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1.  Indoor fungal concentration in the homes of allergic/asthmatic children in Delhi, India 
Allergy & Rhinology  2011;2(1):21-32.
Allergy to fungi has been linked to a wide range of illnesses, including rhinitis and asthma. Therefore, exposure to fungi in home environment is an important factor for fungal allergy. The present study was aimed to investigate types of airborne fungi inside and outside the homes of asthmatic children and control subjects (nonasthmatic children). The dominant fungi were evaluated for their quantitative distribution and seasonal variation. The air samples were collected from indoors and immediate outdoors of 77 selected homes of children suffering from bronchial asthma/allergic rhinitis using Andersen volumetric air sampler. The isolated fungal genera/species were identified using reference literature, and statistical analysis of the dominant fungi was performed to study the difference in fungal concentration between indoor and immediate outdoor sites as well as in between different seasons. A total of 4423 air samples were collected from two indoor and immediate outdoor sites in a 1-year survey of 77 homes. This resulted in the isolation of an average of 110,091 and 107,070 fungal colonies per metric cube of air from indoor and outdoor sites, respectively. A total of 68 different molds were identified. Different species of Aspergillus, Alternaria, Cladosporium, and Penicillium were found to be the most prevalent fungi in Delhi homes, which constituted 88.6% of the total colonies indoors. Highest concentration was registered in autumn and winter months. Total as well as dominant fungi displayed statistically significant differences among the four seasons (p < 0.001). The largest number of isolations were the species of Aspergillus (>40% to total colony-forming units in indoors as well as outdoors) followed by Cladosporium spp. Annual concentration of Aspergillus spp. was significantly higher (p < 0.05) inside the homes when compared with outdoors. Most of the fungi also occurred at a significantly higher (p < 0.001) rate inside the homes when compared with immediate outdoors. Asthmatic children in Delhi are exposed to a substantial concentration of mold inside their homes as well as immediate outdoor air. The considerable seasonal distributions of fungi provide valuable data for investigation of the role of fungal exposure as a risk for respiratory disorders among patients suffering from allergy or asthma in Delhi.
doi:10.2500/ar.2011.2.0005
PMCID: PMC3390125  PMID: 22852111
Asthma; Delhi; indoor fungi; prevalence; respiratory allergy; seasonal variation
2.  Fungal Levels in the Home and Allergic Rhinitis by 5 Years of Age 
Environmental Health Perspectives  2005;113(10):1405-1409.
Studies have repeatedly demonstrated that sensitization to fungi, such as Alternaria, is strongly associated with allergic rhinitis and asthma in children. However, the role of exposure to fungi in the development of childhood allergic rhinitis is poorly understood. In a prospective birth cohort of 405 children of asthmatic/allergic parents from metropolitan Boston, Massachusetts, we examined in-home high fungal concentrations (> 90th percentile) measured once within the first 3 months of life as predictors of doctor-diagnosed allergic rhinitis in the first 5 years of life. In multivariate Cox regression analyses, predictors of allergic rhinitis included high levels of dust-borne Aspergillus [hazard ratio (HR) = 3.27; 95% confidence interval (CI), 1.50–7.14], Aureobasidium (HR = 3.04; 95% CI, 1.33–6.93), and yeasts (HR = 2.67; 95% CI, 1.26–5.66). The factors controlled for in these analyses included water damage or mild or mildew in the building during the first year of the child’s life, any lower respiratory tract infection in the first year, male sex, African-American race, fall date of birth, and maternal IgE to Alternaria > 0.35 U/mL. Dust-borne Alternaria and non-sporulating and total fungi were also predictors of allergic rhinitis in models excluding other fungi but adjusting for all of the potential confounders listed above. High measured fungal concentrations and reports of water damage, mold, or mildew in homes may predispose children with a family history of asthma or allergy to the development of allergic rhinitis.
doi:10.1289/ehp.7844
PMCID: PMC1281288  PMID: 16203255
allergic rhinitis; fungi; mold; respiratory health effects; water damage
3.  Socioeconomic predictors of high allergen levels in homes in the greater Boston area. 
Environmental Health Perspectives  2000;108(4):301-307.
In the United States, childhood asthma morbidity and prevalence rates are the highest in less affluent urban minority communities. More than 80% of childhood asthmatics are allergic to one or more inhalant allergens. We evaluated whether socioeconomic status was associated with a differential in the levels and types of indoor home allergens. Dust samples for an ELISA allergen assay were collected from the homes of 499 families as part of a metropolitan Boston, Massachusetts, longitudinal birth cohort study of home allergens and asthma in children with a parental history of asthma or allergy. The proportion of homes with maximum home allergen levels in the highest category was 42% for dust mite allergen (> or = 10 microg/g Der p 1 or Der f 1), 13% for cockroach allergen (> or = 2 U/g Bla g 1 or Bla g 2), 26% for cat allergen (> or = 8 microg/g Fel d 1), and 20% for dog allergen (> or = 10 microg/g Can f 1). Homes in the high-poverty area (> 20% of the population below the poverty level) were more likely to have high cockroach allergen levels than homes in the low-poverty area [51 vs. 3%; OR, 33; 95% confidence interval (CI), 12-90], but less likely to have high levels of dust mite allergen (16 vs. 53%; OR, 0.2; CI, 0.1-0.4). Lower family income, less maternal education, and race/ethnicity (black or Hispanic vs. white) were also associated with a lower risk of high dust mite levels and a greater risk of high cockroach allergen levels. Within a single U.S. metropolitan area we found marked between-community differences in the types of allergens present in the home, but not necessarily in the overall burden of allergen exposure.
