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Environmental Management of Pediatric Asthma West Virginia Department of Education King. Strong Conference June Environmental Management of Pediatric Asthma West Virginia Department of Education King. Strong Conference June 18, 2014 Abby Nerlinger MD Mid-Atlantic Center for Children’s Health & the Environment Pediatric Hospital Medicine Fellow Children’s National Health System

Dr. Nerlinger has NO conflicts of interest to declare This material was developed by Dr. Nerlinger has NO conflicts of interest to declare This material was developed by the Mid-Atlantic Center for Children’s health & the Environment and funded under the cooperative agreement award number 1 U 61 TS 000118 -05 from the Agency for Toxic Substances and Disease Registry (ATSDR). Acknowledgement: The U. S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-7592301301 -0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

Objectives Upon completion of this activity, the participant should be able to: • Identify Objectives Upon completion of this activity, the participant should be able to: • Identify 5 environmental triggers of pediatric asthma • Identify practical and efficient measures to decrease environmental asthma triggers in the home and school • Provide resources for patients and families with further questions about children’s environmental health issues

Asthma Pathology Chronic, reversible disease of mediumsized airways Terminology: • Airway inflammation • Bronchospasm Asthma Pathology Chronic, reversible disease of mediumsized airways Terminology: • Airway inflammation • Bronchospasm • bronchiole hyperreactivity • Reactive airway disease http: //www. nhlbi. nih. gov/health-topics/asthma/

Irreversible If Left Untreated Normal Asthmatic Irreversible If Left Untreated Normal Asthmatic

Environmental Allergens, Sensitization, and Asthma Allergen enters airway 6 Binds immune cells in airway Environmental Allergens, Sensitization, and Asthma Allergen enters airway 6 Binds immune cells in airway epithelium Recognized by allergen-specific Ig. E on mast cell B cells release allergenspecific Ig. E Mast cell releases inflammatory mediators like histamine and leukotriene Inflammation of bronchioles including: - Mucous production - Airway edema - Smooth muscle contraction

Conceptual Model of Asthma 7 Conceptual Model of Asthma 7

National Childhood Asthma Epidemiology • Most common disease of childhood • Number one cause National Childhood Asthma Epidemiology • Most common disease of childhood • Number one cause of school absenteeism • 14 million missed school days per year • Millions of hours of lost work per year for parents • 10% prevalence of asthma among children in 2008 • Some communities up to 25% of children • Higher prevalence among families with income below federal poverty level • Nicholas et al. 2005. Am J Public Health. 95: 245– 249 • Akinbami L et al. Trends in Asthma Prevalence, Health Care Use, and Mortality in the US, 2001 -2010. http: //www. cdc. gov/nchs/databriefs/db 94. pdf 8

National Childhood Asthma Cost • 7. 1 million children <18 y living with asthma National Childhood Asthma Cost • 7. 1 million children <18 y living with asthma in the US in 2009* • 3. 4 million ambulatory visits (2% of total) • 640, 000 ED visits*** • 157, 000 hospital admissions*** • Annual direct and indirect cost associated with asthma: $56 billion**** *National Health Interview Survey **National Ambulatory Medical Care Survey ***National Hospital Medical Care Survey ****CDC. May 2011. Asthma in the US Vital Signs. http: //www. cdc. gov/vitalsigns/asthma 9

Asthma prevalence among children 0 to 17 years of age in the United States, Asthma prevalence among children 0 to 17 years of age in the United States, in 1980– 2007 Akinbami L J et al. Pediatrics 2009; 123: S 131 -S 145 © 2009 by American Academy of Pediatrics

