School Inner-City Asthma Study Research Articles

Biomarkers of Oxidative Stress Associated with Radon Exposure in the School Inner-City Asthma Study (SICAS)

Biomarkers of Oxidative Stress Associated with Radon Exposure in the School Inner-City Asthma Study (SICAS)

Effect of radon exposure on asthma morbidity in the School Inner-City Asthma study.

Radon may have a role in obstructive lung disease outside its known carcinogenicity. Little is known about radon's effects on asthma morbidity. To determine the effect of radon on fractional exhaled nitric oxide (FE NO), asthma symptom-days, and lung function in inner-city asthmatic school children. Two hundred ninety-nine school-aged asthmatic children enrolled in the School Inner-City Asthma Study (SICAS-1) were followed. One and two-month averaged radon was assessed using a spatiotemporal model predicting zip code-specific monthly exposures. FE NO and spirometry were measured twice during the academic year. Asthma symptoms were assessed four times during the academic year. The interaction between indoor radon exposure (Bq/m3 ) and seasonality predicting log-transformed FE NO, forced expiratory volume in 1 s (FEV1 ) % predicted, forced vital capacity (FVC) % predicted, FEV1 /FVC, and asthma symptom-days was evaluated. Participants with high radon exposure had greater change in FE NO from warm to cold periods compared to low radon exposure (interaction p = 0.0013). Participants with >50th percentile radon exposure experience significant FE NO increase from warm to cold weather ( = 0.29 [95% confidence interval [CI]: 0.04-0.54], p = 0.0240). We report a positive association between radon 1-month moving average (incidence rate ratio [IRR] = 1.01, p = 0.0273) and 2-month moving average (IRR = 1.01, p = 0.0286) with maximum asthma symptom-days (n = 299, obs = 1167). In asthmatic children, radon may be associated with increased asthma morbidity, suggesting radon may be a modifiable environmental risk factor for airway inflammation.

Associations of Snoring and Asthma Morbidity in the School Inner-City Asthma Study

Associations of Snoring and Asthma Morbidity in the School Inner-City Asthma Study

Mouse allergen levels in schools over the decade

Asthma is the most common disease of childhood, with a disproportionate burden in inner-city populations.1 Within inner-city homes, specific aeroallergen exposures, particularly mouse and cockroach, have been associated with asthma morbidity.2,3 Inner-city schools have also been shown to be a significant source of allergen exposure contributing to asthma morbidity.4 The first School Inner-City Asthma Study (SICAS 1), occurring between 2008 and 2013, revealed an association between exposure to mouse allergen in schools and worsening asthma symptoms, independent of sensitization status or home environmental exposure.

Cross-sectional study of urinary biomarkers of environmental tobacco and e-cigarette exposure and asthma morbidity

Exposure to environmental tobacco smoke or e-cigarette exposure (ETS) is common and may have a significant impact on asthma control.1 We leveraged the School Inner-City Asthma Study to establish whether urinary cotinine and total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) levels (hereafter referred to as tobacco biomarkers), are independently associated with asthma morbidity. Furthermore, we studied the interaction between tobacco biomarkers and asthma morbidity by allergen sensitization, as an effect modifier.

Atopic Dermatitis Mediates the Association Between an IL4RA Variant and Food Allergy in School-Aged Children

