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School Inner-City Asthma Study: Working with the Community to Make a Difference:

HARVARD MEDICAL SCHOOL. School Inner-City Asthma Study: Working with the Community to Make a Difference:. Wanda Phipatanakul , M.D., M.S. asthma@childrens.harvard.edu Associate Professor of Pediatrics Boston Children’s Hospital New England Society of Allergy

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School Inner-City Asthma Study: Working with the Community to Make a Difference:

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  1. HARVARD MEDICAL SCHOOL School Inner-City Asthma Study: Working with the Community to Make a Difference: Wanda Phipatanakul, M.D., M.S. asthma@childrens.harvard.edu Associate Professor of Pediatrics Boston Children’s Hospital New England Society of Allergy Fall Meeting, Providence, RI, October 5, 2013

  2. Disclosures/Conflicts of Interest • Funding NIH • AAAAI Environmental Occupational Respiratory Disease Secretary • JCAAI/ACAAI/AAAAI Environment Committee/ Practice Parameters • New England Society of Allergy Secretary • Associate Editor Annals of Allergy, Asthma, Immunology • SICAS Data Collection Ongoing- Most of SICAS data presented is Preliminary, Unpublished CONFIDENTIAL Data

  3. Objectives • To Identify Specific Environmental Exposures Important in Asthma Morbidity in Vulnerable Inner-City Children • To Identify Potentially Successful Environmental Intervention Strategies to Reduce Allergic Respiratory Disease • To Discuss Lessons Learned on Working with the Community to Make a Difference

  4. HOME Allergen Exposure and Asthma Morbidity in Inner City Children Hospitalizations Unscheduled Medical Visits p=0.001 p<0.001 0.4 3 0.3 2 Hospitalizations in Past Year No. of Visits in Past Year 0.2 1 0.1 0 0 Change in Care Giver’s Plans neg neg skin test, low allergen exposure skin test, low allergen exposure p=0.006 neg neg skin test, high allergen exposure* skin test, high allergen exposure* 20 pos skin test, low allergen exposure pos skin test, low allergen exposure 15 pos skin test, high allergen exposure* pos skin test, high allergen exposure* Days With Changed Plans in Past Year 10 g 1 > 8 U/gram * * Bla Bla 5 0 Rosenstreich et al., N Eng J Med, 336: 1356-1363, 1997

  5. Inner City Asthma Study HOME Intervention Reduces Asthma Morbidity Reductions in cockroach and dust mite allergens highly correlated with reduced asthma morbidity Morgan et al., N Eng J Med, 351: 1068-1080, 2004

  6. Mouse allergenin Inner-City Homes • 95% of inner city homes have detectable mouse allergen • High mouse allergen levels are associated with cockroach infestation • More atopic kids had more mouse allergy when exposed to mouse in homes Phipatanakul et al., J. All. Clin. Immunol. (2000) 106:1070-74 Phipatanakul et al., J. All. Clin. Immunol. (2000) 106:1075-80

  7. Home Mouse Allergen Exposure is Associated with Asthma Morbidity * adjusted for age, sex, atopy, cockroach sensitization and exposure, public health insurance, and study visit

  8. Mapping Mouse Allergen in Boston Homes

  9. Professional IPM & Mouse Allergen p<.05 Phipatanakul W. Ann All Asthma Imm. 92:420, 2004.

  10. ICAS: Home IPM & Asthma Morbidity • N=150/155 • asthma • +SPT • Rodent module • Traps, education, air filters • Change in BR floor Mus m 1 • -27% vs. +28% ↓sleep crtker ↓activity child Unsch Visit Max sx dys Pongracic J, Ann Allergy Asthma Immunol2008

  11. Mouse Allergen Asthma Intervention Trial (MAAIT)asthma@childrens.harvard.edu • 350 Children with Asthma, +Mouse in Home and + Mouse PST (Randomized Int/Control) • IPM Intervention/ Air Filters/ Dust Mite Covers/Education/ Cleaning • Control Education Only • Outcomes of Asthma Morbidity • Families get IPM/Air Filters/Dust Mite Covers/$Compensation/ Allergy/Asthma Home Evaluations/Travel

  12. Background/Rationale • Indoor allergen exposure is a known trigger that increases asthma morbidity • NIH funded Inner-City Asthma studies have established that cockroach and mouse allergen may be unique in urban environments and exposure and sensitization strongly associated with asthma morbidity • Most indoor allergen studies have targeted the home/bedroom (Considered primary exposure site) • Children spend the majority of their day in schools • Little is known about the role of school/classroom specific environmental exposure and asthma

