2005 Progress Report: A Randomized Controlled Trial of Behavior Changes in Home Exposure Control

EPA Grant Number: R832139C002
Subproject: this is subproject number 002 , established and managed by the Center Director under grant R832139
(EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).

Center: Johns Hopkins Center for Childhood Asthma in the Urban Environment
Center Director: Breysse, Patrick N.
Title: A Randomized Controlled Trial of Behavior Changes in Home Exposure Control
Investigators: Breysse, Patrick N.
Current Investigators: Butz, Arlene
Institution: The Johns Hopkins University
EPA Project Officer: Callan, Richard
Project Period: November 1, 2003 through October 31, 2008 (Extended to October 31, 2010)
Project Period Covered by this Report: November 1, 2004 through October 31, 2005
RFA: Centers for Children's Environmental Health and Disease Prevention Research (2003) RFA Text |  Recipients Lists
Research Category: Children's Health , Health Effects , Health

Objective:

The objectives of this community-based prevention project are to: (1) conduct a randomized controlled trial (RCT) of the effectiveness of an environmental intervention based on home air filters and smoking behavior modification on reducing hazardous exposures and their adverse health effects; and (2) complete the analysis of the intervention trial conducted under the previous grant (EPA Agreement No. R826724) and publish these results.

Progress Summary:

During Year 2 of the project, a protocol has been developed to extend the results of the completed RCT conducted under the previous grant (EPA Agreement No. R826724). In the first intervention, particulate matter (PM) was reduced substantially (38%) by a combination of a HEPA air filter in the child’s bedroom, mattress and pillow covers on the child’s bed, cockroach extermination, and education for the family. The new intervention trial will compare increased filtration (two HEPA air filters) and intensive behavioral intervention to reduce environmental tobacco smoke (ETS) exposure (a major source of PM in the home). After baseline evaluation and morbidity assessment, children with persistent asthma will be randomized into three groups: placebo, filtration alone, or filtration plus ETS behavior change. The trial will last 6 months. Families will be interviewed monthly to assess frequency of asthma symptoms, medication use, emergency department (ED) visits, and hospitalizations as well as smoking behavior. Home visits will be conducted at baseline, 3, and 6 months to inspect the home, collect dust from the child’s bedroom for allergen analysis, and sample airborne particulates (PM10, PM2.5, total suspended particles, MIE), NO2, nicotine, and O3. Clinic visit evaluation will be conducted at baseline and 12 months to administer questionnaires, perform spirometry, and collect urine for cotinine and creatinine measurements. The primary outcome will be indoor PM10, PM2.5, and MIE. Secondary outcomes will be child’s health and cotinine measurements. We will monitor HEPA filter use through a passive monitor.

Analysis and Publication of Intervention Clinical Trial From Grant No. R826724

The following is the abstract for the publication that describes the Center’s RCT of environmental intervention in children with asthma:

Rationale. Airborne pollutants and indoor allergens increase asthma morbidity in inner-city children so reducing exposure, if feasible, should improve asthma morbidity.

Objectives. We conducted an RCT of methods to reduce home environmental exposure in the homes of asthmatic children living in the inner city.

Methods. After completion of questionnaires, forced expiratory volume in one second and allergen skin tests, home inspection, and measurement of home air pollutants and allergens, 100 asthmatic children aged 6-12 years were randomized to a treatment (home-based education, cockroach and rodent extermination, mattress and pillow encasings, and HEPA air cleaner) and control (treated at the end of the 1-year trial). Outcome was assessed with home evaluations at 6 and 12 months, clinic evaluation at 12 months, and repeated telephone interviews.

Measurements and Main Results. In the treatment group, 84 percent received cockroach extermination and 75 percent used the air cleaner. PM10 fell by up to 39 percent in the treatment group but increased in the control group (p < 0.001). Cockroach allergen fell by 43 percent. Symptoms increased in the control group and decreased in the treatment group (p = 0.04).

Conclusions. We concluded that a global environmental treatment can reduce airborne PM and indoor allergens in inner-city homes; these changes are associated with a modest reduction in daily asthma symptoms in children living there.

Pilot Study in Howard County/East Baltimore

In proposing that these factors contribute to morbidity in inner-city children with asthma, investigators assume that the conditions in inner-city homes differ from housing in general. Surveys from the U.S. Census, however, suggest that 10-12 percent of homes will have had water leakage in the previous12 months, and only limited data are available regarding pollutants in middle-class homes. To provide a comparison of the two home environments, we examined the home exposures of inner-city and suburban asthmatic children.