Atopic dermatitis (AD) and food allergy (FA) may share genetic risk factors. It is unknown whether genetic factors directly cause FA or are mediated through AD, as the dual-allergen hypothesis suggests. To test the hypothesis that AD mediates the relationship between an IL-4 receptor alpha chain gene (IL4RA) variant, the human IL-4 receptor alpha chain protein-R576 polymorphism, and FA. A total of 433 children with asthma enrolled in the School Inner-City Asthma Study underwent genotyping for the IL4RA576 allele. Surveys were administered to determine FA, AD, and associated allergic responses. Mediation analysis was performed adjusting for race and ethnicity, age, sex, and household income. Multivariate models were used to determine the association between genotype and FA severity. AD was reported in 193 (45%) and FA in 80 children (19%). Each risk allele increased odds of AD 1.39-fold ([1.03-1.87], P= .03), and AD increased odds of FA 3.67-fold ([2.05- 6.57], P < .01). There was an indirect effect of genotype, mediated by AD, predicting FA; each risk allele increased the odds of FA by 1.13 (odds ratio [95% CI], Q/R= 1.13 [1.02-1.24], R/R= 1.28 [1.04-1.51]; P < .01). Each risk allele increased the odds of severe FA symptoms 2.68-fold ([1.26-5.71], P= .01). In a cohort of children with asthma, AD is part of the causal pathway between an IL4RA variant and FA. This variant is associated with increased risk of severe FA reactions. Addressing AD in children with an IL4RA polymorphism may modulate the risk of FA.

Obesity May Enhance the Adverse Effects of NO2 Exposure in Urban Schools on Asthma Symptoms in Children

To evaluate relationships between inner-city classroom NO2 exposure and asthma symptoms and morbidity by BMI category.Children aged 4 to 13 (n = 271) years from 37 inner-city schools who had physician-diagnosed asthma for at least 1 year and were using daily preventive asthma medication, had wheezing within the last year, and/or had at least 1 unscheduled health care visit for asthma within the past year.This was a single-center prospective study conducted within the School Inner-City Asthma Study. Before the start of the academic year, baseline demographics, environmental factors, and asthma symptoms and medication use were obtained by questionnaire. Baseline evaluations included skin testing to common seasonal and perennial aeroallergens or by assessment serum-specific IgE to the same allergens, spirometry, and fractional exhaled nitric oxide (FeNO) measurement. BMI percentile was calculated and categorized by using CDC classifications. Classroom NO2 was measured twice during the school year, ∼6 months apart. The primary outcome was the number of days with asthma symptoms within the previous 14 days. The secondary outcomes assessed in the previous 2 weeks were the number of exacerbations (hospitalizations or unscheduled health care visits for asthma), the number of days caretakers had to change plans because of the child’s asthma symptoms, FeNO level, and pulmonary function (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]).Participants were predominantly African American and Hispanic (35% each) and impoverished (49% had an annual household income <$25 000). A total of 50% had normal BMI (fifth percentile to <85th percentile), 15% were overweight (85th percentile to <95% percentile), and 35% were obese (≥95th percentile). Most (69%) were atopic, with specific immunoglobulin E to at least 1 aeroallergen. Obese students with asthma had statistically (but likely not clinically relevant) lower pulmonary function (FEV1 and FVC but not FEV1/FVC ratio), more positive skin test results, and lower FeNO than students with normal weight. The BMI category did not affect asthma symptom days, asthma symptoms, medication use, health care use for asthma, or missed school days. Caretakers of children with normal weight changed their plans more often than those of students who were overweight or obese. For children with normal weight or those who were overweight, NO2 levels were not associated with any of the measured outcomes. However, among children who were obese, for every 10-fold increase in NO2 level there were increased odds of asthma symptom days (1.9-fold), acute asthma-related health care use (2.4-fold), a missed school day because of asthma (3.1-fold), and care takers’ plans being changed because of the child’s asthma (4.2-fold). As compared with children with normal weight, in students who were obese, every 10 parts per billion increase in classroom NO2 level increased the likelihood of an asthma symptom day (odds ratio: 1.86; 95% confidence interval: 1.15 to 3.02) and of care takers changing their plans (odds ratio: 4.24; 95% confidence interval: 2.33 to 7.70). NO2 levels did not affect other outcomes, lung function, or FeNO across BMI categories.Obesity in inner-city students with asthma appears to increase susceptibility to the adverse effects of classroom NO2.NO2 is formed by combustion of liquid or solid fossil fuels. Indoor sources include gas stoves, heaters, and poorly ventilated furnaces and fireplaces. Furthermore, outdoor levels are elevated in heavily trafficked urban areas. The Environmental Protection Agency’s standard for safe outdoor level of NO2 is ∼50 parts per billion over a 1-year averaging time and 100 parts per billion over a 1 hour averaging time. Although the authors of this study do not specifically report classroom NO2 levels, it is clear from the 2 figures in the article that levels did not exceed 30 parts per billion, hence they were nowhere near the level up to which the Environmental Protection Agency considers safe. This is a warning that “safe” might not be safe enough. I think we all recognize the multiple and varied effects that both pollution and obesity have on health. With this study, the authors suggest synergy between 2 health risk factors and indicate that, as physicians, we must address all known risk factors for disease as we provide the best preventive and prospective care we can.

