PEER EDUCATION IN PREGNANCY STUDY (PEPS)

1. PEER EDUCATION IN PREGNANCY STUDY (PEPS) Victoria Persky, M.D. Supported by NIEHS grants R21ES08716 and R01ES011377

2. Asthma Statistics • Fifteen million persons in the US currently have asthma • Between 400,000 and 500,000 people are hospitalized each year for asthma • Approximately 4,000-5,000 persons per year die from asthma

3. Trends in Asthma Deaths United States 1980-2004 Akinbami L: The State of Childhood Asthma, United States 1980-2005, National Center for Health Statistics, Advance Data December 12, 2006

4. Results - Mortality Rates by Geographic Region Average Annual Mortality Rates** in Chicago Community Areas Ages 0-54 Year Old Population 1990-1998 **Mortality Rates were age-adjusted to average of 1990 and 2000 Chicago populations

5. Associations of Zip Code SES with Asthma Hospital Admissions: Chicago 1987-89 • P<0.001 Targonski et al : J Asthma 32: 365-372, 1995

6. Hypothesized Causes of Increasing in Asthma Mortality • Decreased access to appropriate health care • Increased prevalence • Increased prevalence of triggers • Changes in medical management

7. KNOWN ASTHMA TRIGGERS • Pets • Dust mites • Cockroaches • Rodents • Molds • Smoke • Pollutants • Pollens

8. Trends in Asthma Prevalence Akinbami L: The State of Childhood Asthma, United States 1980-2005, National Center for Health Statistics, Advance Data December 12, 2006

9. Trends in Asthma Prevalence • Asthma prevalence increased in children between 1970s and 1990s in US • Asthma prevalence (ever diagnosed disease) in children in Chicago has stabilized at 15% since 1995

11. Chicago Asthma Prevalence Study Sample Number of Description Students Overall Sample 5505 Public and Parochial 7th, 8th and 9th Grade Students Random Sample 3670 Public and Parochial 7th and 8th Grade Students Catholic Sample 2273 7th, 8th and 9th Grade Students for Risk Factor Analysis

12. Prevalence of Asthma and Asthma Symptoms by Type of School Schools Wheezing Asthma Sleep In Last Year Diagnosis Disturbed by Asthma Catholic 19.2 13.2 10.2 Public 17.5 17.3 12.6 Public in Poverty Census Tracts 19.4 22.2 17.6 Persky Ann Allergy Asthma Immunol 81:266-271, 1998

13. Percent of Students with Asthma by Race/Ethnicity * A Physician has diagnosed the child with having asthma **A physician has diagnosed the child with having asthma and wheezing in the last 12 months

14. Allergic Diseases by Place of Birth: Mexican American Children NHANES III *p<0.05, Eldeirawi K et al JACI 2005; 116: 42-8

15. Skin Test Reactivity by Place of Birth: Mexican American Children NHANES III +Adjusted for sex, age, ear infection, regular health care and area of residence. Eldeirawi K et al JACI2005; 116:42-48

16. Hypothesized Causes for Trends in Asthma Prevalence • Increased exposure to risk factors • Antibiotics • Immunizations • Tylenol • Fever • Hygiene hypothesis • Lower asthma in children on farms • Lower asthma in children exposed to dogs • Higher asthma in first born children • Lower asthma in children in daycare • Lower asthma in children exposed to TB and parasites

17. Risk of Asthma and Wheezing by Exposure to Cigarette Smoke – Chicago Asthma Prevalence Study (CAPS) * p< 0.05, Turyk et al, in preparation

18. Risk of Asthma and Wheezing by Home Environment – CAPS * P < 0.05, Turyk et al in preparation

19. Risk of Asthma and Wheezing by Exposure to Pets (CAPS) * P < 0.05, Turyk et al in preparation

20. Vaccines and Asthma • Aluminum adjuvants in vaccines cause IgE mediated inflammation in lab animals. • Administration of vaccines may effect immune system development. • Many studies have examined the relationship between vaccines and asthma.

21. Adjusted Prevalence Rate Ratios for any Vaccination Exposure *** * p < 0.05 ** p < 0.005 *** p < 0.0005 ** Prevalence Rate Ratio * ** ** Adjusted for age, sex, exposure to traditional medicine, antibiotic use in the first year of life, and familial clustering. Enriquez R et al JACI 2005; 115: 737-744

22. Evolving Vaccine Schedule Enriquez et al Pediatrics 119: 222-223, 2007

23. Use of Paracetamol and Asthma at 69-81 Months, ALSPAC Study (n=8511)+ + Adjusted for confounders, Shaheen et al Clin Exp Allergy 2005; 35: 18-25

24. Febrile Episodes First Year and Asthma Age 6-7 * p < 0.05 for trend, Williams et al JACI 2004; 113: 291-296

25. Baseline Caregiver Stress and >2 Reports Wheeze in First 14 Months Wright R et al Am J Resp Crit Care Med 2002; 165: 368-365

26. Association of Asthma with Stressful Life Events (CAPS) + Adjusted for family history, age, gender, median family income census tract, race/ethnicity, dampness/mold home, smokers home, inhaled drug use, Turyk et al In Press