Images
PMCID: PMC1638021  PMID: 10753087
4.  Air- and Dustborne Mycoflora in Houses Free of Water Damage and Fungal Growth 
Applied and Environmental Microbiology  2004;70(11):6394-6400.
Typically, studies on indoor fungal growth in buildings focus on structures with known or suspected water damage, moisture, and/or indoor fungal growth problems. Reference information on types of culturable fungi and total fungal levels are generally not available for buildings without these problems. This study assessed 50 detached single-family homes in metropolitan Atlanta, Ga., to establish a baseline of “normal and typical” types and concentrations of airborne and dustborne fungi in urban homes which were predetermined not to have noteworthy moisture problems or indoor fungal growth. Each home was visually examined, and samples of indoor and outdoor air and of indoor settled dust were taken in winter and summer. The results showed that rankings by prevalence and abundance of the types of airborne and dustborne fungi did not differ from winter to summer, nor did these rankings differ when air samples taken indoors were compared with those taken outdoors. Water indicator fungi were essentially absent from both air and dust samples. The air and dust data sets were also examined specifically for the proportions of colonies from ecological groupings such as leaf surface fungi and soil fungi. In the analysis of dust for culturable fungal colonies, leaf surface fungi constituted a considerable portion (>20%) of the total colonies in at least 85% of the samples. Thus, replicate dust samples with less than 20% of colonies from leaf surface fungi are unlikely to be from buildings free of moisture or mold growth problems.
doi:10.1128/AEM.70.11.6394-6400.2004
PMCID: PMC525119  PMID: 15528497
5.  Mite, cat, and cockroach exposure, allergen sensitisation, and asthma in children: a case-control study of three schools 
Thorax  1999;54(8):675-680.
BACKGROUND—The amount of allergen necessary to sensitise genetically "at risk" children is unclear. The relation between allergen exposure and asthma is also uncertain.
METHODS—To ensure a wide range of allergen exposures the data from case-control studies of asthma in children aged 12-14 years attending three schools in Los Alamos, New Mexico and Central Virginia were combined. Skin prick tests to indoor and outdoor allergens and bronchial hyperreactivity to histamine were assessed in children with and without symptoms of asthma. The concentration of mite, cat, and cockroach allergens in dust from the children's homes was used as a marker of exposure.
RESULTS—Three hundred and thirty two children (157 with asthmatic symptoms and 175 controls) were investigated. One hundred and eighty three were classified as atopic on the basis of allergen skin prick tests and 68 as asthmatic (symptoms plus bronchial responsiveness). The prevalence and degree of sensitisation to mite and cockroach, but not cat, was strongly associated in atopic children with increasing domestic concentrations of these allergens. Asthma was strongly associated with sensitisation to indoor allergens (p<10-6) and weakly to outdoor allergens (p = 0.026). There was an association between current asthma and the concentration of mite allergen amongst atopic children (p = 0.008) but not amongst those who were specifically mite sensitised (p = 0.16).
CONCLUSIONS—The domestic reservoir concentration of mite and cockroach, but not cat, allergen was closely related to the prevalence of sensitisation in atopic children. However, the prevalence of current asthma had a limited relationship to these allergen measurements, suggesting that other factors play a major part in determining which allergic individuals develop asthma.


PMCID: PMC1745561  PMID: 10413718
6.  House dust mite control measures in the treatment of asthma 
Sensitization to the house dust mite (Dermataphagoides pteronyssinus) (HDM) is the most common risk factor associated with the development of asthma in adults and children. The effectiveness of HDM control measures in the treatment of asthma is not yet proven. The strategies for control for avoidance depend on our understanding of the biology of the HDM. The evidence suggests a favorable effect of transferring allergic asthmatic children to naturally low dust mite environments, such as at altitude or in hospital, but little to suggest that this can be replicated in general practice by simple practical measures such as mattress covers. However, a recent multi-allergen reduction approach has suggested benefits may be achievable. HDM densities tend to be high in warm, humid conditions in the home, which may be modified by external factors, such as ventilation. However, ventilation control to reduce indoor humidity has had inconsistent effects on dust mite levels and asthma. The challenge is to further refine the interventions in large placebo-controlled trials such that clinical outcomes may be more easily demonstrated.
PMCID: PMC1936356  PMID: 18360647
house dust mite; asthma; allergy; control
7.  Indoor exposure to molds and allergic sensitization. 
Environmental Health Perspectives  2002;110(7):647-653.