Methods. Indoor PM10, PM2.5, airborne, and dust allergen levels were measured in the homes of 120 asthmatic children, 100 living in inner-city Baltimore and 20 living in the surrounding counties. Home conditions and health outcome measures also were compared.

Results. Inner-city and suburban children had similar asthma symptoms, medications, and health care provider visits but differed with respect to inhaled steroid use (17/100, 9/20, p = 0.014). The inner-city homes had more cigarette smoking (67/100, 1/20, p < 0.001), signs of disrepair (77/100, 1/20, p < 0.001), and cockroach (64/100, 0/20, p < 0.001) and mouse (80/100, 1/20, p < 0.001) infestation. The inner-city homes had higher median levels (p < 0.001) of PM10 (48 μg/m3, 18 μg/m3), PM2.5 (35 μg/m3, 9.8 μg/m3), NO2 (19 ppb, below detection [BD]), and O3 (1.6 ppb, BD) than suburban homes. The inner-city homes had lower median bedroom dust allergen levels of dust mite (0.18 μg/g, 0.39 μg/g, p = 0.022), dog (0.26 μg/g, 7.8 μg/g, p < 0.001) and cat (0.49 μg/g, 13 μg/g, p = 0.039), but higher levels of mouse (4.0 μg/g, 0.009 μg/g, p < 0.001) and cockroach (4.7 IU/g, BD, p < 0.001). The inner-city homes also had higher median airborne mouse allergen levels (0.06 ng/m3, BD, p = 0.002).

Conclusions. Compared with the homes of suburban asthmatic children, the homes of inner-city Baltimore asthmatic children had higher levels of airborne pollutants and home characteristics that predispose to greater asthma morbidity.

Findings, Relevance to Field

We believe that our findings are encouraging. It appears that education, combined with a few hundred dollars worth of physical equipment (mattress covers, air cleaner, pest control) can reduce pollutant and allergen exposure substantially in inner-city homes, and that these reductions are associated with significant reduction in asthma morbidity. The intervention could be carried out in a public heath department or in a managed care network, and judging from the decease in ED visits and hospitalizations that was seen in the treated group, might be economically advantageous to either organization. In addition, this outcome confirms our hypothesis that the interaction of pollutants and allergens in a home environment increases asthma morbidity.

Potential Practical Application

The intervention tested the effectiveness (efficacy and feasibility) of home environmental treatment procedures that are currently recommended and have not been rigorously tested for their ability to affect asthma morbidity. We have supported an important public health measure in the long-term treatment and prevention of asthma in childhood. Since indoor allergen and pollutant exposure has been shown to be an extremely important risk factor for asthma morbidity, it is reasonable to expect that effective methods of reducing exposure will reduce asthma morbidity.

Future Activities:

The newly planned intervention will begin. Initial activities include revision of data collection forms, preparation of a manual of operations, recruitment and training of new staff to replace staff lost in the last year because of delayed funding, and beginning to recruit participants. Recruitment will be made easier by the existence of a recruitment database maintained by the Data Management Core. This database has been approved by the Johns Hopkins University Institutional Review Board and includes families who have completed other research projects conducted by Center personnel, signed a Health Insurance Portability and Accountability Act waiver, and consented to be included in this database. Periodic mailings serve to both maintain interest and to determine that the present address is active.

Data cleaning and preliminary analyses are completed and are discussed in weekly data meetings. Several manuscripts have been accepted or are under review.