Childhood Asthma in West Virginia Factor Measure Disease burden • Greater than 31, 000 Childhood Asthma in West Virginia Factor Measure Disease burden • Greater than 31, 000 children with asthma • Current prevalence (7. 8%) less than national level (10%) • Lifetime prevalence of 10. 6% under age 18 Control Greater than half of children with asthma had at least one exacerbation in past 12 months Risk for hospitalization Children less than age 15 is age group with greatest risk of hospitalization due to asthma Socioeconomic factors Individuals without high school diploma or household income less than $25, 000 are more likely to suffer from asthma Cost of hospitalizations due to asthma increased from $10. 3 million in 1996 to $23. 2 million in 2005 Quality of Life Missed days of school, play, and work A Strategic Plan for Addressing Asthma in West Virginia 2010 -2014. West Virginia Asthma Education and Prevention Program, West Virginia Department of Health and Human Resources. 11

Asthma in West Virginia Asthma in West Virginia

Goals of Asthma Care in West Virginia 13 Goals of Asthma Care in West Virginia 13

Asthma Assessment and Management • National Heart, Lung, and Blood Institute, National Asthma Education Asthma Assessment and Management • National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program • Expert Panel Report 3 • Guidelines for the Diagnosis & Management of Asthma • http: //www. nhlbi. nih. gov/gui delines/asthma/asthgdln. htm • Guidelines Implementation Panel Report • http: //www. nhlbi. nih. gov/gui delines/asthma/gip_rpt. pdf

Guidelines Implementation Panel Report 6 Priority Messages: • • • Use inhaled corticosteroids Use Guidelines Implementation Panel Report 6 Priority Messages: • • • Use inhaled corticosteroids Use a written asthma action plan Assess asthma severity Assess and monitor asthma control Schedule periodic asthma visits Control environmental exposures

Principles of Management • Focus on concepts of “severity”: intermittent vs persistent • Domains Principles of Management • Focus on concepts of “severity”: intermittent vs persistent • Domains of impairment and risk • Impairment (current) • Frequency/Intensity • Functional limitations • Risk (future) • Asthma exacerbations • Pulmonary function assessment • Determine control: well controlled, not well controlled, very poorly controlled • Six treatment steps (step-up/step-down) • Frequent follow up visits with goal of minimum medications as possible

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First Line Controller: Inhaled Corticosteroid • ICS are the most potent and consistently effective First Line Controller: Inhaled Corticosteroid • ICS are the most potent and consistently effective long term control medication • Compliance and daily use imperative for control • No matter how compliant with meds, still need to address environmental exposures • Control of triggers will help minimize use of controller medications 19

The Joint Commission Core Measures for children’s asthma care: 1. Use of relievers for The Joint Commission Core Measures for children’s asthma care: 1. Use of relievers for inpatient asthma 2. Use of systemic corticosteroids for inpatient asthma 3. Home management plan of care given to patient/caregiver http: //www. jointcommission. org/core_measure_sets. aspx

West Virginia Child Asthma Plan (0 -5 years) • All medications written in one West Virginia Child Asthma Plan (0 -5 years) • All medications written in one place • Based on peak flow monitoring • Find out predicted peak flow based on height • Green Zone: 80% of predicted or more • Yellow Zone: 50 -80% of predicted • Red Zone: 50% of predicted or less

Control of Environmental Measures • Patients who have asthma at any level of severity Control of Environmental Measures • Patients who have asthma at any level of severity should be asked about allergen and irritant exposure and counseled appropriately • Children with indoor allergen sensitization have worse outcomes

Children Are Not Little Adults • Lungs not completely formed at birth • Continued Children Are Not Little Adults • Lungs not completely formed at birth • Continued development until adolescence • The bronchial tree • The alveoli (air sacs) • More lung surface area per unit body weight • Different respiratory pattern • Different activity pattern • Have a longer “shelf life”

Taking a Pediatric Environmental Exposure History • National Environmental Education Foundation • Environmental History Taking a Pediatric Environmental Exposure History • National Environmental Education Foundation • Environmental History Form for Pediatric Asthma Patients • Applies to all childhood environments • Administered by health care provider • Available in English and Spanish www. neefusa. org/health/asthmahistoryform