Associations of Snoring and Asthma Morbidity in the School Inner-City Asthma Study

Inner-city children are disproportionately affected by asthma and sleep-disordered breathing (SDB). However, little is known about the association of SDB symptoms with asthma morbidity in this vulnerable population. Assess the relationship between snoring frequency and asthma morbidity. This study was part of the School Inner-City Asthma Study, a longitudinal prospective cohort study of children with persistent asthma who attended schools in the Northeast United States from 2008 to 2013. Participants had baseline assessments of asthma symptoms, snoring, and allergy status. Caregivers completed quarterly surveys for 12 months on symptoms of asthma, snoring, and health care outcomes. Snoring frequency (non-, rare-, sometimes-, habitual-snoring) and its relationship with asthma symptoms and asthma morbidity were assessed by mixed-effects models. There were 1186 observations from 339 subjects. Mean age was 7.9 years; roughly half were male, and most were of minority race. Half were overweight or obese, and 65.5% had atopy. At initial snoring assessment, 24.8% reported habitual snoring, but report of snoring frequency varied over the study period. Multivariate analyses revealed increased odds of maximum asthma symptom days for habitual snoring compared with nonsnoring (1.58; 95% CI, 1.19-2.10; P < .002) and all other snoring categories. Habitual snoring was associated with greater odds of health care utilization (incidence rate ratio, 1.72; 95% CI, 1.10-2.69; P= .02) and worse asthma control (odds ratio, 1.49; 95% CI, 1.05-2.11; P= .03) compared with nonsnoring. Snoring is common among inner-city school-age children with asthma, and habitual snoring is associated with increased asthma symptom burden and health care utilization.

Asthma Prevalence and Mold Levels in US Northeastern Schools

Asthma is among the most common chronic diseases of children in the United States (US). Mold exposures have been linked to asthma development and exacerbation. In homes, mold exposures have been quantified using the Environmental Relative Moldiness Index (ERMI) and higher home ERMI values have been linked to occupant asthma. In this analysis of the School Inner-City Asthma Study 2 (SICAS 2), we aimed to evaluate the ERMI’s applicability to measuring mold in schools compared to homes, to assess the relationship between the prevalence of asthma in schools and mold levels, and to examine the prevalence of asthma in relationship to students’ demographics and the physical characteristics of school-buildings. Northeastern US schools (n=32) and homes (n=33) were selected and the 36-ERMI molds were quantified in a dust sample from each classroom or home. School building characteristics, student demographics and asthma prevalence data were collected from the SICAS 2 study or obtained from government websites. Linear regression and mixed models were fit to assess the association of current asthma prevalence and physical characteristics of the school, make-up of the student body and the ERMI metric. Levels of outdoor Group 2 molds were significantly (p<0.01) greater in schools compared to homes and higher Group 2 levels in schools were linked to higher asthma prevalence for their students. The presence of AC in school buildings correlated significantly (p=0.02) with lower asthma prevalence. Higher mold levels in northeastern US schools were associated with an increase in students’ asthma.

