Exposure Assessments and Risk of

Disease in Multiple Settings

Wanda Phipatanakul, M.D., M.S. Associate Professor of Pediatrics Boston Children’s Hospital Harvard Medical School Pediatric Allergy and Immunology AAAAI, Symposia 2305 March 1, 2014 wanda.phipatanakul@childrens.harvard.edu HARVARD

MEDICAL SCHOOL

Disclosure

• NIH funding • I have no other relevant financial or other

conflicts of interest to disclose

Objectives

• Review Exposure Assessment Strategies in Multiple Settings

• Describe the most common indoor air quality issues that cause negative health effects

• Review unique exposure and health effects in unique settings and call for future research

The Environment and Asthma in US Inner Cities

Eggleston, 2007

Environmental exposure model.

5

Environment in Inner City Asthma

• NCICAS & ICAS – Inner City Environment focused on the Home

»Maybe only half the story • SICAS (School Inner City Asthma Study-NIAID)

– Children spend 6-10 hours/day at school- nearly every child’s required “occupation”

– Important venue to examine potential triggers of asthma, likely different from home

– Ultimately, may lead to a cost effective environmental intervention

Classroom Mold Sampling- Burkard Samplers

Air Pollution Sampling

• Fastened to Air

Samplers to collect pollutants passively

• Particulate Matter black boxes correlated with area samplers NIEHS

School Vs. Home Allergen Levels

0.2

0.05 0.04

0.47

0.08

0.41

0.02

0.56

1.66 ***

1.38

0.02

0.66 **

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8G

eom

etri

c M

eans

(µg/

g)

SchoolHome

Bla g 2(Cockroach)

Fel d 1 (Cat)

Can f 1 (Dog)

Der f 1 (Dust Mite)** p < 0.001

Der p 1 (Dust Mite)

MUP (Mouse)

*** p < 0.001

0.2

0.05 0.04

0.47

0.08

0.41

0.02

0.56

1.66 ***

1.38

0.02

0.66 **

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8G

eom

etri

c M

eans

(µg/

g)

SchoolHome

Bla g 2(Cockroach)

Fel d 1 (Cat)

Can f 1 (Dog)

Der f 1 (Dust Mite)** p < 0.001

Der p 1 (Dust Mite)

MUP (Mouse)

*** p < 0.001

Bla g 2(Cockroach)

Fel d 1 (Cat)

Can f 1 (Dog)

Der f 1 (Dust Mite)** p < 0.001

Der p 1 (Dust Mite)

MUP (Mouse)

*** p < 0.001Sheehan WJ, Phipatanakul W Ann Allergy Asthma Immunol. 2009;102:125-30 Permaul P, Phipatanakul W Peds Allergy Immunol. 2012 ;23(6):543-9

Classroom vs. Bedroom Endotoxin Levels for Children with Asthma

0

5,000

10,000

15,000

20,000

CLASSROOM (n=104) BEDROOM (n=104)

Endo

toxi

n Le

vel (

EU/g

)

Median

•Sheehan WJ, Phipatanakul Ann Allergy 2012;108(6):418-222.

Mold Grouping

Geomean ±

Geostd (spores/m3)

Detectable Min Max

Total Mold 175.6 ± 4.2 100% 11 16,288.5 Unidentifiable spores 31.2 ± 2.8 98% 0 448.8 Cladosporium 29.3 ± 4.2 97% 0 1,525.7 Smut spores (Ustilaginomycetes) 12.6 ± 4.0 89% 0 639.4 Penicillium/Aspergillus 15.0 ± 5.4 88% 0 8,586.0 Other Basidiospores* 6.6 ± 7.1 67% 0 2,445.5

Basidispores small hyaline* 4.9 ± 9.6 54% 0 11,173.1

Distribution of molds in classrooms

•Baxi SN, Phipatanakul W, Pediatric Allergy & Immunol 2013 24: 697-703

Photograph of Boston Skyline taken at 10 a.m. on in January

PM2.5 concentration at this time in the 55-65 µg/m3 range Photograph from CAMNET web site (http://hazecam.net)

SKC UMEx 100 Passive Formaldehyde Sampler

Chemiluminescent analyzer Exhaled NO (NIOX TM System, Aerocrine, Sweden)

Polytetrafluoroethylene (Teflon) filter and Single-stage Personal Modular Impactor

Portable sampling pump (SKI, Inc., Eighty Four, PA)

Passive nicotine badges

Passive VOC badges

Real-time sampling/measurement devices

Passive air sampling e.g., VOCs, aldehydes

Passive air sampling

From Hammond and Leaderer (1987)

e.g., nicotine

Grab sampling for VOCs

Integrated Sampling

Integrated air sampling

Other monitors

PID

Other devices – data loggers Common uses: temperature, RH, CO2

TEMP and RH logger CO2 monitor

Conclusions- Future Directions • Home, school settings pose a unique set of

environmental and sociologic factors leading to increased asthma morbidity

• Allergens, mold, and indoor air pollution influence asthma morbidity, and different exposures may be more prevalent in different environments

