¹Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
²Harvard University Medical School, Boston, Massachusetts
³Department of Environmental Health, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
⁴Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
⁵Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
⁶Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, Massachusetts
⁷Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
⁸Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston
⁹Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston
¹⁰Division of Pediatric Pulmonology, Allergy and Immunology, Department of Pediatrics, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
¹¹Division of General Pediatrics, Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts
¹²Division of Pediatric Pulmonology and Department of Population and Quantitative Health Sciences, University of Massachusetts Memorial Medical School, Worcester
¹³Division of Allergy and Immunology, Brigham and Women’s Hospital, Boston, Massachusetts
¹⁴Department of Occupational and Environmental Health, University of Iowa, Iowa City
¹⁵Divisions of Pulmonary and Critical Care Medicine and Allergy and Immunology, Brigham and Women’s Hospital, Boston, Massachusetts
¹⁶Department of Environmental Health, School of Public Health, Columbia University, New York, New York,
¹⁷Channing Division of Network Medicine, Department of Laboratory Medicine, Brigham and Women’s Hospital, Boston, Massachusetts

School Inner-City Asthma Intervention study teamfor the

Read article on JAMA Network

Read Article Take Quiz

Key Points

Question Does use of a school-wide integrated pest management (IPM) program or high-efficiency particulate air (HEPA) filter purifiers in the classrooms reduce asthma symptoms in students with active asthma?

Findings This factorial randomized clinical trial included 236 students (attending 41 elementary schools with 209 classrooms) randomized to an IPM program at the school level, use of HEPA filter purifiers at the classroom level, or both. Use of the school-wide IPM program resulted in a mean of 1.5 symptom-days with asthma during a 2-week period vs 1.9 symptom-days for no IPM; use of HEPA filter purifiers resulted in a mean of 1.6 symptom-days with asthma vs 1.8 symptom-days for sham HEPA filter purifiers; neither comparison was statistically significant.

Meaning Among children with active asthma, use of a school-wide IPM program or HEPA filter purifiers in the classrooms did not significantly reduce symptom-days with asthma.

Abstract

Importance School and classroom allergens and particles are associated with asthma morbidity, but the benefit of environmental remediation is not known.

Objective To determine whether use of a school-wide integrated pest management (IPM) program or high-efficiency particulate air (HEPA) filter purifiers in the classrooms improve asthma symptoms in students with active asthma.

Design, Setting, and Participants Factorial randomized clinical trial of a school-wide IPM program and HEPA filter purifiers in the classrooms was conducted from 2015 to 2020 (School Inner-City Asthma Intervention Study). There were 236 students with active asthma attending 41 participating urban elementary schools located in the Northeastern US who were randomized to IPM by school and HEPA filter purifiers by classroom. The date of final follow-up was June 20, 2020.

Interventions The school-wide IPM program consisted of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for school staff. Infestation was assessed every 3 months, with additional treatments as needed. Control schools received no IPM, cleaning, or education. Classroom portable HEPA filter purifiers were deployed and the filters were changed every 3 months. Control classrooms received sham HEPA filters that looked and sounded like active HEPA filter purifiers. Randomization was done independently (split-plot design), with matching by the number of enrolled students to ensure a nearly exact 1:1 student ratio for each intervention with 118 students randomized to each group. Participants, investigators, and those assessing outcomes were blinded to the interventions.

Main Outcomes and Measures The primary outcome was the number of symptom-days with asthma during a 2-week period. Symptom-days were assessed every 2 months during the 10 months after randomization.

Results Among the 236 students who were randomized (mean age, 8.1 [SD, 2.0] years; 113 [48%] female), all completed the trial. At baseline, the 2-week mean was 2.2 (SD, 3.9) symptom-days with asthma and 98% of the classrooms had detectable levels of mouse allergen. The results were pooled because there was no statistically significant difference between the 2 interventions (P = .18 for interaction). During a 2-week period, the mean was 1.5 symptom-days with asthma after use of the school-wide IPM program vs 1.9 symptom-days after no IPM across the school year (incidence rate ratio, 0.71 [95% CI, 0.38-1.33]), which was not statistically significantly different. During a 2-week period, the mean was 1.6 symptom-days with asthma after use of HEPA filter purifiers in the classrooms vs 1.8 symptom-days after use of sham HEPA filter purifiers across the school year (incidence rate ratio, 1.47 [95% CI, 0.79-2.75]), which was not statistically significantly different. There were no intervention-related adverse events.