Asthma Prevalence and Mold Levels in US Northeastern Schools

Asthma is among the most common chronic diseases of children in the United States (US). Mold exposures have been linked to asthma development and exacerbation. In homes, mold exposures have been quantified using the Environmental Relative Moldiness Index (ERMI), and higher home ERMI values have been linked to occupant asthma. In this analysis of the School Inner-City Asthma Study (SICAS), we aimed to evaluate the ERMI's applicability to measuring mold in schools compared with homes and to examine the prevalence of asthma in relationship to students' demographics and the physical characteristics of school buildings. Northeastern US schools (n = 32) and homes (n = 33) were selected, and the 36 ERMI molds were quantified in a dust sample from each classroom (n = 114) or home. School building characteristics data were collected from SICAS. Asthma prevalence and student demographics data were obtained from government websites. Linear regression and mixed models were fit to assess the association of the current asthma prevalence and physical characteristics of the school, make-up of the student body, and the ERMI metric. Levels of outdoor group 2 molds were significantly (P < .01) greater in schools compared with homes. The presence of air-conditioning in school buildings correlated significantly (P = .02) with lower asthma prevalence. The prevalence of asthma in student bodies is associated with many factors in schools and homes.

Urinary Biomarkers of Environmental Tobacco Smoke Exposure and Asthma Morbidity in the School Inner-City Asthma Study

Introduction: Despite significant progress, asthma remains the most common and costly chronic disease of childhood. Unfortunately, exposure to environmental tobacco smoke (ETS), a major asthma precipitant, is common in the inner-city. The primary objectives of this study were to understand the sources and degree of ETS exposure, to determine if urinary cotinine can be reliably correlated with caregiver reports of a child’s ETS exposure, and to estab lish if urinary cotinine levels are independently associated with asthma morbidity or allergic sensitization in a …

Urinary Biomarkers of Environmental Tobacco Smoke Exposure and Asthma Morbidity in the School Inner-City Asthma Study

Urinary Biomarkers of Environmental Tobacco Smoke Exposure and Asthma Morbidity in the School Inner-City Asthma Study

Obesity may enhance the adverse effects of NO2 exposure in urban schools on asthma symptoms in children

Sparse data address the effects of nitrogen dioxide (NO2) exposure in inner-city schools on obese students with asthma. We sought to evaluate relationships between classroom NO2 exposure and asthma symptoms and morbidity by body mass index (BMI) category. The School Inner-City Asthma Study enrolled students aged 4 to 13 years with asthma from 37 inner-city schools. Students had baseline determination of BMI percentile. Asthma symptoms, morbidity, pulmonary inflammation, and lung function were monitored throughout the subsequent academic year. Classroom NO2 data, linked to enrolled students, were collected twice per year. We determined the relationship between classroom NO2 levels and asthma outcomes by BMI stratification. A total of 271 predominantly black (35%) or Hispanic students (35%) were included in analyses. Fifty percent were normal weight (5-84th BMI percentile), 15% overweight (≥85-94th BMI percentile), and 35% obese (≥95th BMI percentile). For each 10-parts per billion increase in NO2, obese students had a significant increase in the odds of having an asthma symptom day (odds ratio [OR], 1.86; 95% CI, 1.15-3.02) and in days caregiver changed plans (OR, 4.24; 95% CI, 2.33-7.70), which was significantly different than normal weight students who exhibited no relationship between NO2 exposure and symptom days (OR, 0.90; 95% CI, 0.57-1.42; pairwise interaction P= .03) and change in caregiver plans (OR, 1.37; 95% CI, 0.67-2.82; pairwise interaction P= .02). Relationships between NO2 levels and lung function and fractional exhaled nitric oxide did not differ by BMI category. If we applied a conservative Holm-Bonferroni correction for 16 comparisons (obese vs normal weight and overweight vs normal weight for 8 outcomes), these findings would not meet statistical significance (all P> .003). Obese BMI status appears to increase susceptibility to classroom NO2 exposure effects on asthma symptoms in inner-city children. Environmental interventions targeting indoor school NO2 levels may improve asthma health for obese children. Although our findings would not remain statistically significant after adjustment for multiple comparisons, the large effect sizes warrant future study of the interaction of obesity and pollution in pediatric asthma.

