities’ preparedness were moderate (&lt;3.5), and only slightly higher in the health versus the educational or other government services. SHVs who recognized the severity of DDS and potential impact on asthmatic children were more likely to support school-based interventions for DDS events (OR = 7.3, 95% CI: 2.1-25.3).

Conclusions

Asthma management practices in school settings in Cyprus are suboptimal and responses during DDS are fragmented. While SHV’s awareness and support for interventions is high, this is not reflected in current practices. A concerted effort is needed for adoption of policies and implementation of action plans for DDS within school settings.

Key messages

• Suboptimal asthma management policies and practices were found to be implemented in schools in Cyprus, a country highly exposed to dust events.

• School health visitors recognize the health impact of desert dust on asthmatic children and support the plan for dust-mitigation programmes in schools, despite authorities’ low preparedness.

Pediatric asthma symptom control during lockdown for the COVID-19 pandemic in Spring 2020: A prospective community-based study in Cyprus and Greece

OBJECTIVES

To prospectively quantify at the community level changes in asthma symptom control and other morbidity indices, among asthmatic schoolchildren in response to coronavirus disease 2019 (COVID-19) lockdown measures.

METHODS

In Spring 2019 and Spring 2020, we prospectively assessed monthly changes in pediatric asthma control test (c-ACT), asthma medication usage, infections and unscheduled visits for asthma among schoolchildren with active asthma in Cyprus and Greece. We compared asthma symptom control and other morbidity indices before and during lockdown measures, while participants' time spent at home was objectively assessed by wearable sensors.

RESULTS

A total of 119 asthmatic children participated in the study during Spring 2020. Compared to a mean baseline (pre-COVID-19 lockdown) c-ACT score of 22.70, adjusted mean increases of 2.58 (95% confidence interval [CI]: 1.91, 3.26, p < 0.001) and 3.57 (95% CI: 2.88, 4.27, p < 0.001) in the 2nd and 3rd monthly assessments were observed after implementation of lockdown measures. A mean increase in c-ACT score of 0.32 (95% CI: 0.17, 0.47, p < 0.001) was noted per 10% increase in the time spent at home. Improvement was more profound in children with severe asthma, while significant reductions in infections, asthma medication usage and unscheduled visits for asthma were also observed. During Spring 2019, 39 children participated in the study in the absence of lockdown measures and no changes in c-ACT or other indices of disease severity were observed.

CONCLUSIONS

Clinically meaningful improvements in asthma symptom control, among asthmatic schoolchildren were observed during the COVID-19 lockdown measures in Spring 2020. Improvements were independently associated with time spent at home and were more profound in the children with severe asthma.

Health effects of desert dust storm events in the south-eastern Mediterranean: perceptions and practices of local stakeholders

Background

The south-eastern Mediterranean experiences frequent desert dust storm events (DDS) that have been shown to be associated with adverse health effects.

Aims

This study assessed the perceptions and practices towards DDS of local authorities and stakeholders from 3 countries in the region, Cyprus, Greece and Israel.

Methods

Between October 2017 and April 2018, we administered a semi-structured questionnaire to regulatory authorities involved in public protection from DDS as well as social stakeholders in the 3 countries. The questionnaire addressed their knowledge regarding DDS, perceptions on the relationship between DDS and health effects and relevant actions taken towards public protection.

Results

Out of 58 stakeholders contacted, 49 participated in the study (84.5% response rate). Fourteen (28.6%) were regulatory authorities and 35 (71.4%) were social stakeholders. All responders were familiar with DDS but several underestimated the frequency of events while the majority (73%) instinctively reported that elders, children and respiratory patients are susceptible subpopulations. Nevertheless, 71% were unaware of a national policy on DDS, or considered that this was lacking in their country. Although several stakeholders reportedly receive questions from the public regarding DDS effects, only few reply according to a pre-determined action plan.

Conclusions

Regulatory authorities and social stakeholders in Cyprus, Greece and Israel are characterized by good knowledge of DDS and associated health effects, although implementation of pre-determined action plans for public protection is limited. Future efforts should concentrate on increasing awareness among stakeholders and the public and developing national policies, including effective measures to minimize DDS exposure.

Maternal and neonatal risk factors for neonatal respiratory distress syndrome in term neonates in Cyprus: a prospective case-control study

Background

Neonatal respiratory distress syndrome (NRDS) is strongly associated with premature birth, but it can also affect term neonates. Unlike the extent of research in preterm neonates, risk factors associated with incidence and severity of NRDS in term neonates are not well studied. In this study, we examined the association of maternal and neonatal risk factors with the incidence and severity of NRDS in term neonates admitted to Neonatal Intensive Care Unit (NICU) in Cyprus.

Methods

In a prospective, case-control design we recruited term neonates with NRDS and non-NRDS admitted to the NICU of Archbishop Makarios III hospital, the only neonatal tertiary centre in Cyprus, between April 2017–October 2018. Clinical data were obtained from patients’ files. We used univariate and multivariate logistic and linear regression models to analyse binary and continuous outcomes respectively.

Results

During the 18-month study period, 134 term neonates admitted to NICU were recruited, 55 (41%) with NRDS diagnosis and 79 with non-NRDS as controls. In multivariate adjusted analysis, male gender (OR: 4.35, 95% CI: 1.03–18.39, p = 0.045) and elective caesarean section (OR: 11.92, 95% CI: 1.80–78.95, p = 0.01) were identified as independent predictors of NRDS. Among neonates with NRDS, early-onset infection tended to be associated with increased administration of surfactant (β:0.75, 95% CI: − 0.02-1.52, p = 0.055). Incidence of pulmonary hypertension or systemic hypotension were associated with longer duration of parenteral nutrition (pulmonary hypertension: 11Vs 5 days, p < 0.001, systemic hypotension: 7 Vs 4 days, p = 0.01) and higher rate of blood transfusion (pulmonary hypertension: 100% Vs 67%, p = 0.045, systemic hypotension: 85% Vs 55%, p = 0.013).

Conclusions

This study highlights the role of elective caesarean section and male gender as independent risk factors for NRDS in term neonates. Certain therapeutic interventions are associated with complications during the course of disease. These findings can inform the development of evidence-based recommendations for improved perinatal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-021-01086-5.

Use of wearable sensors to assess compliance of asthmatic children in response to lockdown measures for the COVID-19 epidemic

Between March and April 2020, Cyprus and Greece health authorities enforced three escalated levels of public health interventions to control the COVID-19 pandemic. We quantified compliance of 108 asthmatic schoolchildren (53 from Cyprus, 55 from Greece, mean age 9.7 years) from both countries to intervention levels, using wearable sensors to continuously track personal location and physical activity. Changes in 'fraction time spent at home' and 'total steps/day' were assessed with a mixed-effects model adjusting for confounders. We observed significant mean increases in 'fraction time spent at home' in Cyprus and Greece, during each intervention level by 41.4% and 14.3% (level 1), 48.7% and 23.1% (level 2) and 45.2% and 32.0% (level 3), respectively. Physical activity in Cyprus and Greece demonstrated significant mean decreases by - 2,531 and - 1,191 (level 1), - 3,638 and - 2,337 (level 2) and - 3,644 and - 1,961 (level 3) total steps/day, respectively. Significant independent effects of weekends and age were found on 'fraction time spent at home'. Similarly, weekends, age, humidity and gender had an independent effect on physical activity. We suggest that wearable technology provides objective, continuous, real-time location and activity data making possible to inform in a timely manner public health officials on compliance to various tiers of public health interventions during a pandemic.