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. "Protection of Children from Environmental Health Risks and Safety Risks" –Charges agencies to consider special environmental risks to children A high priority to identify and assess environmental health risks to children –National Institute for Environmental Health Sciences (NIEHS) and Environmental Protection Agency (EPA) Fund research centers Executive Order April, 1997

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

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

5. 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 MMWR March 29, 2002 / 51(SS01);1-13

6. 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

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

8. 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.

9. 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

10. 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

11. 387 children enrolled in asthma education program 180 eligible and interested 13 ineligible 42 refused or unable to contact 125 consented, questionnaire completed 116 baseline home evaluation 100 randomized 97 competed 1 year study 6 refused or unable to contact 16 failed scheduled visits 3 moved out of area 3 dropped out of study 93 ineligible 44 refused Recruitment

12. 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

13. STUDY AREA Air monitoring station

15. 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

16. Intervention Protocol questionnaire skin test serum,FEV 1 home environment telephone 0 3 6 9 12 BASELINE CONTROL TREATMENT INTERVENTION

17. 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

18. Air Cleaner

19. Environmental Monitoring Indoor Air Pollutants were measured over a 72-hr period in child's bedroom –Particulate Matter PM 10 PM 2.5 Data-logging Nephelometer –Ozone –Nitrogen Dioxide –Airborne nicotine (marker for passive smoking exposure)

20. In-Home Air Sampling Set-Up

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

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

23. Baseline Characteristics CONTROLTREATMENT Age (mean)8.38.5 home ETS (%)6573 Cockroach (%)6662 Pos skin test (%)6575 Mod/severe syx (%)2028 controller meds (%)3428 FEV1 (% pred)94±21101±20 ED visit/3 mon (%)3632

24. Housing Characteristics Characteristic% % Row House91Leaks in bedroom18 Roof Leaks24Food in bedroom29 Cats26Cockroaches in bedroom8 Dogs20Mouse droppings in bedroom 7 Current smoker46 Moisture damage in kitchen22 Cockroaches in kitchen31 Mouse droppings in kitchen38

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

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

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

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

29. Other Health Outcomes Other health outcomes not different between the two groups –Nighttime symptoms –ED visits –Hospitalizations –FEV 1

30. Summary A global environmental intervention was able to reduce levels of PM 10, PM 2.5 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

31. 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