Conclusions and Relevance Among children with active asthma, use of a school-wide IPM program or classroom HEPA filter purifiers did not significantly reduce symptom-days with asthma. However, interpretation of the study findings may need to consider allergen levels, particle exposures, and asthma symptoms at baseline.

Trial Registration ClinicalTrials.gov Identifier: NCT02291302

Take Quiz

Buy This Activity

Article Information

Corresponding Author: Wanda Phipatanakul, MD, MS, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (wanda.phipatanakul@childrens.harvard.edu).

Accepted for Publication: June 27, 2021.

Author Contributions: Drs Phipatanakul and Coull had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Phipatanakul, Koutrakis, Coull, Petty, Sheehan, Samnaliev, Baxi, Hauptman, Adamkiewicz, Baccarelli, Gold.

Acquisition, analysis, or interpretation of data: Phipatanakul, Coull, Petty, Gaffin, Sheehan, Lai, Bartnikas, Kang, Wolfson, Samnaliev, Cunningham, Baxi, Permaul, Hauptman, Trivedi, Louisias, Liang, Thorne, Metwali, Israel, Baccarelli, Gold.

Drafting of the manuscript: Phipatanakul, Coull, Petty, Sheehan, Bartnikas, Kang, Baxi, Metwali.

Critical revision of the manuscript for important intellectual content: Phipatanakul, Koutrakis, Coull, Petty, Gaffin, Sheehan, Lai, Bartnikas, Wolfson, Samnaliev, Cunningham, Baxi, Permaul, Hauptman, Trivedi, Louisias, Liang, Thorne, Adamkiewicz, Israel, Baccarelli, Gold.

Statistical analysis: Phipatanakul, Coull, Petty, Sheehan, Lai, Hauptman, Liang, Israel.

Obtained funding: Phipatanakul, Liang, Gold.

Administrative, technical, or material support: Phipatanakul, Kang, Cunningham, Baxi, Permaul, Trivedi, Louisias, Thorne, Metwali.

Supervision: Phipatanakul, Koutrakis, Coull, Gaffin, Wolfson, Cunningham, Baxi, Louisias, Adamkiewicz.

Conflict of Interest Disclosures: Dr Phipatanakul reported receiving nonfinancial support from Coway Co Ltd (provided HEPA filter intervention), ALK-Abelló (provided skin testing reagents), and Monaghen (provided aerochambers); receiving grants from Thermo Fisher and the National Institutes of Health; receiving consulting fees from Genentech/Novartis, Regeneron/Sanofi, and GlaxoSmithKline; receiving funding, clinical trial support, and medications from Genentech/Novartis, Regeneron/Sanofi, and GlaxoSmithKline; and receiving clinical trial medication support from Bohringer Ingelheim, AstraZeneca, Merck, and CSL Behring. Dr Coull reported receiving grants from Apple Inc. Dr Sheehan reported receiving consulting fees from GlaxoSmithKline for serving on an advisory board. Dr Louisias reported receiving grants from the Brigham and Women’s Hospital Nesson Fellowship. Dr Israel reported receiving personal fees from the National Asthma Education and Prevention Program for serving on the coordinating committee, which advises on the asthma guidelines for the US. No other disclosures were reported.