  13. The School Inner-City Asthma Study (SICAS) Design, Methods, and Lessons Learned • First study in US to comprehensively evaluate the role of allergen and mold exposure in urban schools and asthma morbidity • NIH/NIAID AI073964 Allergens in Inner-City Schools and Childhood Asthma (Phipatanakul) • Primary goal: To fully evaluate school/classroom specific modifiable environmental risk factors and asthma morbidity, adjusting for home exposure

  14. School Inner-City Asthma Study Repeating Annual Schema Class Sampling Class Sampling Spring Summer Fall Winter Spring 3, 6, 9 ,12 months Screening & Recruitment 8-10 schools 75 Students/yr Baseline Phenotype Survey Spirometry Skin testing Blood/Nasal Follow-up Health Outcomes Linked to Sampling Spirometry, FeNO, Nasal

  15. SICAS Methods – skin testing • Children skin tested to: • Molds (aspergillus, cladosporium, alternaria, penicillium) • Indoor allergens (cat, dog, dust mite, roach, mouse, rat) • Outdoor allergens (grass, pollen, ragweed)

  16. Dust/Air Home/School Environmental Sample Testing • Multiplex array for indoor allergens (MARIA™) • Dust/Air Samples analyzed for common indoor allergens • Cockroach – Bla g 2 • Dust Mite – Der f 1, Der p 1 • Cat – Fel d 1 • Dog – Can f 1 • Mouse – Mus m 1 • Rat- Rat n 1 • Alt-a 1 (mold)

  17. Classroom Mold Sampling Methods • Airborne fungal spores were collected by Burkard samplers from inner-city elementary schools twice during the academic school year • Slides were analyzed at 1000X magnification • A segment representing the school day (8a-4p) was scanned and all fungal spores were counted and identified • Results were reported as spores per cubic meter of air (spores/m3) for the 8-hour school day

  18. Air Pollution Sampling • Fastened to Air Samplers to collect pollutants passively • Particulate Matter black boxes correlated with area samplers NIEHS

  19. School Sampling Visits- Want to Sign Up for This Study? • 8 Air Samplers • 2-3 Vacuums/ Dust Samplers • 4 Burkard Mold Samplers • 8 Pollution Particle Box Samplers • 8 NO2 Samplers • 3-4 Staff • 1-2 Cars Not During MCAS (State Testing) please

  20. School Vs. Home Allergen Levels Sheehan WJ, Phipatanakul W Ann Allergy Asthma Immunol. 2009;102:125-30 Permaul P, Phipatanakul W Peds Allergy Immunol. 2012 ;23(6):543-9

  21. Classroom Airborne vs. Settled Dust Mouse Levels Permaul P, Phipatanakul W Peds Allergy Immunol. 2012 ;23(6):543-9

  22. SICAS-Next Phase • School/classroom environment important • School-based intervention could efficiently and effectively benefit a community of children as opposed to home intervention which benefits only single child or family in a home • Establishing trust and relationships with the community vital for success in this type of work and can pave the way for sustainable, policy changing school-based interventions in the future- Stay Tuned

  23. Acknowledgements • Diane Gold • PetrosKoustrakis • Mike Wolfson • Wan-Chan Lee • Steve Melly • Steve Ferguson • Carter Petty • Brent Coull • Andrea Baccarelli • Peggy Lai • Trainees at BCH • William Sheehan • Jonathan Gaffin • SachinBaxi • PerditaPermaul • Michael Muilenberg • WatcharootKanchongkittiphon • Don Rivard • NIH/ NIAID/ACAAI • SICAS- Ann Bailey/ACRC Staff • Lincoln Diagnostics/Greer • CTSU • Community/Schools/Principals/Teachers/School Nurses/Adminstraters • Jeff Lane/Linda Grant • Study Participants • Collaborations- Pulmonary/others