Evidence that indoor dampness and mold growth are associated with respiratory health has been accumulating, but few studies have been able to examine health risks in relation to measured levels of indoor mold exposure. In particular, little is known about the contribution of indoor molds to the development of allergic sensitization. As a part of an ongoing study examining the effects of ambient air pollutants on respiratory health and atopic diseases in German school children, we examined the relation between viable mold levels indoors and allergic sensitization in 272 children. We examined whether allergic sensitization in children is associated with higher fungal spore count in settled house dust sampled from living room floors. Adjusting for age, sex, parental education, region of residency, and parental history of atopy, we found that mold spore counts for Cladosporium and Aspergillus were associated with an increased risk of allergic sensitization. Sensitized children exposed to high levels of mold spores (> 90th percentile) were more likely to suffer from symptoms of rhinoconjunctivitis. We conclude that elevated indoor concentrations of molds in wintertime might play a role in increasing the risk of developing atopic symptoms and allergic sensitization not only to molds but also to other common, inhaled allergens. These effects were strongest in the group of children who had lived in the same home since birth.
PMCID: PMC1240910  PMID: 12117641
8.  Relationship between indoor and outdoor bioaerosols collected with a button inhalable aerosol sampler in urban homes 
Indoor air  2006;16(1):37-47.
This field study investigated the relationship between indoor and outdoor concentrations of airborne actinomycetes, fungal spores, and pollen. Air samples were collected for 24 h with a button inhalable aerosol sampler inside and outside of six single-family homes located in the Cincinnati area (overall, 15 pairs of samples were taken in each home). The measurements were conducted during three seasons – spring and fall 2004, and winter 2005. The concentration of culturable actinomycetes was mostly below the detection limit. The median indoor/outdoor ratio (I/O) for actinomycetes was the highest: 2.857. The indoor of fungal and pollen concentrations followed the outdoor concentrations while indoor levels were mostly lower than the outdoor ones. The I/O ratio of total fungal spores (median = 0.345) in six homes was greater than that of pollen grains (median = 0.025). The low I/O ratios obtained for pollen during the peak ambient pollination season (spring) suggest that only a small fraction penetrated from outdoor to indoor environment. This is attributed to the larger size of pollen grains. Higher indoor concentration levels and variability in the I/O ratio observed for airborne fungi may be associated with indoor sources and/or higher outdoor-to-indoor penetration of fungal spores compared to pollen grains.
doi:10.1111/j.1600-0668.2005.00396.x
PMCID: PMC2233950  PMID: 16420496
Bioaerosol; Exposure; Indoor; Outdoor; Bacteria; Fungal spore; Pollen
9.  Asthmatic Symptoms among Pupils in Relation to Winter Indoor and Outdoor Air Pollution in Schools in Taiyuan, China 
Background
There are few studies on associations between children’s respiratory heath and air pollution in schools in China. The industrial development and increased traffic may affect the indoor exposure to air pollutants in school environment. Moreover, there is a need to study respiratory effects of environmental tobacco smoke (ETS) and emissions from new building materials in homes in China.
Objectives
We studied the associations between pupils’ asthmatic symptoms and indoor and outdoor air pollution in schools, as well as selected home exposures, in a coal-burning city in north China.
Methods
A questionnaire survey was administered to pupils (11–15 years of age) in 10 schools in urban Taiyuan, collecting data on respiratory health and selected home environmental factors. Indoor and outdoor school air pollutants and climate factors were measured in winter.
Results
A total of 1,993 pupils (90.2%) participated; 1.8% had cumulative asthma, 8.4% wheezing, 29.8% had daytime attacks of breathlessness. The indoor average concentrations of sulfur dioxide, nitrogen dioxide, ozone, and formaldehyde by class were 264.8, 39.4, 10.1, and 2.3 μg/m3, respectively. Outdoor levels were two to three times higher. Controlling for possible confounders, either wheeze or daytime or nocturnal attacks of breathlessness were positively associated with SO2, NO2, or formaldehyde. In addition, ETS and new furniture at home were risk factors for wheeze, daytime breathlessness, and respiratory infections.
Conclusions
Indoor chemical air pollutants of mainly outdoor origin could be risk factors for pupils’ respiratory symptoms at school, and home exposure to ETS and chemical emissions from new furniture could affect pupils’ respiratory health.
doi:10.1289/ehp.10576
PMCID: PMC2199281  PMID: 18197305
air pollution; asthma; China; formaldehyde; indoor; nitrogen dioxide; ozone; outdoor; school; sulfur dioxide
10.  Prevalence of Indoor Allergen Exposures among New Orleans Children with Asthma 
Studies of inner-city asthmatic children have shown significant regional variation in dust allergen exposures. The home environment of asthmatic children in the Gulf South region of the USA has not been characterized. This study describes indoor dust allergen levels in the homes of 86 asthmatic children in New Orleans and explores regional variability in dust allergen exposure. Data were used from baseline home visits of children in the New Orleans Healthy Homes Initiative. Interview, visual observation, and environmental dust sampling data of 86 children between 4 and 17 years of age were analyzed. Seventy-seven percent of households had moderate (>2.0–9.9 μg/g) or high (≥10.0 μg/g) levels of either Der p 1 or Der f 1 dust mite allergen and 56.6% had moderate (>2.0–8.0 U/g) or high (>8.0 U/g) levels of cockroach allergen (Bla g 1). The prevalence of high (>10 μg/g) levels of dog (Can f 1) allergen was 26.5%, and few households (6.0%) had high cat allergen (Fel d 1) levels (>8.0 μg/g). Households with average humidity levels >50% were three times more likely to have elevated dust mite levels (odds ratio=3.2; 95% confidence interval=1.1, 9.3; p=0.03). Home ownership and education level were inversely associated with cockroach and dust mite allergen levels, respectively. Our findings reinforce the evidence of regional variability in dust allergen exposure levels. Asthmatic children living in the Gulf South are exposed to multiple indoor allergen exposures and live in a highly allergenic environment.
doi:10.1007/s11524-007-9216-0
PMCID: PMC2232043  PMID: 17917814
Child health; Asthma; Allergens; Environmental health; Dog allergen; House dust
11.  Household airborne Penicillium associated with peak expiratory flow variability in asthmatic children 
Background
Exposure to airborne fungi has been associated with increased airway hyperreactivity and asthma prevalence.
