Conducting A Community-Based Study of Asthma in Baltimore”: Conducting A Community-Based Study of Asthma in Baltimore” Patrick Breysse, PhD, CIH  Professor & Director Division of Environmental Health Engineering Department of Environmental Health Sciences Director Center for Childhood Asthma in the Urban Environment


Slide2: "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


Slide3: Centers for Children’s Environmental Health Co sponsored by NIEHS, EPA, CDC


Johns Hopkins Center for the Asthmatic Child in the Urban Environment (CCAUE): 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


Why Focus on Asthma?: 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


CCAUE: 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


Environmental Factors in Urban Asthma Research Model: 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


CCAUE Study Components: 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.


CCAUE – Asthma Intervention Study : 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


Slide10: STUDY AREA


Recruitment Plan: 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


Slide13: Recruitment


Intervention Protocol: Intervention Protocol INTERVENTION


Intervention: 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


Leaky Faucet, Dirty Dishes and a …Guest: Leaky Faucet, Dirty Dishes and a …Guest


Kitchen ceiling hole with water damage : Kitchen ceiling hole with water damage


Moldy Wall in Basement of Home: Moldy Wall in Basement of Home


Slide19: Air Cleaner


Environmental Monitoring: 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)


In-Home Air Sampling Set-Up: In-Home Air Sampling Set-Up


Slide22: Air Monitoring Station


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


Baseline Characteristics: Baseline Characteristics


Housing Characteristics: Housing Characteristics


Slide26: PM10 treatment PM 2.5 treatment PM 10 control PM 2.5 control p<0.001 p<0.001 p=0.08 p=0.019 Particulate Concentrations: % Change PM10 treatment PM 2.5 treatment PM 10 control PM 2.5 control


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


Proportion of children with wheeze, cough, dyspnea in last 2 weeks: 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


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


CCAUE Community Outreach: CCAUE Community Outreach Community Advisory Committee 9 members representing political organizations, schools, churches, parents 2 principals, pastor, nun, 2 community association presidents, parent of child with asthma, retired environmental health professional, social worker Meet in neighborhood school Advisory Functions Protocol feasibility Community priorities, concerns Translation of results to local community


Community OutreachCore Values: Community Outreach Core Values Developed in partnership with community advisory committee and members of the community during a series of workshops Represent a common set of guiding principals or beliefs Establishing core values clarified the basis for the collaboration and formed the heart of future discussions


Core Values: Core Values Cultural competence and inclusiveness: investigators and community members recognize, accept, and celebrate their differences and value and include different community perspectives; First do no harm: studies should be drafted so that they are safe and ethical Honesty: conversations between the community and investigators should be frank and honest Confidentiality: private information should be kept confidential Productive use of resources: efficiency in time, effort, and money is important to investigators and community members


Core Values Continued: Core Values Continued Effective communication: communications between investigators and community will be open and continuing and participants have a right to know study findings Commitment to advocacy: investigators and community should use their information and energy to advocate for community improvement Education/co-learning/sustainability: community and investigators should learn and share with one another Sound science: any community intervention or research planning must be compatible with sound scientific principles


Co-Learning: Co-Learning CAB sponsored “staff development seminars” Purpose is to learn about the community Included a half-day guided tour of the neighborhood


CAB Interactions: CAB Interactions Assisted in hiring field and support staff Recruit from the community Support approval efforts with School Board, and Baltimore City Health Department Requested help with general environmental health concerns Trash in alleys Traffic pollution Building Demolition Risk Communication