The Role of Allergy Testing • Focus on low-cost interventions that target allergens identified The Role of Allergy Testing • Focus on low-cost interventions that target allergens identified in patient’s environment • Consider allergy referral to define clinically significant allergens • Allergen specific Ig. E through skin and serum testing • Test results interpreted in context of environmental history • More costly interventions performed after allergy testing completed 25

WVA Goals of Environmental Control • West Virginia Asthma Education and Prevention Program Strategic WVA Goals of Environmental Control • West Virginia Asthma Education and Prevention Program Strategic Plan • Disease surveillance, coalition building, strategic plan, address health disparities • Strategic Plan 2010 -2014 • Decrease environmental smoke exposure in asthmatic children from 19. 3% to 10% • Decrease exposure to home wood burning in asthmatic children from 26% to 15% • Home visiting programs for family education

Importance of Protecting Children from Indoor Air Allergens • Home and school environment • Importance of Protecting Children from Indoor Air Allergens • Home and school environment • Children spend about 90% of their time indoors • School age children spend 30 -50 hours a week in and around school buildings Source: http: //www. cdc. gov/nceh/publications/books/ housing/cha 05. htm

Allergens in the Indoor Air Indoor air pollutants that can trigger asthma exacerbations: Other Allergens in the Indoor Air Indoor air pollutants that can trigger asthma exacerbations: Other triggers: Causal Relationship: * • Cat • Cockroach • Environmental tobacco smoke (preschooler) • House dust mite • Animals: pets, rodents • Chemicals and pollutants in the air • cleaning agents • perfume, cosmetics • Pesticides Association: * • Dog • Molds • Rhinovirus • NO 2/NOx • Clearing the Air. Committee on the Assessment of Asthma and Indoor Air; Division of Health. Promotion and Disease Prevention; Institute of Medicine, 2000. • *Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation.

Indoor Air Quality • No governmental agency regulates indoor air pollutants with the exception Indoor Air Quality • No governmental agency regulates indoor air pollutants with the exception of laws pertaining to smoking in public places • EPA recommendations for voluntary programs • Report by the U. S. Government Accounting Office, the Condition of America's Schools • over half schools surveyed reported at least one environmental problem which affects indoor air quality

Home Indoor Air Pollution Sources: • Particulates • Environmental tobacco smoke • Wood burning Home Indoor Air Pollution Sources: • Particulates • Environmental tobacco smoke • Wood burning fireplace/stove • VOCs • Chemicals/cleaners • NO 2 secondary to combustion • gas heat and appliances 30 Remediation: • Install exhaust fans close to source • HEPA filters for particulates but source removal is ideal • Ventilate room if fuel burning appliance used • Tight-fitting wood stove doors • Venting of fireplaces and gas stoves • Consider replacement of gas stove with electric • Never use gas-cooking appliances as heat sources • Avoid use of products that act as irritants Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation. **Matsui et al. AAP Clinical Report: Environmental Control Practices and Asthma Management. Publication Pending.

Schools and Indoor Air Quality • Outdoor pollutants infiltrating building • School bus idling Schools and Indoor Air Quality • Outdoor pollutants infiltrating building • School bus idling • Dampness • Mold: potted plants, gym lockers, gym showers • VOCs off-gassing • Building materials, carpet, cleaning materials • Toxic debris from construction or demolition inside occupied schools • Dust and chalk www. impact-dc. org

Indoor Air Quality and Asthma Symptoms at School Clues to indoor air problems • Indoor Air Quality and Asthma Symptoms at School Clues to indoor air problems • Symptoms widespread within class or school • Symptoms diminish or disappear after leaving school • Sudden onset after a change in school; i. e. , painting, pesticide application • Those with allergies and asthma have reactions indoors but not outdoors 32