Objective
To investigate the association between common indoor fungi and airway hyperreactivity measured by peak expiratory flow variability in asthmatic children.
Methods
Children 6 to 12 years of age (n = 225) with a physician diagnosis of asthma were enrolled in the study to have their peak expiratory flow recorded twice daily during a 2-week period. Genus-specific, quantitative, in-home airborne mold concentrations were measured. Logistic regression models were used to examine the relationship between a mean peak expiratory flow variability greater than 18.5% (75th percentile) and any mold in the home (total mold, Cladosporium, Penicillium, Aspergillus, and Alternaria).
Results
Mold was detected in 93% of the homes. The most common molds were Cladosporium in 72% and Penicillium in 42% of the samples. Controlling for sex, ethnicity, age, and winter season of sampling, Penicillium measured in the home was associated with a mean peak expiratory flow variability greater than 18.5% (odds ratio, 2.4; 95% confidence interval, 1.2–4.8). Greater peak expiratory flow variability was not associated with total mold or other mold measured in the home.
Conclusion
Exposure to airborne Penicillium is associated with increased peak expiratory flow variability in asthmatic children.
PMCID: PMC2746059  PMID: 19663123
12.  Asthma randomized trial of indoor wood smoke (ARTIS): Rationale and Methods 
Contemporary clinical trials  2012;33(5):1080-1087.
Background
Particulate matter (PM) exposures have been linked with poor respiratory health outcomes, especially among susceptible populations such as asthmatic children. Smoke from biomass combustion for residential home heating is an important source of PM in many rural or peri-urban areas in the United States.
Aim
To assess the efficacy of residential interventions that reduce indoor PM exposure from wood stoves and to quantify the corresponding improvements in quality of life and health outcomes for asthmatic children.
Design
The Asthma Randomized Trial of Indoor wood Smoke (ARTIS) study is an in-home intervention study of susceptible children exposed to biomass combustion smoke. Children, ages 7 to 17, with persistent asthma and living in homes that heat with wood stoves were recruited for this three arm randomized placebo-controlled trial. Two household-level intervention strategies, wood stove replacement and air filters, were compared to a sham air filter placebo. Improvement in quality of life of asthmatic children was the primary outcomes. Secondary asthma-related health outcomes included peak expiratory flow (PEF) and forced expiratory volume in first second (FEV1), biomarkers in exhaled breath condensate, and frequency of asthma symptoms, medication usage, and healthcare utilization. Exposure outcomes included indoor and outdoor PM2.5 mass, particle counts of several size fractions, and carbon monoxide.
Discussion
To our knowledge, this was the first randomized trial in the US to utilize interventions targeting residential wood stoves to assess the impact on indoor PM and health outcomes in a susceptible population.
Trial registration
ClincialTrials.gov NCT00807183.
doi:10.1016/j.cct.2012.06.006
PMCID: PMC3408844  PMID: 22735495
pediatric; asthma; home intervention; wood stove; filter; biomass combustion
13.  The Association between Phthalates in Dust and Allergic Diseases among Bulgarian Children 
Environmental Health Perspectives  2007;116(1):98-103.
Background
Recent studies have identified associations between the concentration of phthalates in indoor dust and allergic symptoms in the airways, nose, and skin.
Objectives
Our goal was to investigate the associations between allergic symptoms in children and the concentration of phthalate esters in settled dust collected from children’s homes in Sofia and Burgas, Bulgaria.
Methods
Dust samples from the child’s bedroom were collected. A total of 102 children (2–7 years of age) had symptoms of wheezing, rhinitis, and/or eczema in preceding 12 months (cases), and 82 were nonsymptomatic (controls). The dust samples were analyzed for their content of dimethyl phthalate (DMP), diethyl phthalate (DEP), di-n-butyl phthalate (DnBP), butyl benzyl phthalate (BBzP), di(2-ethylhexyl) phthalate (DEHP), and di-n-octyl phthalate (DnOP).
Results
A higher concentration of DEHP was found in homes of case children than in those of controls (1.24 vs. 0.86 mg/g dust). The concentration of DEHP was significantly associated with wheezing in the preceding 12 months (p = 0.035) as reported by parents. We found a dose–response relationship between DEHP concentration and case status and between DEHP concentration and wheezing in the preceding 12 months.
