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Baltimore Asthma Intervention Trial

Baltimore Asthma Intervention Trial. Patrick N. Breysse, PhD Professor and Director Division of Environmental Health Engineering Department of Environmental Health Sciences Johns Hopkins Bloomberg School of Public Health Associate Director

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Baltimore Asthma Intervention Trial

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  1. Baltimore Asthma Intervention Trial Patrick N. Breysse, PhD Professor and Director Division of Environmental Health Engineering Department of Environmental Health Sciences Johns Hopkins Bloomberg School of Public Health Associate Director Center for Childhood Asthma in the Urban Environment

  2. Centers for Children’s Environmental Health Co sponsored by NIEHS, EPA, CDC

  3. Johns Hopkins Center for the Asthmatic Child in the Urban Environment (CCAUE) Director: Peyton A. Eggleston, MD Associate Director: Patrick Breysse, PhD Investigators Sekhar Reddy, PhD Arlene Butz, RN, DSc Cynthia Rand, PhD Marsha Wills-Karp, PhD Steve Georas, MD Tim Buckley, PhD Gregory Diette, MD, MS Sukon Kanchanaraska, PhD Jerry Krishnan, MD Elizabeth Matsui, MD

  4. Why Focus on Asthma? • In 1999… • 10,488,000 persons with asthma in US (3.8%) • 14.5 million work days lost with asthma • 3,114,000 children < 14 yrs old with asthma (4.9%) • 14 million lost school days • 14.6% report activity limited by asthma • 10,808,000 physician visits • 1,997,000 ER visits for acute asthma • 478,000 hospitalizations for asthma • 4657 deaths CDC MMWRMarch 29, 2002 / 51(SS01);1-13

  5. CCAUE • Multidisciplinary research center • Combine basic research and community based studies • Long Term Goals • Understand mechanism by which allergens, pollutant increases airway inflammation and asthma morbidity • Develop effective intervention strategies

  6. Environmental Factors in Urban Asthma Research Model IMMUNOLOGIC SENSITIZATION ALLERGENS CHILDREN LIVING IN URBAN ENVIRONMENTS AIR POLLUTANTS ASTHMATIC AIRWAY OBSTRUCTION RESPIRATORY MORBIDITY SUSCEPTIBILITY FACTORS ATOPY, INFLAMMATION CONTROL BRONCHIAL HYPERRESPONSIVENESS UNDERLYING SOCIAL SUSCEPTIBILITY FACTORS POVERTY, STRESS, CONFLICTING NEEDS, EDUCATION, ADHERENCE, ACCESS TO CARE

  7. CCAUE Study Components • Community Based Studies • Cohort Study of Environmental Asthma • Longitudinal comparison of environmental exposures and other risk factors • Greg Diette et al. • Asthma Susceptibility to Particulates, Allergens • Genetic association of environmental exposures and asthma • Greg Diette et al. • Asthma Intervention Trial • Randomized trial to reduced household exposures to particulate matter and allergens • Peyton Eggleston et al.

  8. CCAUE Study Components • Basic Biologic Research • Genetics of Response to Ozone • Mouse model examining genetic basis of Ozone and endotoxin inflammation • Sekhar Reddy, Steve Kleeberger • Inflammatory Response to Particulate Matter • Mouse model comparing susceptible and non-susceptible strains • Compare indoor and outdoor particulate matter • Marsha Wills-Karp • Dendritic Cell Response to Particulate Matter • In vitro response of cultured dendritic cells • Steve Georas

  9. CCAUE Community Outreach • Community Advisory Committee • 9 members representing political organizations, schools, churches, parents • Advisory Functions • Protocol feasibility • Community priorities, concerns • Translation of results to local community

  10. 387 children enrolled in asthma education program 93 ineligible 44 refused 180 eligible and interested 13 ineligible 42 refused or unable to contact 125 consented, questionnaire completed 6 refused or unable to contact 116 baseline home evaluation 16 failed scheduled visits 3 moved out of area 100 randomized 97 competed 1 year study 3 dropped out of study Recruitment

  11. CCAUE – Asthma Intervention Study • Randomized Controlled Trial of Home Exposure Control in Asthma • Rationale • Strong epidemiologic evidence that indoor environmental exposure relates to asthma morbidity • Effective treatments available for indoor environmental exposure • Goal • Test hypothesis that reduction of allergen and pollutant exposure in the homes of asthmatic children will reduce morbidity

  12. Air monitoring station STUDY AREA

  13. Recruitment Plan • 100 children recruited from elementary schools in inner city neighborhoods • Eligibility: • 6 – 12 years old • Doctor-diagnosed asthma • Current asthma symptoms • No other lung disease • Live in catchment area

  14. TREATMENT BASELINE TREATMENT CONTROL questionnaire skin test serum,FEV1 home environment telephone 0 3 6 9 12 Intervention Protocol INTERVENTION

  15. Intervention • 3-4 home visits by home health educators • Roach extermination, sealed plastic containers • Allergen-proof bedding encasings • HEPA air cleaner in child’s bedroom • Smoking cessation education and support

  16. Air Cleaner

  17. Environmental Monitoring • Indoor Air Pollutants were measured over a 72-hr period in child's bedroom • Particulate Matter • PM10 • PM2.5 • Data-logging Nephelometer • Ozone • Nitrogen Dioxide • Airborne nicotine (marker for passive smoking exposure)

  18. In-Home Air Sampling Set-Up

  19. Comparison of Indoor, Outdoor at the Home, and Outdoor Central Site Particulate Matter

  20. Reservoir Dust Allergen Samples • Vacuum samples collected in bedroom, living room/family room, and kitchen • Analyzed for • Cockroach • Dust mite • Cat • Dog • Mouse

  21. Baseline Characteristics

  22. Housing Characteristics

  23. Median Particulate Concentrations PM10 treatment PM 2.5 treatment PM 10 control PM 2.5 control g/m3 (median)

  24. Particulate Concentrations: % Change PM10 treatment PM 2.5 treatment PM 10 control PM 2.5 control PM10 treatment PM 2.5 treatment PM 10 control PM 2.5 control p=0.08 p<0.001 p=0.019 p<0.001

  25. Bedroom Cockroach Allergen Bla g 1 U/gm Treatment Control p=0.001 p=0.07

  26. Proportion of children with wheeze, cough, dyspnea in last 2 weeks p=<0.001 Control group p=0.60 p=<0.001 p=0.02 Change in proportion with symptoms Treatment group

  27. Other Health Outcomes • Other health outcomes not different between the two groups • Nighttime symptoms • ED visits • Hospitalizations • FEV1

  28. Summary • A global environmental intervention was able to reduce levels of PM10, PM2.5 and cockroach allergen in inner city homes • There was an associated reduction in symptoms in asthmatic children living in the homes • Persistence of reduction is uncertain

  29. Acknowledgements • In addition the investigators previously mentioned • Chris Beck - Nowella Durkin • D’Ann Williams - Mayme Grant • Jean Curtin-Brosnan - Craig Lewis • Lee Swartz - Jennette Logan • Barry Merriman - Zina Nettles-Smith • Karen Callahan - Dena Scott

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