Schools and Air Pollution Resources • School bus Idling • EPA: Clean School Bus Schools and Air Pollution Resources • School bus Idling • EPA: Clean School Bus Idle Reduction Campaign • West Virginia Idling Policy* • State Board of Education Rule • prohibits school bus idling except if outdoor temp ≥ 40 F, necessary to defrost windows, or student safety at risk • School driveways appropriately placed to avoid accumulation of carbon monoxide in idling school buses • Toxic fumes from paints, glues and new carpets • Toolkit for Safe Chemical Management *Environmental Law Institute: Vehicle Idling at Schools – Overview of State Laws. May 2013. http: //www. eli. org/buildings/topics-school-environmental-health

EPA Environmental School Resources • www. epa. gov/schools/programs. html • Tools for Schools • EPA Environmental School Resources • www. epa. gov/schools/programs. html • Tools for Schools • Some state laws direct school districts to implement • Healthy. SEAT • School Environments Assessment Tool • Software to help school districts evaluate school facilities for environmental, safety, and health issues

Green Cleaning • Industrial strength cleaning products and room deodorizers can add to indoor Green Cleaning • Industrial strength cleaning products and room deodorizers can add to indoor air pollution • Why is non-toxic cleaning important? • Most chemicals, including those found in household cleaning products, have no human health toxicity data • Cleaning for Healthy Schools Toolkit • http: //www. cleaningforhealthyschools. org/ • Identification of green cleaning products • Educational materials http: //www. epa. gov/schools/gr-clean. pdf

Cleaning Product Selection Non-toxic alternatives: • • • Baking soda Liquid soap Vinegar Choosing Cleaning Product Selection Non-toxic alternatives: • • • Baking soda Liquid soap Vinegar Choosing safer cleaning products: • • • 36 Ingredients listed on the label Non-aerosol No overwhelming chemical odor Fragrance-free Dye-free Source: American Academy of Pediatrics Council on Environmental Health. Child Care Settings. In: Etzel, PA, ed. Pediatrics Environmental Health 3 rd Edition Elk Grove Village, IL: American Academy of Pediatrics; 2012: 125

Pest Management in Schools What is a pest? • Living organisms that occur where Pest Management in Schools What is a pest? • Living organisms that occur where they are not wanted or cause damage to crops or humans or other animals • Insects • Mice and other animals, • Unwanted plants (weeds) • Fungi (mold), bacteria, viruses • Balancing risk and benefit • Allergen control versus • Minimizing exposure to pesticide • Children are routinely exposed to pesticides in their home, diet and schools

Solution: Integrated Pest Management Pest control strategy that involves “least toxic methods first. ” Solution: Integrated Pest Management Pest control strategy that involves “least toxic methods first. ” Principles: • Target pesticides to areas not contacted by or accessible to the students, faculty or staff • Goal is prevention • Apply pesticides only as needed • Select the least hazardous pesticides EPA IPM in schools: www. epa. gov/pesticides/ipm

Other IPM Strategies • Address sources: water, temperature, food • Mousetraps or gels • Other IPM Strategies • Address sources: water, temperature, food • Mousetraps or gels • Sealing cracks and holes • Generalized cleaning • Keeping trash covered • Reducing moisture • Education • Food storage http: //schoolipm. ifas. ufl. edu/doc/whatipm. ppt

Cockroach Allergen Favorable environment: warmth, moisture, food Questions for Family: • How many cockroaches Cockroach Allergen Favorable environment: warmth, moisture, food Questions for Family: • How many cockroaches do you see every day? • Do you see cockroach droppings? Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers. National Environmental Education Foundation.