Conclusions
This study shows an association between concentration of DEHP in indoor dust and wheezing among preschool children in Bulgaria.
doi:10.1289/ehp.10498
PMCID: PMC2199301  PMID: 18197306
allergy; asthma; children; DEHP; phthalates
14.  Coarse and Fine Culturable Fungal Air Concentrations in Urban and Rural Homes in Egypt 
The main objective of the present study was to assess culturable airborne fungal concentrations, and types in different seasons. Two-stage viable impactor samplers were used with malt extract agar medium as the collection media. Culturable airborne fungal concentrations were collected indoors and outdoors of 43 homes in urban and rural environments from November 2008 to October 2009 in Egypt. Fungal concentrations were significantly higher in the rural environment than the urban environment. The median indoor and outdoor total fungal concentrations were 608 and 675 CFU/m3 in the urban environment and 1,932 and 1,872 CFU/m3 in the rural environment, respectively. The greatest concentrations were found in the autumn and spring season. Indoor and outdoor concentrations were significantly correlated (P < 0.001). The highest concentrations were observed in the fungal size range of <8 µm (fine fraction). The indoor/outdoor (I/O) ratios were not statistically different between seasons. Alternaria, Aspergillus, Cladosporium, Penicillium and yeasts were the predominant genera indoors and outdoors, and the abundance of genera varied by season and region. This study is of a potential interest as little reported research on the indoor fungal air quality from Egypt.
doi:10.3390/ijerph10030936
PMCID: PMC3709295  PMID: 23466829
air; fungi; homes; rural; urban
15.  Culturability and concentration of indoor and outdoor airborne fungi in six single-family homes 
In this study, the culturability of indoor and outdoor airborne fungi was determined through long-term sampling (24-h) using a Button Personal Inhalable Aerosol Sampler. The air samples were collected during three seasons in six Cincinnati area homes that were free from moisture damage or visible mold. Cultivation and total microscopic enumeration methods were employed for the sample analysis. The geometric means of indoor and outdoor culturable fungal concentrations were 88 and 102 colony-forming units (CFU) m-3, respectively, with a geometric mean of the I/O ratio equal to 0.66. Overall, 26 genera of culturable fungi were recovered from the indoor and outdoor samples. For total fungal spores, the indoor and outdoor geometric means were 211 and 605 spores m-3, respectively, with a geometric mean of I/O ratio equal to 0.32. The identification revealed 37 fungal genera from indoor and outdoor samples based on the total spore analysis. Indoor and outdoor concentrations of culturable and total fungal spores showed significant correlations (r = 0.655, p<0.0001 and r = 0.633, p<0.0001, respectively). The indoor and outdoor median viabilities of fungi were 55% and 25%, respectively, which indicates that indoor environment provides more favorable survival conditions for the aerosolized fungi. Among the seasons, the highest indoor and outdoor culturability of fungi was observed in the fall. Cladosporium had a highest median value of culturability (38% and 33% for indoor and outdoor, respectively) followed by Aspergillus/Penicillium (9% and 2%) among predominant genera of fungi. Increased culturability of fungi inside the homes may have important implications because of the potential increase in the release of allergens from viable spores and pathogenicity of viable fungi on immunocompromised individuals.
doi:10.1016/j.atmosenv.2006.01.011
PMCID: PMC2367149  PMID: 18458748
Indoor air; Outdoor air; Total fungal spore; Culturable fungi; Culturability
16.  In-Home Particle Concentrations and Childhood Asthma Morbidity 
Environmental Health Perspectives  2008;117(2):294-298.
Background
Although outdoor particulate matter (PM) has been linked to mortality and asthma morbidity, the impact of indoor PM on asthma has not been well established.
Objective
This study was designed to investigate the effect of in-home PM on asthma morbidity.
Methods
For a cohort of 150 asthmatic children (2–6 years of age) from Baltimore, Maryland, a technician deployed environmental monitoring equipment in the children’s bedrooms for 3-day intervals at baseline and at 3 and 6 months. Caregivers completed questionnaires and daily diaries during air sampling. Longitudinal data analyses included regression models with generalized estimating equations.
Results
Children were primarily African Americans (91%) from lower socioeconomic backgrounds and spent most of their time in the home. Mean (± SD) indoor PM2.5–10 (PM with aerodynamic diameter 2.5–10 μm) and PM2.5 (aerodynamic diameter < 2.5 μm) concentrations were 17.4 ± 21.0 and 40.3 ± 35.4 μg/m3. In adjusted models, 10-μg/m3 increases in indoor PM2.5–10 and PM2.5 were associated with increased incidences of asthma symptoms: 6% [95% confidence interval (CI), 1 to 12%] and 3% (95% CI, –1 to 7%), respectively; symptoms causing children to slow down: 8% (95% CI, 2 to 14%) and 4% (95% CI, 0 to 9%), respectively; nocturnal symptoms: 8% (95% CI, 1 to 14%) and 6% (95% CI, 1 to 10%), respectively; wheezing that limited speech: 11% (95% CI, 3 to 19%) and 7% (95% CI, 0 to 14%), respectively; and use of rescue medication: 6% (95% CI, 1 to 10%) and 4% (95% CI, 1 to 8%), respectively. Increases of 10 μg/m3 in indoor and ambient PM2.5 were associated with 7% (95% CI, 2 to 11%) and 26% (95% CI, 1 to 52%) increases in exercise-related symptoms, respectively.