Funding/Support: Coway Co Ltd provided the HEPA filter purifiers. Other in-kind materials were provided by ALK-Abelló, Lincoln Diagnostics, and Thermo Fisher Scientific. This study was supported by grants 5K12HS022986-03, 8UL1TR000170, P30ES031663, P30ES000002, K23ES023700, K23AI104780, K23AI106945, K23AI123517, K23AI143962, K24AI106822, K23HL150341, L30HL143781, P30ES005605, and U01AI110397 from the National Institutes of Health. Additional support was provided by grants DW-75-95877701, NU61TS000296, RD-834798, and RD-835872 from the US Environmental Protection Agency. This work also was supported by the Harvard Catalyst/Harvard Clinical and Translational Science Center and Harvard University and its affiliated academic health care centers.

Role of the Funder/Sponsor: The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The members of the School Inner-City Asthma Intervention study team appear in Supplement 3.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Harvard Catalyst/Harvard Clinical and Translational Science Center, Harvard University and its affiliated academic health care centers, the National Center for Research Resources, or the National Institutes of Health. In addition, the US Environmental Protection Agency does not endorse the purchase of any commercial products or services mentioned in the publication.

Additional Contributions: We thank the pest management teams from Buono Pest Control Co Inc and the pest management consultants, Rivard’s Resources, who received compensation for their services. We also thank the participating schools, the students, and their families for the support they provided for the study. This study was additionally monitored by independent monitors at Pharmaceutical Product Development LLC.

References

Del-Rio-Navarro BE , Navarrete-Rodríguez EM , Berber A , Reyes-Noriega N , García-Marcos Álvarez L ; Grupo GAN México, Grupo ISAAC México. The burden of asthma in an inner-city area: a historical review 10 years after Isaac. World Allergy Organ J. 2020;13(1):100092. doi:10.1016/j.waojou.2019.100092 PubMed Google Scholar

Rabito FA , Carlson JC , He H , Werthmann D , Schal C . A single intervention for cockroach control reduces cockroach exposure and asthma morbidity in children. J Allergy Clin Immunol. 2017;140(2):565-570. doi:10.1016/j.jaci.2016.10.019 PubMed Google Scholar Crossref

DiMango E , Serebrisky D , Narula S , et al. Individualized household allergen intervention lowers allergen level but not asthma medication use: a randomized controlled trial. J Allergy Clin Immunol. 2016;4(4):671-679,e4. doi:10.1016/j.jaip.2016.01.016 Google Scholar Crossref

Matsui EC , Perzanowski M , Peng RD , et al. Effect of an integrated pest management intervention on asthma symptoms among mouse-sensitized children and adolescents with asthma: a randomized clinical trial. JAMA. 2017;317(10):1027-1036. doi:10.1001/jama.2016.21048 PubMed Google Scholar Crossref

Olson C , Leu CS , Alper H , Millican M , Reznik M . A randomized trial of a one-time pest intervention: impact on childhood asthma outcomes. J Asthma. 2021;58(5):616-624. doi:10.1080/02770903.2019.1709870 PubMed Google Scholar Crossref

Riederer AM , Krenz JE , Tchong-French MI , et al. Effectiveness of portable HEPA air cleaners on reducing indoor PM_2.5 and NH₃ in an agricultural cohort of children with asthma: a randomized intervention trial. Indoor Air. 2021;31(2):454-466. doi:10.1111/ina.12753 PubMed Google Scholar Crossref

Sheehan WJ , Permaul P , Petty CR , et al. Association between allergen exposure in inner-city schools and asthma morbidity among students. JAMA Pediatr. 2017;171(1):31-38. doi:10.1001/jamapediatrics.2016.2543 PubMed Google Scholar Crossref

Jhun I , Gaffin JM , Coull BA , et al. School environmental intervention to reduce particulate pollutant exposures for children with asthma. J Allergy Clin Immunol. 2017;5(1):154-159,e3. doi:10.1016/j.jaip.2016.07.018 Google Scholar Crossref

Phipatanakul W , Koutrakis P , Coull BA , et al. The School Inner-City Asthma Intervention Study: design, rationale, methods, and lessons learned. Contemp Clin Trials. 2017;60:14-23. doi:10.1016/j.cct.2017.06.008 PubMed Google Scholar Crossref

10.