Asthma Morbidity Associated with Cockroach Antigen -/- no allergy/low exposure -/+ no allergy/high exposure Asthma Morbidity Associated with Cockroach Antigen -/- no allergy/low exposure -/+ no allergy/high exposure +/- allergy/low exposure +/+ allergy/high exposure Rosenstreich, et al. NEJM. 336(19): 1356 -63, 1997 May 8 41

Cockroach Environmental Control Reduction in cockroach allergen correlates with asthma symptom improvement* Environmental remediation Cockroach Environmental Control Reduction in cockroach allergen correlates with asthma symptom improvement* Environmental remediation strategies** • Integrated Pest Management • Baits, traps, and gels before sprays • Limit access to food • Keep food and trash in closed containers • Clean up all spilled food • No food in bedrooms • Clean counters daily • Eliminate water - leaky plumbing, leaky roof • Boric acid *Morgan et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004; 351(11): 1068 -80. **Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation. 42 DO NOT • Spray liquids in the house • Use industrial strength pesticide sprays that require dilution

Dust Mite Allergen • Favorable environment: warmth, moisture, food • Live in mattresses, upholstered Dust Mite Allergen • Favorable environment: warmth, moisture, food • Live in mattresses, upholstered furniture and carpet • Mites and allergens most common in humid environments • Difficult to see so take climate into account or home dust testing • Children who are sensitized to dust mites have more severe asthma 43

Evidence for Dust Mite Control • 1992 randomized controlled trial comparing dust mite interventions Evidence for Dust Mite Control • 1992 randomized controlled trial comparing dust mite interventions for mattresses and carpets* • Children using bedding casing and carpet treatment showed decreased dust mite allergen on mattresses and decreased airway reactivity • 2003 Danish study using mattress covers** • Decreased dust mite allergen in those children using dust mite covers • Decreased dose of controller ICS by 9 months • No effect on airway reactivity • Overall: allergen removal correlates with clinical improvement 44 *Enhert B, et al. Allergy Clin Immunology 1992; 90: 135 -8. **Halken S, et al. J Allergy Clin Immunol 2003; 111. 169 -176. Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation.

Dust Mite Control • Allergen impermeable pillow and mattress covers • Wash bedding weekly Dust Mite Control • Allergen impermeable pillow and mattress covers • Wash bedding weekly • Wash and dry, or freeze stuffed toys weekly • Wash in HOT water (130 F) to kill mites • Damp mop floor surfaces, dust with wet rag • Remove carpeting or vacuum carpets with HEPA vacuum cleaner • Humidity below 50% - avoid humidifiers • Results usually seen in one month • Since dust is larger particle it settles • Unclear benefit of air filtration Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation. 45

Mold = Fungus = Mildew • Microorganisms that grow in warm and damp environments Mold = Fungus = Mildew • Microorganisms that grow in warm and damp environments • Many types of mold often occurring in the same environment • Spore aerosolization • No guideline for acceptable levels • Molds irritate mucous membranes • Produces allergic responses in children who are sensitive to mold Institute of Medicine. Damp Indoor Spaces and Health. NAS; 2004. http: //www. epa. gov/iedmold 1/mold_remediation. html http: //i 2. cdn. turner. com/cnn/dam/assets/111222124333 -school-mold-cnn-story -top. jpg

Questions for Families* • • • Do you see mold growth in the home? Questions for Families* • • • Do you see mold growth in the home? How large is the area? Do other locations (school, daycare) have mold growth? Do you have moisture or leaks in your home? Do you frequently have condensation on windows? Have you made attempts to decrease humidity? *Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers. National Environmental Education Foundation. 47

Mold Control Prevention of growth: • Dehumidifier ideally below 50% • Central air conditioner Mold Control Prevention of growth: • Dehumidifier ideally below 50% • Central air conditioner • Vent bathrooms and clothes driers to outside • Use exhaust fan in bathroom or other damp areas • Keep drip pans for fridge, air conditioner dry • Fix leaks of faucets and pipes • Prevent condensation on windows No raking, mowing if allergy Home remediation of mold: • Discard items too moldy to clean • Hard surfaces: Clean small areas with detergent and water • Dilute chlorine bleach improves appearance but does not remove allergen • Fix sources of water • If area larger than 3 x 3 ft: professional remediation • Porous materials usually require replacement Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation. 48