Conclusions
Among preschool asthmatic children in Baltimore, increases in in-home PM2.5–10 and PM2.5 were associated with respiratory symptoms and rescue medication use. Increases in in-home and ambient PM2.5 were associated with exercise-related symptoms. Although reducing PM outdoors may decrease asthma morbidity, reducing PM indoors, especially in homes of inner-city children, may lead to improved asthma health.
doi:10.1289/ehp.11770
PMCID: PMC2649234  PMID: 19270802
air pollution; asthma; indoor; particulate matter; pediatric; urban
17.  The Innate Immune Response in House Dust Mite-Induced Allergic Inflammation 
Hypersensitivity to house dust mite (HDM; Dermatophagoides sp.) allergens is one of the most common allergic responses, affecting up to 85% of asthmatics. Sensitization to indoor allergens is the strongest independent risk factor associated with asthma. Additionally, >50% of children and adolescents with asthma are sensitized to HDM. Although allergen-specific CD4+ Th2 cells orchestrate the HDM allergic response through induction of IgE directed toward mite allergens, activation of innate immunity also plays a critical role in HDM-induced allergic inflammation. This review highlights the HDM components that lead to activation of the innate immune response. Activation may due to HDM proteases. Proteases may be recognized by protease-activation receptors (PARs), Toll-like receptors (TLRs), or C-type lectin receptors (CTRs), or act as a molecular mimic for PAMP activation signaling pathways. Understanding the role of mite allergen-induced innate immunity will facilitate the development of therapeutic strategies that exploit innate immunity receptors and associated signaling pathways for the treatment of allergic asthma.
doi:10.4168/aair.2013.5.2.68
PMCID: PMC3579094  PMID: 23450108
House dust mites; innate immunity; toll-like receptors; C-type lectin receptors; dendritic cells
18.  Indoor Air Pollution and Asthma in Children 
The purpose of this article is to review indoor air pollution factors that can modify asthma severity, particularly in inner-city environments. While there is a large literature linking ambient air pollution and asthma morbidity, less is known about the impact of indoor air pollution on asthma. Concentrating on the indoor environments is particularly important for children, since they can spend as much as 90% of their time indoors. This review focuses on studies conducted by the Johns Hopkins Center for Childhood Asthma in the Urban Environment as well as other relevant epidemiologic studies. Analysis of exposure outcome relationships in the published literature demonstrates the importance of evaluating indoor home environmental air pollution sources as risk factors for asthma morbidity. Important indoor air pollution determinants of asthma morbidity in urban environments include particulate matter (particularly the coarse fraction), nitrogen dioxide, and airborne mouse allergen exposure. Avoidance of harmful environmental exposures is a key component of national and international guideline recommendations for management of asthma. This literature suggests that modifying the indoor environment to reduce particulate matter, NO2, and mouse allergen may be an important asthma management strategy. More research documenting effectiveness of interventions to reduce those exposures and improve asthma outcomes is needed.
doi:10.1513/pats.200908-083RM
PMCID: PMC3266016  PMID: 20427579
particulate matter; air pollution; pediatric; urban; bronchial hyperreactivity
19.  Fungal chitin from asthma-associated home environments induces eosinophilic lung infiltration 
Development of asthma and allergic inflammation involves innate immunity but the environmental contributions remain incompletely defined. Analysis of dust collected from the homes of asthmatic individuals revealed that the polysaccharide chitin is environmentally widespread, and associated with β-glucans, possibly from ubiquitous fungi. Cell wall preparations of Aspergillus isolated from house dust induced robust recruitment of eosinophils into mouse lung, an effect that was attenuated by enzymatic degradation of cell wall chitinand β-glucans. Mice expressing constitutively active acidic mammalian chitinase (AMCase) in the lungs demonstrated a significant reduction in eosinophil infiltration after fungal challenge. Conversely, chitinase inhibition prolonged the duration of tissue eosinophilia. Thus, fungal chitin derived from home environments associated with asthma induces eosinophilic allergic inflammation in the lung, and mammalian chitinases, including AMCase, limit this process.
doi:10.4049/jimmunol.1100972
PMCID: PMC3159725  PMID: 21824866
20.  Reduction in Asthma Morbidity in Children as a Result of Home Remediation Aimed at Moisture Sources 
Environmental Health Perspectives  2006;114(10):1574-1580.
Objective
Home dampness and the presence of mold and allergens have been associated with asthma morbidity. We examined changes in asthma morbidity in children as a result of home remediation aimed at moisture sources.
Design
In this prospective, randomized controlled trial, symptomatic, asthmatic children (n = 62), 2–17 years of age, living in a home with indoor mold, received an asthma intervention including an action plan, education, and individualized problem solving. The remediation group also received household repairs, including reduction of water infiltration, removal of water-damaged building materials, and heating/ventilation/air-conditioning alterations. The control group received only home cleaning information. We measured children’s total and allergen-specific serum immuno-globulin E, peripheral blood eosinophil counts, and urinary cotinine. Environmental dust samples were analyzed for dust mite, cockroach, rodent urinary protein, endotoxin, and fungi. The follow-up period was 1 year.