  24. Questions?asthma@childrens.harvard.edu wanda.phipatanakul@childrens.harvard.edu 857-218-5336

  25. References • Lodrup Carlsen KC, Roll S, Carlsen KH, Mowinckel P, Wijga AH, Brunekreef B, et al.Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of individual participant data from 11 European birth cohorts. PLoS One. 2012;7(8):e43214. • Konradsen JR, Nordlund B, Nilsson OB, van Hage M, Nopp A, Hedlin G, et al.High basophil allergen sensitivity (CD-sens) is associated with severe allergic asthma in children. Pediatric Allergy and Immunology. 2012;23(4):376-84. • Brauner EV, Loft S, Raaschou-Nielsen O, Vogel U, Andersen PS, Sorensen M.Effects of a 17q21 chromosome gene variant, tobacco smoke and furred pets on infant wheeze. Genes Immun. 2012;13(1):94-7. • Delfino RJ, Staimer N, Tjoa T.Personal endotoxin exposure in a panel study of school children with asthma. Environ Health. 2011;10:69. • Pa¨ ivi M. Salo, PhD, Michelle L. Sever, MSPH, and Darryl C. Zeldin, Indoor allergens in school and day care environments. J Allergy Clin Immunol 2009;124:185-92

  26. References • PhipatanakulW, Matsui E, Portnoy J, Williams PB, Barnes C, Kennedy K, Bernstein D, Blessing-Moore J, Cox L, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D, Sublett J, Bernstein J, Grimes C, Miller JD, Seltzer J. • Rodent ParametersAnn Allergy Asthma Immunol. 2012 Dec;109(6):375-87. • Sheehan WJ, Rangsithienchai PA, Wood RA, Rivard D, Chinratanapisit S, Persanowski MS, Chew GL, Seltzer JM, Matsui EC and Phipatanakul W.   “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.”   Journal of Allergy and Clinical Immunology 2010;125(3):575-81 • www.epa.gov , • Air Pollutants and the Respiratory Tract 2nd Ed. Eds. W. Michael Foster and Daniel L. Costa. • Health Effects of Air Pollution Rostrum. J Allergy Clinical Immunology 2004;114:1116-23.

  27. SICAS References • Phipatanakul W, Bailey A, Hoffman EB, Sheehan WJ, Lane JP, Baxi S, Rao D, Permaul P, Gaffin JM, Rogers CA, Muilenberg M, and Gold DR. The School Inner-City Asthma Study (SICAS): Design, Methods, and Lessons Learned 2011 J Asthma 2011; 48:1007-14. • Baxi SN, Sheehan WJ, Gaffin JM, Yodying J, Panupattanapong S, Lane JP, Fu C, Hoffman EB, Gold DR, Phipatanakul W. Agreement between Parent and Student Responses to an Asthma and Allergy Questionnaire in a Diverse Inner City Elementary School Population.” Annals Allergy, Asthma, and Immunology 2011;107 : 371-3. • Sheehan WJ, Hoffman EB, Fu C, Baxi S, Bailey A, King EM, Chapman MD, Lane JP, Gaffin JM, Permaul P, Gold DR, Phipatanakul, W. Endotoxin Exposure in Inner-City Schools and Homes of Children with Asthma Annals of Allergy, Asthma, and Immunology 2012;108(6):418-222. • PermaulP, Sheehan WJ, Baxi SN, Gaffin JM, Fu C, Petty CR, Gold DR, Phipatanakul W. Predictors of Indoor Exposure to Mouse Allergen in Inner-City Elementary Schools. Annals Allergy, Asthma, Immunol 2013 (In Press).

  28. SICAS References • Permaul P, Sheehan WJ, Baxi SN, Gaffin JM, Fu C, Petty CR, Gold DR, Phipatanakul W. Predictors of Indoor Exposure to Mouse Allergen in Inner-City Elementary Schools. Annals Allergy, Asthma, Immunol 2013 (In Press). • BaxiSN, Muilenberg M, Rogers CA, Sheehan WJ, Gaffin JM, Permaul P, Kopel L, Lai P, Lane JP, Bailey A, Petty C, Fu Chunxia, Gold DR, Phipatanakul W.Exposures to Molds in School Classrooms of Children with Asthma. Peds Allergy and Immunolgy (In Press) • Friedlander J, Sheehan WJ, Hoffman EB, Fu C, Gold DR, Phipatanakul W. Food allergy and increased asthma morbidity in a school inner-city asthma study. J Allergy ClinImmunol : In Practice 2013;1: 479-84. • Gaffin JM, Raby B, Petty C, Hoffman E, Gold DR, Phipatanakul W. B2 adrenergic receptor gene methylation is associated with decreased asthma severity, Clinical Experimental Allergy 2013 (In Press)

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