Redline S , Gruchalla RS , Wolf RL , et al. Development and validation of school-based asthma and allergy screening questionnaires in a 4-city study. Ann Allergy Asthma Immunol. 2004;93(1):36-48. doi:10.1016/S1081-1206(10)61445-7 Google Scholar Crossref

11.

Morgan WJ , Crain EF , Gruchalla RS , et al; Inner-City Asthma Study Group. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;351(11):1068-1080. doi:10.1056/NEJMoa032097 PubMed Google Scholar Crossref

12.

Rosenstreich DL , Eggleston P , Kattan M , et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. 1997;336(19):1356-1363. doi:10.1056/NEJM199705083361904 PubMed Google Scholar Crossref

13.

American Academy of Allergy and Immunology Board of Directors. Allergen skin testing. J Allergy Clin Immunol. 1993;92(5):636-637. doi:10.1016/0091-6749(93)90004-Y PubMed Google Scholar Crossref

14.

American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med. 1995;152(3):1107-1136.PubMed Google Scholar Crossref

15.

Wu TD , Perzanowski M , Peng RD , et al. Validation of the maximum symptom day among children with asthma. J Allergy Clin Immunol. 2019;143(2):803-805,e10. doi:10.1016/j.jaci.2018.10.008 Google Scholar Crossref

16.

Busse WW , Morgan WJ , Gergen PJ , et al. Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children. N Engl J Med. 2011;364(11):1005-1015. doi:10.1056/NEJMoa1009705 PubMed Google Scholar Crossref

17.

Wildfire JJ , Gergen PJ , Sorkness CA , et al. Development and validation of the Composite Asthma Severity Index—an outcome measure for use in children and adolescents. J Allergy Clin Immunol. 2012;129(3):694-701. doi:10.1016/j.jaci.2011.12.962 PubMed Google Scholar Crossref

18.

Krouse RZ , Sorkness CA , Wildfire JJ , et al. Minimally important differences and risk levels for the Composite Asthma Severity Index. J Allergy Clin Immunol. 2017;139(3):1052-1055. doi:10.1016/j.jaci.2016.08.041 PubMed Google Scholar Crossref

19.

Szefler S , Weiss S , Tonascia J , et al; Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med. 2000;343(15):1054-1063. doi:10.1056/NEJM200010123431501 PubMed Google Scholar

20.

Goldstein H . Multilevel Statistical Models. 3rd ed. Arnold; 2003.

21.

Applied Longitudinal Analysis. Wiley & Sons; 2011.

22.

Phipatanakul W , Eggleston PA , Wright EC , Wood RA . Mouse allergen, II: the relationship of mouse allergen exposure to mouse sensitization and asthma morbidity in inner-city children with asthma. J Allergy Clin Immunol. 2000;106(6):1075-1080. doi:10.1067/mai.2000.110795 Google Scholar Crossref

23.

Tseloni A , Pease K . Repeat personal victimization: random effects, event dependence and unexplained heterogeneity. Br J Criminol. 2004;44(6):931-945. doi:10.1093/bjc/azh047 Google Scholar Crossref

24.

Phipatanakul W , Celedon JC , Hoffman EB , Abdulkerim H , Ryan LM , Gold DR . Mouse allergen exposure, wheeze and atopy in the first seven years of life. Allergy. 2008;63(11):1512-1518. doi:10.1111/j.1398-9995.2008.01679.x Google Scholar Crossref

Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active AsthmaA Randomized Clinical Trial

School Classrooms as Targets to Reduce Allergens and Improve Asthma

See More About

If you are not a JN Learning subscriber, you can either:

A subscription to JN Learning (CME from JAMA Network) provides:

Sign in to access

If you are not a JN Learning subscriber, you can either:

Sign in to customize your interests

With a personal account, you can:

Name Your Search

Sign in to save your search

With a personal account, you can:

Lookup An Activity

My Saved Searches

Sign in to customize your interests

With a personal account, you can:

Purchase access