27. The Original Hygiene Hypothesis Negative feedback TH1 response Umetsu et al, 2002. Nature Immunology, 3(8), 715-720

28. Revised Hygiene Hypothesis Umetsu et al, 2002. Nature Immunology, 3(8), 715-720

29. Hygiene Hypothesis • May explain variations between developed and undeveloped countries but hard to explain trends in western societies • Also hard to explain differences among ethnic/racial groups within United States

30. Asthma and Atopy in East and West Germany (%) *P<0.05 Von Mutius et al Am J Resp Crit Care Med 149:358-64, 1994

31. Endotoxin and Asthma in 6-13 Year Old Children Braun-Fahrlander et al New Eng J Med 347:869-77, 2002

32. Allergic Responsiveness and Exposure to Dogs and Cats in First Year of Life (%) * P<0.05, Ownby et al JAMA 288: 963-972, 2002

33. Levels of Penicillium and Respiratory Symptoms in Infancy + low:1-499; medium 500-599; high >1,000 CFU/m3; * P<0.05; Gent et al EHP 2002; 110: A781-A786

34. Cockroach Allergen and Wheeze in First Year of Life Gold D et al Am J Respir Crit Care Med 1999; 160: 227-238

35. Primary Prevention Trials: Dust Mite Avoidance • SPACE (Europe): Mattress covers infant/ parent beds 696 newborns: No effect age 2 • Manchester: Mattress covers, HEPA filter, Acarosan 620 prenatal 1 year severe wheeze • PIAMA: Mattress covers 810 prenatal, 2 yr – only effect nocturnal cough; no effect yr 4

36. Primary Prevention Trials: Multifaceted • Isle of Wight: Mattress covers/food avoidance - 120 birth cohort; 8 yr less asthma/atopy • Canadian: Avoidance mites, pets, ETS, daycare; breast feeding – 545 prenatal; year 2 less asthma; smoking largest effect; year 7 also less asthma • CAPS (Australia): Mite avoidance + Omega-3 fatty acids – 616 prenatal 18 mo. Diet group less wheeze- 3 yr less cough ; HDM group no effect;

37. Peer Education in Pregnancy Study (PEPS) • Purpose: to examine the effect of environmental modifications in the home during pregnancy on the development of asthma in children at risk for the disease • Randomized controlled trial • Currently: Approximately 483 women enrolled; 383 randomized; 363 active mother/child pairs; 351 (91.6%) children followed to one year old; 338 have reached three years old

38. Partners • UIC School of Public Health • Erie Family Health Center • Family Focus • Emerson House/Chicago Commons • Medical College of Georgia (RAST tests) • U of Iowa (dust measurements) • U of Pennsylvania (pesticide measurements) • Network of community collaborators

39. PEPS HYPOTHESES • Original hypothesis: Modification of home environment in utero will decrease incidence of asthma and wheezing • Additional hypotheses: Risk of asthma will be increased by • Ingestion of tylenol in utero and early in life • In utero exposure to antioxidants and fish • In utero stress • Mother’s length of residence in US

40. Participant Selection • Pregnant – before 18 weeks • First degree relative of unborn child with asthma, hayfever or eczema • Living West town/Humboldt Park/Logan – later recruitment area expanded • Stable living situation

41. Measurements in Utero • Health status of mother • Demographics/migration history • Diet • Exposure to smoke • Psychosocial • Environment

42. Endpoints • Incidence of wheezing • Incidence of asthma • Incidence of other allergic symptoms • IgE (total and allergen specific)

43. Lodged in Community Setting • Responsiveness to evolving community needs • Development of culturally sensitive educational materials (eg Asthma Game) • Training of peer educators to work with parents of children with asthma • Presentations by peer educators/professional staff • Home education program • Integration with community resources (Family Focus, Chicago Commons, Mental Health Services)

44. Goals of Visits • Establish rapport and explain purpose of study • Home assessment, collection of dust samples, educational material • Implementation of intervention • Follow-up, importance of emergency medical plans and communication with health care provider and school staff

45. Intervention Strategies • Dust control • Removal of pets • Elimination of carpets, if possible • Decrease humidity and molds • Removal of feather pillows and stuffed toys • Covering mattresses and upholstered furniture • Integrated pest management • Decrease use of pesticides • Decrease exposure to smoke

46. Baseline Exposures: PEPS(n=279) • Predominantly Hispanic • Mobile • 4% smokers • 46% exposed to passive smoke • 35% with pets • 50% have mold/moisture in home • 18% leaks in kitchen/bath • 20% holes in the wall • 30% cockroaches • 19% rodents

47. Home Environmental Exposures by Place of Birth: PEPS *p<0.05

48. Living Room Allergen Levels by Place of Birth: PEPS * p=0.06 t test log-transformed data

49. Relationships of Home Environment with Presence of Cockroaches and Rodents: PEPS *p<0.05

50. Description Cohort of 345 Mother/Child Pairs (PEPS) • 62% Mexican • 70% used tylenol at least once in pregnancy: 40% early; 49% late (after 4-5 months gestation) • 87.8% breast fed; 68.7% breast fed > 4 mos • 70.1% started formula at birth • Active smoking pregnancy rare (5% late pregnancy)