Association of Systemic IL-6 Inflammation with Body Mass Index, Asthma Morbidity, and Metabolic Dysfunction in the School Inner-City Asthma Study

Association of Systemic IL-6 Inflammation with Body Mass Index, Asthma Morbidity, and Metabolic Dysfunction in the School Inner-City Asthma Study

Proximity to major roadways and asthma symptoms in the School Inner-City Asthma Study

Traffic proximity has been associated with adverse respiratory health outcomes. Less is known about the combined impact of residential and school exposures on pediatric asthma. We sought to use spatial analysis methodology to analyze residential and school proximity to major roadways and pediatric asthma morbidity. The School Inner-City Asthma Study (n=350) recruited school-aged children with asthma. Each participant's school and home addresses were geocoded, and distances from major roadways were measured to calculate a composite measure accounting for both home and school traffic exposure. Generalized estimating equation models were clustered by subject and adjusted for age, race/ethnicity, sex, income, environmental tobacco smoke, controller medication, upper respiratory tract infections, and seasonality. The majority of participants (62%) attended schools within 100m from major roadways, and 40% also resided within 100m of major roadways. In multivariate analyses major roadway proximity was independently associated with increased asthma symptom days. At greater than the threshold of 100m, children had 29% less odds of a symptom day over the past 2weeks for each 100-m increase in distance from a major roadway (odds ratio, 0.71; 95% CI, 0.58-0.87; P<.01). Children farther from a major roadway also had significantly less reported health care use (odds ratio, 0.63; 95% CI, 0.47-0.85; P<.01) and were significantly less likely to have poor asthma control (odds ratio, 0.80; 95% CI, 0.69-0.94; P<.01). There was not a meaningful association between distance to a major roadway and lung function outcomes. Proximity to a major roadway, a composite measure of home and school exposure but primarily driven by home exposure, was associated with greater asthma morbidity. More studies are needed to evaluate the independent effect of school distance to a roadway on asthma morbidity.

Nitrogen dioxide exposure in school classrooms of inner-city children with asthma

Ambient and home exposure to nitrogen dioxide (NO2) causes asthma symptoms and decreased lung function in children with asthma. Little is known about the health effects of school classroom pollution exposure. We aimed to determine the effect of indoor classroom NO2 on lung function and symptoms in inner-city school children with asthma. Children enrolled in the School Inner-City Asthma Study were followed for 1 academic year. Subjects performed spirometry and had fraction of exhaled nitric oxide values measured twice during the school year at school. Classroom NO2 was collected by means of passive sampling for 1-week periods twice per year, coinciding with lung function testing. Generalized estimating equation models assessed lung function and symptom relationships with the temporally nearest classroom NO2 level. The mean NO2 value was 11.1ppb (range, 4.3-29.7ppb). In total, exposure data were available for 296 subjects, 188 of whom had complete spirometric data. At greater than a threshold of 8ppb of NO2 and after adjusting for race and season (spirometry standardized by age, height, and sex), NO2 levels were associated highly with airflow obstruction, such that each 10-ppb increase in NO2 level was associated with a 5% decrease in FEV1/forced vital capacity ratio (β=-0.05; 95% CI, -0.08 to -0.02; P=.01). Percent predicted forced expiratory flow between the 25th and 75th percentile of forced vital capacity was also inversely associated with higher NO2 exposure (β=-22.8; 95% CI, -36.0 to -9.7; P=.01). There was no significant association of NO2 levels with percent predicted FEV1, fraction of exhaled nitric oxide, or asthma symptoms. Additionally, there was no effect modification of atopy on lung function or symptom outcomes. In children with asthma, indoor classroom NO2 levels can be associated with increased airflow obstruction.