Evidence for Mold Remediation 2006 randomized controlled trial examining mold remediation and asthma symptoms* Evidence for Mold Remediation 2006 randomized controlled trial examining mold remediation and asthma symptoms* • Mold remediation group: • Significant decrease in mold levels • Significant decrease in asthma symptoms days • Significant decrease in rate of asthma exacerbations *Kercmar CM, et al. Env Health Persp 2006; 114: 1574 -80. Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Power. Point Training. National Environmental Education Foundation. 49

Animal Allergens: Pets and Nonpets • • Cats Dogs Rodents Birds 50 Animal Allergens: Pets and Nonpets • • Cats Dogs Rodents Birds 50

Prevalence of Animal Allergens Cats: • Smaller particles so remain suspended and easily transferred Prevalence of Animal Allergens Cats: • Smaller particles so remain suspended and easily transferred • Cat dander and schools Mice: Mouse allergen in inner cities • Found in most inner city homes** • Allergen concentration higher in cities than suburbs • Boston: 42% of population tested had mouse allergen detectable in house* • Risk factors: black race, visible mice, cockroach allergen *Phipatanakul W et al. Allergy 2005; 60: 697 -701. **Matsui et al. AAP Clinical Report: Environmental Control Practices and Asthma Management. Publication Pending. 51

Pet Allergen Control • Find a new home for indoor pets • Keep pet Pet Allergen Control • Find a new home for indoor pets • Keep pet outside • Pillow/mattress encasings • HEPA air filter and vacuum • Keep pet out of bedroom • 24 -30 weeks of interventions prior to allergen levels normalizing to levels of non-cat household* • Bathing cat may only decrease allergen for 1 -2 days** 52 RA et al. J Allergy Clin Immunol 1989; 83: 730 -4 • **Ownby D et al. J Allergy Clin Immunol 2006: 118: 521 -2 • Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Training Power. Point. National Environmental Education Foundation. • *Wood

Environmental Tobacco Smoke Consists of more than 3800 chemical compounds Gasses and particulates Decreasing Environmental Tobacco Smoke Consists of more than 3800 chemical compounds Gasses and particulates Decreasing exposure to ETS over last decade Children exposed to ETS in utero or infancy are more likely to develop asthma • Children with asthma who are exposed to ETS are more likely to have an asthma attack • • 53

Environmental Tobacco Smoke Interventions • Ideally smoke-free all environments • If not: focus on Environmental Tobacco Smoke Interventions • Ideally smoke-free all environments • If not: focus on indoor (house, car) • Support quitting • Nicotine gum/patch, medications • HEPA filters will help with particulates but not gases 54

Combined Asthma Trigger Management • Multitrigger management recommended* • Variability in evidence-based outcomes for Combined Asthma Trigger Management • Multitrigger management recommended* • Variability in evidence-based outcomes for individual allergen triggers • Sensitivity and exposure to multiple triggers likely • Studies: goal to show that • Intervention decreases allergen level • Decrease in allergen level associated with decreased symptoms *CDC Task Force Findings and Rationale Statement Interventions for Children and Adolescents with Asthma www. thecommunityguide. org/asthma/rrchildren. html Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Power. Point Training. National Environmental Education Foundation. 55

Evidence In Action: Inner City Asthma Study • • Management of multiple triggers 7 Evidence In Action: Inner City Asthma Study • • Management of multiple triggers 7 sites including Washington, DC 937 pediatric asthmatics in inner city Intervention: • Environmental questionnaire • Skin testing • Home allergen sampling • Environmental control measures • Mattress and pillow covers • HEPA air and vacuum filters • Professional pest control Results: 1 year follow up • Increased number symptom free days • Decreased allergen levels • Decreased dust and cockroach levels associated with decreased asthma complications Morgan WJ et al. New Engl J Med 2004; 351: 1068 -80. Kattan M et al. J Allergy Clin Immunol 2005; 116: 1058 -63. Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Power. Point Training. National Environmental Education Foundation. 56