Results
Children in both groups showed improvement in asthma symptomatic days during the preremediation portion of the study. The remediation group had a significant decrease in symptom days (p = 0.003, as randomized; p = 0.004, intent to treat) after remodeling, whereas these parameters in the control group did not significantly change. In the postremediation period, the remediation group had a lower rate of exacerbations compared with control asthmatics (as treated: 1 of 29 vs. 11 of 33, respectively, p = 0. 003; intent to treat: 28.1% and 10.0%, respectively, p = 0.11).
Conclusion
Construction remediation aimed at the root cause of moisture sources and combined with a medical/behavioral intervention significantly reduces symptom days and health care use for asthmatic children who live in homes with a documented mold problem.
doi:10.1289/ehp.8742
PMCID: PMC1626393  PMID: 17035145
asthma; children; damp housing; home remediation; indoor mold
21.  Clinical experience and results of a Sentinel Health Investigation related to indoor fungal exposure. 
Environmental Health Perspectives  1999;107(Suppl 3):489-494.
This is a review of exposure conditions, clinical presentation, and morbidity of children and adults with indoor fungal exposure such as toxic Stachybotrys chartarum. Indoor exposure was characterized using different methods including microscopic, culture, cytotoxicity screening tests, and chemical analyses. Clinical case histories and physical and laboratory findings are presented of children (age < 18 years, n = 22; mean age 9 years; 60% females) and adults (age >18 years, n = 125; mean age 39 years, 67% females) who consulted an environmental health specialty clinic. In the pediatric patients' exposure history, widespread fungal contamination of water-damaged building materials with known toxic or allergic fungi was identified. Primarily disorders of the respiratory system, skin, mucous membranes, and central nervous system were reported. Some enumeration and functional laboratory abnormalities, mainly of the lymphatic blood cells, were observed, although no statistically significant differences were found. IgE or IgG fungi-specific antibodies, used as exposure markers, were positive in less than 25% of all tested cases. In an evaluation of a symptomatic girl 11 years of age (sentinel case investigation) living in an apartment with verified toxigenic fungi (i.e., S. chartarum), several health indicators showed improvement after exposure cessation.
Images
PMCID: PMC1566219  PMID: 10346997
22.  Nitric Oxide Oxidation Products are Increased in the Epithelial Lining Fluid of Children with Persistent Asthma 
Background
Children with severe allergic asthma have persistent airway inflammation and oxidant stress.
Objectives
We hypothesized that children with severe allergic asthma would have increased concentrations of the NO oxidation products nitrite, nitrate, and nitrotyrosine in the proximal and distal airway epithelial lining fluid (ELF). We further hypothesized that NO oxidation products would be associated with higher exhaled nitric oxide (FENO), greater allergic sensitization, and lower pulmonary function.
Methods
Bronchoalveolar lavage (BAL) was obtained from 15 children with mild-to-moderate asthma, 30 children with severe allergic asthma, 5 non-asthmatic children and 20 non-smoking adults. The BAL was divided into proximal and distal portions and nitrite, nitrate, and nitrotyrosine were quantified.
Results
Children with mild-to-moderate and severe allergic asthma had increased concentrations of nitrite (adult control: 15 ± 3; pediatric control: 23 ± 4; mild-to-moderate asthma: 56 ± 26; severe asthma: 74 ± 18 µM), nitrate (37 ± 13 vs. 145 ± 38 vs. 711 ± 155 vs. 870 ± 168 µM) and nitrotyrosine (2 ± 1 vs. 3 ± 1 vs. 9 ± 3 vs. 10 ± 4 µM) in the proximal ELF. Similar results were seen in the distal ELF although the concentrations were significantly lower (p < 0.05 for each). Although univariate analyses revealed no associations between NO oxidation products and clinical features, multivariate analyses revealed FENO to be a significant predictor of NO oxidation in asthmatic children.
Conclusions
NO oxidation products are increased in the ELF of asthmatic children. The relationship between FENO and airway nitrosative stress is complicated and requires further study.
doi:10.1016/j.jaci.2009.08.039
PMCID: PMC2776730  PMID: 19895987
Asthma; Children; Nitric oxide; Nitrogen oxides; Nitrosation; Nitrosative Stress; Reactive nitrogen species
23.  Use of a robotic sampling platform to assess young children's exposure to indoor bioaerosols 
Indoor Air  2011;22(2):159-169.
Indoor exposures to allergens, mold spores and endotoxin have been suggested as etiological agents of asthma; therefore, accurate determination of those exposures, especially in young children (6–36 months), is important for understanding the development of asthma. Since use of personal sampling equipment in this population is difficult, and in children < 1 year of age impossible, we developed a personal sampling surrogate: the Pretoddler Inhalable Particulate Environmental Robotic sampler (PIPER) to better estimate their exposures. During sampling, PIPER simulates the activity patterns, speed of motion and the height of the breathing zones of young children, and mechanically resuspends the deposited dust just as a young child does during running and crawling. The concentrations of allergens, mold spores and endotoxin measured by PIPER were compared to those measured using traditional stationary air sampling in 75 homes in central New Jersey, US.
Endotoxin was detected in all homes with median concentrations of 1.0 and 0.55 EU/m3 for PIPER and stationary sampler, respectively. The difference in median concentrations obtained using the two methods was statistically significant for homes with carpeted floors (p= 0.0001) in the heating season. For such homes, the average ratio of endotoxin concentration measured by PIPER and the stationary sampler was 2.96 (95% CI 2.29–3.63).