Gene-environment interaction between an IL4R variant and school endotoxin exposure contributes to asthma symptoms in inner-city children

Gene-environment interaction between an IL4R variant and school endotoxin exposure contributes to asthma symptoms in inner-city children

The School Inner-City Asthma Intervention Study: Design, rationale, methods, and lessons learned

Asthma is the most common chronic disease of childhood in the United States, causes significant morbidity, particularly in the inner-city, and accounts for billions of dollars in health care utilization. Home environments are established sources of exposure that exacerbate symptoms and home-based interventions are effective. However, elementary school children spend 7 to 12h a day in school, primarily in one classroom. From the observational School Inner-City Asthma Study we learned that student classroom-specific exposures are associated with worsening asthma symptoms and decline in lung function. We now embark on a randomized, blinded, sham-controlled school environmental intervention trial, built on our extensively established school/community partnerships, to determine the efficacy of a school-based intervention to improve asthma control. This factorial school/classroom based environmental intervention will plan to enroll 300 students with asthma from multiple classrooms in 40 northeastern inner-city elementary schools. Schools will be randomized to receive either integrated pest management versus control and classrooms within these schools to receive either air purifiers or sham control. The primary outcome is asthma symptoms during the school year. This study is an unprecedented opportunity to test whether a community of children can benefit from school or classroom environmental interventions. If effective, this will have great impact as an efficient, cost-effective intervention for inner city children with asthma and may have broad public policy implications.

Association Between Allergen Exposure in Inner-City Schools and Asthma Morbidity Among Students

ImportanceHome aeroallergen exposure is associated with increased asthma morbidity in children, yet little is known about the contribution of school aeroallergen exposures to such morbidity.ObjectiveTo evaluate the effect of school-specific aeroallergen exposures on asthma morbidity among students, adjusting for home exposures.Design, Setting, and ParticipantsThe School Inner-City Asthma Study was a prospective cohort study evaluating 284 students aged 4 to 13 years with asthma who were enrolled from 37 inner-city elementary schools in the northeastern United States between March 1, 2008, and August 31, 2013. Enrolled students underwent baseline clinical evaluations before the school year started and were then observed clinically for 1 year. During that same school year, classroom and home dust samples linked to the students were collected and analyzed for common indoor aeroallergens. Associations between school aeroallergen exposure and asthma outcomes during the school year were assessed, adjusting for home exposures.ExposuresIndoor aeroallergens, including rat, mouse, cockroach, cat, dog, and dust mites, measured in dust samples collected from inner-city schools.Main Outcomes and MeasuresThe primary outcome was maximum days in the past 2 weeks with asthma symptoms. Secondary outcomes included well-established markers of asthma morbidity, including asthma-associated health care use and lung function, measured by forced expiratory volume in 1 second.ResultsAmong 284 students (median age, 8 years [interquartile range, 6-9 years]; 148 boys and 136 girls), exposure to mouse allergen was detected in 441 (99.5%) of 443 school dust samples, cat allergen in 420 samples (94.8%), and dog allergen in 366 samples (82.6%). Levels of mouse allergen in schools were significantly higher than in students’ homes (median settled dust level, 0.90 vs 0.14 µg/g; P < .001). Exposure to higher levels of mouse allergen in school (comparing 75th with 25th percentile) was associated with increased odds of having an asthma symptom day (odds ratio, 1.27; 95% CI, 1.05-1.54; P = .02) and 4.0 percentage points lower predicted forced expiratory volume in 1 second (95% CI, –6.6 to –1.5; P = .002). This effect was independent of allergic sensitization. None of the other indoor aeroallergens were associated with worsening asthma outcomes.Conclusions and RelevanceIn this study of inner-city students with asthma, exposure to mouse allergen in schools was associated with increased asthma symptoms and decreased lung function. These findings demonstrate that the school environment is an important contributor to childhood asthma morbidity. Future school-based environmental interventions may be beneficial for this important public health problem.

Black and Hispanic perceptions of asthma medication in the School Inner-City Asthma Study

Racial/ethnic minorities suffer a disproportionate rate of asthma morbidity1. We aimed to determine racial/ethnic differences in perception of asthma medications between caregivers of black and Hispanic school children enrolled in the school inner city asthma study (SICAS). Furthermore, we investigated whether these beliefs were associated with asthma morbidity.