Population Health and Outdoor Air Pollution • • CO SOx (SO 2) NOx (NO, Population Health and Outdoor Air Pollution • • CO SOx (SO 2) NOx (NO, NO 2) “criteria” pollutants Particulates (PM) Ozone Lead Volatile organic compounds (Hydrocarbons) Air toxics (solvents, pesticides, metals, etc. ) 57

Sources of Outdoor Air Pollution • Mobile sources: cars and trucks (particulates) • Coal Sources of Outdoor Air Pollution • Mobile sources: cars and trucks (particulates) • Coal plans • Incinerators/open burning (VOCs) http: //www. airnow. gov/index. cfm? action=aqibasics. ozone 58

Particulates • Mixture of solid and liquid particles • Natural sources: dust from soil, Particulates • Mixture of solid and liquid particles • Natural sources: dust from soil, evaporation of sea water • Combustion: • fly ash from coal • diesel exhaust 59

Traffic-related Air Pollution and Childhood Asthma • Southern California Children’s Health Study • Cohort Traffic-related Air Pollution and Childhood Asthma • Southern California Children’s Health Study • Cohort study (n=2, 497) • Examined the effects of traffic-related pollutants near children’s schools and homes • Asthma and wheeze were strongly associated with residential proximity to a major road¹ • Incidence of asthma was positively associated with traffic pollution among children at school and home², ³ ¹Mc. Connell R, et al. (2006) Traffic, Susceptibility, and Childhood Asthma. Environ Health Perspect 114(5) ²Jerrett M, et al. (2008) Traffic-Related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement. Environ Health Perspect 116(10) ³Mc. Connell R, et al. (2010) Childhood Incident Asthma and Traffic-Related Air Pollution at Home and School. Environ Health Perspect 118(7) Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Power. Point Training. National Environmental Education Foundation. 60

Asthma and Ozone • Ozone and ER Visits: Atlanta • Each increase of 20 Asthma and Ozone • Ozone and ER Visits: Atlanta • Each increase of 20 ppb ozone associated with 4% increase in ER visits • 1996 Summer Olympics – Atlanta • Increased public transportation • Decreased traffic • Peak daily ground level ozone decreased 28% • 42% reduction in asthma acute care events for children with Medicaid Friedman MS, Powell KE, Hutwanger L, et al. JAMA 285: 897 -905, 2001. 61

Mean Levels of Major Pollutants Before, During, and After the 1996 Summer Olympic Games Mean Levels of Major Pollutants Before, During, and After the 1996 Summer Olympic Games as a Percentage of the National Ambient Air Quality Standard (NAAQS)

AIRNow – www. airnow. gov 63 AIRNow – www. airnow. gov 63

Air Quality Index Descriptors Good 0 – 50 Moderate 51 – 100 Unhealthy for Air Quality Index Descriptors Good 0 – 50 Moderate 51 – 100 Unhealthy for Sensitive Groups 101 – 150 Unhealthy 151 – 200 Very Unhealthy 201 - 300 64 Cautionary Statement No message Unusually sensitive individuals Identifiable groups at risk - different groups for different pollutants General public at risk; sensitive groups at greater risk General public at greater risk; sensitive groups at greatest risk

Other Outdoor Allergens • Spring = trees (birch, oak, maple, cedar) • Summer = Other Outdoor Allergens • Spring = trees (birch, oak, maple, cedar) • Summer = grass • Fall = weeds (ragweed) • Pollen can stick to skin, clothing, hair so bath after outside play 65

Prevention of Outdoor Air Pollution • Control of mobile sources • emissions through cleaner Prevention of Outdoor Air Pollution • Control of mobile sources • emissions through cleaner gasoline and diesel engines • alternative fuel vehicles e. g. natural gas, electric, hybrid • motor vehicle use e. g. mass transit, carpools, biking • changes in driving habits e. g. slower starts, trip-stacking, off-hours refueling

Prevention of Outdoor Air Pollution • Control of fixed sources • power plant emissions Prevention of Outdoor Air Pollution • Control of fixed sources • power plant emissions through cleaner construction and operation, and use of cleaner fuels • industrial emissions through advanced production techniques • production through reduce/reuse/recycle initiatives