Journal Articles on this Report : 6 Displayed | Download in RIS Format

Other subproject views: All 31 publications 31 publications in selected types All 30 journal articles
Other center views: All 113 publications 113 publications in selected types All 110 journal articles
Type Citation Sub Project Document Sources
Journal Article Eggleston PA, Butz A, Rand C, Curtin-Brosnan J, Kanchanaraksa S, Swartz L, Breysse P, Buckley T, Diette G, Merriman B, Krishnan JA. Home environmental intervention in inner-city asthma:a randomized controlled clinical trial. Annals of Allergy, Asthma & Immunology 2005;95(6):518-524. R832139 (2004)
R832139 (2005)
R832139 (2006)
R832139 (2007)
R832139 (Final)
R832139C001 (2006)
R832139C002 (2005)
R832139C002 (2006)
R832139C003 (2005)
  • Abstract from PubMed
  • Full-text: Hopkins-Full Text PDF
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  • Abstract: AAAI-Abstract
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  • Other: ScienceDirect - Abstract
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  • Journal Article Eggleston PA. Improving indoor environments: reducing allergen exposures. Journal of Allergy and Clinical Immunology 2005;116(1):122-126. R832139 (2004)
    R832139 (2005)
    R832139 (2006)
    R832139 (2007)
    R832139C002 (2005)
    R832139C003 (2005)
  • Abstract from PubMed
  • Full-text: Science Direct Full Text
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  • Abstract: Journal of Allergy and Clinical Immunology
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  • Other: Science Direct PDF
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  • Journal Article Eggleston PA, Diette G, Lipsett M, Lewis T, Tager I, McConnell R, Chrischilles E, Lanphear B, Miller R, Krishnan J. Lessons learned for the study of childhood asthma from the Centers for Children’s Environmental Health and Disease Prevention Research. Environmental Health Perspectives 2005;113(10):1430-1436. R832139 (2004)
    R832139 (2005)
    R832139 (2006)
    R832139C002 (2005)
    R832139C003 (2005)
    R826710 (Final)
    R827027 (2002)
    R829389 (2003)
    R829389 (2004)
    R829389 (2005)
    R829389 (Final)
    R831710 (2004)
    R831710 (2005)
    R831710 (Final)
    R831861 (2005)
    R831861 (2006)
    R831861C001 (2006)
    R832141 (2006)
    R832141 (2007)
    R832141 (Final)
  • Full-text from PubMed
  • Abstract from PubMed
  • Associated PubMed link
  • Journal Article Limb SL, Brown KC, Wood RA, Wise RA, Eggleston PA, Tonascia J, Hamilton RG, Adkinson Jr NF. Adult asthma severity in individuals with a history of childhood asthma. Journal of Allergy and Clinical Immunology 2005;115(1):61-66. R832139 (2004)
    R832139 (2005)
    R832139 (2006)
    R832139 (2007)
    R832139C002 (2005)
    R832139C003 (2005)
  • Abstract from PubMed
  • Full-text: Science Direct Full Text
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  • Other: Science Direct PDF
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  • Journal Article Matsui EC, Simons E, Rand C, Butz A, Buckley TJ, Breysse P, Eggleston PA. Airborne mouse allergen in the homes of inner-city children with asthma. Journal of Allergy and Clinical Immunology 2005;115(2):358-363. R832139 (2004)
    R832139 (2005)
    R832139 (2006)
    R832139 (2007)
    R832139C002 (2005)
    R832139C003 (2005)
  • Abstract from PubMed
  • Full-text: Science Direct Full Text
    Exit
  • Other: Science Direct PDF
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  • Journal Article Zeldin DC, Eggleston P, Chapman M, Piedimonte G, Renz H, Peden D. How exposures to biologics influence the induction and incidence of asthma. Environmental Health Perspectives 2006;114(4):620-626. R832139 (2004)
    R832139 (2005)
    R832139 (2006)
    R832139 (2007)
    R832139C001 (2007)
    R832139C002 (2005)
    R832139C003 (2005)
  • Full-text from PubMed
  • Abstract from PubMed
  • Associated PubMed link
  • Full-text: Environmental Health Perspectives Full Text
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  • Other: Environmental Health Perspectives PDF
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  • Supplemental Keywords:

    asthma, allergens, smoke, smoking, pollutant exposure, particulate matter, PM, children’s health,, RFA, Health, Scientific Discipline, INTERNATIONAL COOPERATION, ENVIRONMENTAL MANAGEMENT, Health Risk Assessment, Risk Assessments, Disease & Cumulative Effects, Biochemistry, Children's Health, Atmospheric Sciences, Ecological Risk Assessment, Environmental Policy, Risk Assessment, asthma, health effects, environmental health, air pollutants, air toxics, community-based intervention, age-related differences, airway disease, air pollution, children, Human Health Risk Assessment, human exposure, ambient particulates, children's environmental health, disease, human health risk

    Progress and Final Reports:

    Original Abstract
  • 2004 Progress Report
  • 2006 Progress Report
  • 2007 Progress Report
  • 2008
  • 2009
  • Final Report

  • Main Center Abstract and Reports:

    R832139    Johns Hopkins Center for Childhood Asthma in the Urban Environment

    Subprojects under this Center: (EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
    R832139C001 The Epidemiology of Susceptibility to Airborne Particulates and Allergens to Asthma in African Americans
    R832139C002 A Randomized Controlled Trial of Behavior Changes in Home Exposure Control
    R832139C003 Mechanisms of Particulate-Induced Allergic Asthma
    R832139C004 Dendritic Cell Activation by Particulate Matter and Allergen