Fungal spores were detected in all homes, with median fungal concentrations of 316 and 380 spores/m3 for PIPER and stationary sampler, respectively. For fungi, the difference between the two sampling methods was not statistically significant. For both sampling methods, the total airborne mold levels were statistically significantly higher in the non-heating season than in the heating season. Allergens were detected in ~15% of investigated homes.
The data indicate that the traditional stationary air sampling methods may substantially underestimate personal exposures to endotoxin, especially due to resuspension of dust from carpeted floor surfaces. A personal sampling surrogate, such as PIPER, is a feasible approach to estimate personal exposures in young children. PIPER should be seriously considered as the sampling platform for future exposure studies in young children.
doi:10.1111/j.1600-0668.2011.00749.x
PMCID: PMC3260414  PMID: 21954880
Children's exposures; Robotic sampling platform; PIPER; Bioaerosol; Resuspension; Floor type
24.  Occurrence of allergic bronchopulmonary mycosis in patients with asthma: An Eastern India experience 
Background:
Allergic bronchopulmonary mycosis (ABPM) is a clinical syndrome associated with immune sensitivity to various fungi notably Aspergillus spp. that colonize the airways of asthmatics. Early diagnosis and treatment with systemic corticosteroids is the key in preventing the progression of the disease to irreversible lung fibrosis.
Aims:
To study the occurrence of ABPM among asthma patients with fungal sensitization attending a chest clinic of a tertiary hospital of eastern India. The clinico-radiological and aetiological profiles are also described.
Materials and Methods:
All consecutive patients with asthma presenting to the chest clinic over a period of one year were screened for cutaneous hypersensitivity to 12 common fungal antigens. The skin test positive cases were further evaluated for ABPM using standard criteria.
Results:
One hundred and twenty-six asthma patients were screened using twelve common fungal antigens; forty patients (31.74%) were found to be skin test positive, and ABPM was diagnosed in ten patients (7.93%). Of the 10 cases of ABPM, nine cases were those of allergic bronchopulmonary aspergillosis (ABPA) and one case was identified as caused by sensitization to Penicillium spp. A majority of the cases of ABPM had advanced disease and had significantly lower FEV1 compared to non-ABPM skin test positive asthmatics. Central bronchiectasis on high resolution CT scan was the most sensitive and specific among the diagnostic parameters.
Conclusion:
There is a significant prevalence of ABPM in asthma patients attending our hospital and this reinforces the need to screen asthma patients for fungal sensitisation. This will help in early diagnosis and prevention of irreversible lung damage.
doi:10.4103/0970-2113.71949
PMCID: PMC2988171  PMID: 21139717
ABPA; asthma; central bronchiectasis; Eosinophilia
25.  Dust mite, cockroach, cat, and dog allergen concentrations in homes of asthmatic children in the northeastern United States: impact of socioeconomic factors and population density. 
Environmental Health Perspectives  2002;110(4):419-425.
Home exposures to aeroallergens are an important environmental factor in allergic sensitization and in the development and exacerbation of asthma. We assessed variations in home concentrations of dust mite, cockroach, cat, and dog allergens in dust collected in the main living areas of asthmatics' homes by family income, mother's education, dwelling type, population density, household population density, and ethnicity in Connecticut and south-central Massachusetts. Dust samples were collected at the time of home interview in 999 homes as part of an ongoing longitudinal birth cohort study of 1,002 infants and their asthmatic siblings. The analysis employed lower and upper cut points for group 1 dust mite (> or = 2.0 microg/g and > or = 10 microg/g), cockroach (> or = 1.0 U/g and > or = 4.0 U/g), cat (> or = 1.0 microg/g and > or = 8.0 ug/g), and dog (> or = 2.0 microg/g and > or = 10.0 microg/g) allergens. Subject residences were geocoded to assess population density from the U.S. Census, and multiple logistic regression was used to control for confounding. The portion of homes at the lower cut point for dust mite, cockroach, cat, and dog allergens were 46.9%, 24.9%, 42.2%, and 35.6%, respectively; the upper cut point for each of the allergens was reached in 22.4%, 13.4%, 21.0%, and 22.9% of the homes, respectively. In all, 86.0% of the homes had at least one allergen at the lower cut point, and 58.0% had at least one allergen at the upper cut point. Forty-nine percent of the homes had two or more allergens at the lower cut point, and 19.7% had two or more allergens at the upper cut point. Higher education of the mother, higher household income, living in a single-family home in a less densely populated area with fewer people per room, and being a white household were associated with elevated dust mite, cat, and dog allergens and low cockroach allergen. In contrast, low income, living in a multifamily home in a high population density area with a higher occupancy rate per room, and being a Hispanic or black household were associated with elevated cockroach allergens and low concentrations of dust mite, cat, and dog allergens. Although the presence of an individual allergen is more likely associated with one or more socioeconomic or ethnic factors, most homes typically have multiple allergen burdens in excess of concentrations thought to be associated with sensitization and exacerbation of asthma. Mite and cockroach allergens have distinct and opposite associations with socioeconomic factors and population density.
PMCID: PMC1240806  PMID: 11940461

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