Other Resources • CDC educational resources • Initiating Change: Creating An Asthma Friendly School Other Resources • CDC educational resources • Initiating Change: Creating An Asthma Friendly School Video • http: //www. cdc. gov/Healthy. Youth/asthma/creatingafs/index. htm • Head Start Asthma Resource Toolkit • US Department of Health and Human Services and EPA Sponsored • Resources for providers and families on managing environmental asthma triggers • http: //eclkc. ohs. acf. hhs. gov/hslc/tta-system/health/center/physical-health/educationactivities/Asthma. Resource. T. htm • West Virginia Asthma Education and Prevention Program • West Virginia Asthma Coalition • Coordinate WVa organizations for improved compliance with NAEPP recommendations • Asthma-friendly School Award • Take. ACTION educational materials/training • http: //www. wvasthma. org/ • National Environmental Education Foundation Pediatric Asthma Initiative • webinars, educational materials for families and providers • Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers • complement to clinical management of NHLBI Guidelines • steering committee, peer reviewed, evidence –based environmental management strategies • www. neefusa. org/health/asthma/index. htm • IMPACT DC • Asthma Clinic affiliated with Children’s National Medical Center • http: //www. childrensnational. org/impactdc/ 68

When Confronted with an Environmental Health Issue Regarding a Child, Where Does One Turn? When Confronted with an Environmental Health Issue Regarding a Child, Where Does One Turn? To a Pediatric Environmental Health Specialty Unit (PEHSU).

What is a PEHSU? • A resource for pediatricians, public health officials, school personnel, What is a PEHSU? • A resource for pediatricians, public health officials, school personnel, parents and others to get questions answered about children’s health and the environment • National network of pediatricians and occupational/environmental health specialists, pulmonologists, toxicologists • Provides variety of educational functions

What Kinds of Problems do PEHSUs Deal With? • Exposure to hazardous waste sites What Kinds of Problems do PEHSUs Deal With? • Exposure to hazardous waste sites • Environmentally related asthma • Agricultural pollutants • Solvents • Carbon monoxide • Arsenic • Mercury Lead poisoning Pesticide exposures Sick building problems Water pollution Air pollution Job related exposures in adolescents • Volatile Organic Compounds • • •

The Pediatric Environmental Health Specialty Unit (PEHSU) Program is funded by: & The Association The Pediatric Environmental Health Specialty Unit (PEHSU) Program is funded by: & The Association of Occupational and Environmental Clinics is responsible for programmatic and financial management.

PEHSU Regions PEHSU Regions

THE MID-ATLANTIC CENTER FOR CHILDREN’S HEALTH & THE ENVIRONMENT (MACCHE) • Region 3 Pediatric THE MID-ATLANTIC CENTER FOR CHILDREN’S HEALTH & THE ENVIRONMENT (MACCHE) • Region 3 Pediatric Environmental Health Specialty Unit (PEHSU) • Pennsylvania, Delaware, Maryland, Virginia, West Virginia, & the District of Columbia • Affiliated with Children’s National Medical Center • Washington, DC

MACCHE Director • Jerome Paulson, MD, FAAP Pediatrician/Toxicologist • Maryann Mazer-Amirshahi, Pharm. D, MPH MACCHE Director • Jerome Paulson, MD, FAAP Pediatrician/Toxicologist • Maryann Mazer-Amirshahi, Pharm. D, MPH Coordinator • Veronica Tinney, MPH Staff • Abby Nerlinger, MD

Contact Information Mid-Atlantic Center for Children’s Health and the Environment www. childrensnational. org/macche@childrensnational. org Contact Information Mid-Atlantic Center for Children’s Health and the Environment www. childrensnational. org/[email protected] org 202 -471 -4829 1 -866 -622 -2431 @MACCHE_DC

QUESTIONS? QUESTIONS?