• The classroom and school based exposures, independent of home exposure, may play an important role in asthma morbidity, suggesting further work in day, occupational, work environments may be important and interventions targeted towards these exposures may be important

• Monitoring/exposure assessment technology evolving and effective personalized monitoring encountering comprehensive exposure assessment and guide targeted interventions may be on the horizon

Acknowledgements • Diane Gold, MD, MPH • Petros Koustrakis, PhD • Mike Wolfson, PhD • Wan-Chan Lee, PhD© • Steve Melly • Steve Ferguson • Carter Petty, MS • Brent Coull, PhD • Andrea Baccarelli, MD, PhD • Peggy Lai, MD,MPH • Trainees at BCH • William Sheehan, MD • Jonathan Gaffin, MD, MMsc • David Kantor, MD, PhD • Sachin Baxi, MD • Perdita Permaul, MD • Michael Muilenberg, MS • Champ Kanchongkittiphon,MD • Lisa Bartnikas, MD

• Don Rivard, BCE • NIH/ NIAID • Aeorcrine/ATS/Glaxo Fellow Awards • ACAAI/Von Clements/AAP • SICAS- Ann Bailey/ACRC Staff • Lincoln Diagnostics/Greer • CTSU-NIH/Harvard Catalyst • Community/Schools/Principals/Teach

ers/School Nurses/Adminstraters • Jeff Lane, MIH /Linda Grant, MD • Study Participants • Collaborations- Community/ER/Pulm • R01 AI073964 (Phipatanakul) • ARRA AI073964 Suppl (Phipatanakul) • K23ES023700 (Lai) • K23AI106945 (Gaffin) • K24 AI 106822 (Phipatanakul) • K12 HD047349Critical Care Scholars

(Kantor) • Research Scholarship from

Ramathibodi Hospital (Kanchokittiphon)

SICAS References • Phipatanakul W, Bailey A, Hoffman EB, Sheehan WJ, Lane JP, Baxi S, Rao D,

Permaul P, Gaffin JM, Rogers CA, Muilenberg M, and Gold DR. The School Inner-City Asthma Study (SICAS): Design, Methods, and Lessons Learned 2011 J Asthma 2011; 48:1007-14.

• Baxi SN, Sheehan WJ, Gaffin JM, Yodying J, Panupattanapong S, Lane JP, Fu C, Hoffman EB, Gold DR, Phipatanakul W. Agreement between Parent and Student Responses to an Asthma and Allergy Questionnaire in a Diverse Inner City Elementary School Population.” Annals Allergy, Asthma, and Immunology 2011;107 : 371-3.

• Sheehan WJ, Hoffman EB, Fu C, Baxi S, Bailey A, King EM, Chapman MD, Lane JP, Gaffin JM, Permaul P, Gold DR, Phipatanakul, W. Endotoxin Exposure in Inner-City Schools and Homes of Children with Asthma Annals of Allergy, Asthma, and Immunology 2012;108(6):418-222.

•

SICAS References • Permaul P, Sheehan WJ, Baxi SN, Gaffin JM, Fu C, Petty CR, Gold DR,

Phipatanakul W. Predictors of Indoor Exposure to Mouse Allergen in Inner-City Elementary Schools. Annals Allergy, Asthma, Immunol 2013;111(4):299-301.

• Baxi SN, Muilenberg M, Rogers CA, Sheehan WJ, Gaffin JM, Permaul P, Kopel L, Lai P, Lane JP, Bailey A, Petty C, Fu Chunxia, Gold DR, Phipatanakul W. Exposures to Molds in School Classrooms of Children with Asthma. Peds Allergy and Immunolgy 2013; 24: 697-703

• Kanchongkittiphon W. Sheehan WJ, Friedlander J, Chapman MD, King EM ,

Martirosyan K, Baxi SN, Permaul P, Gaffin JM , Kopel L, Bailey A, Fu C, Petty CR, Gold DR ,and Phipatanakul W Allergen Exposure on Desktop Surfaces in Preschools and Elementary Schools of Urban Children with Asthma. Allergy 2013

SICAS References • Friedlander J, Sheehan WJ, Hoffman EB, Fu C, Gold DR, Phipatanakul

W. Food allergy and increased asthma morbidity in a school inner-city asthma study. J Allergy Clin Immunol : In Practice 2013;1: 479-84.

• Gaffin JM, Raby B, Petty C, Hoffman E, Gold DR, Phipatanakul W. B2 adrenergic receptor gene methylation is associated with decreased asthma severity, Clinical Experimental Allergy 2014 (In Press)

• Kopel LS, Gaffin JM, Rao DR, Sheehan WJ, Friedlander JL, Hoffman EB, Fu C, Subramanian SV, Gold DR, and Phipatanakul W. Perceived Neighborhood Safety and Asthma Morbidity in a School-Based Inner-City Asthma Study . Pediatric Pulmonology 2014(In Press).

References Parameters • Phipatanakul W, Matsui E, Portnoy J, Williams PB, Barnes C, Kennedy K, Bernstein D, Blessing-

Moore J, Cox L, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D, Sublett J, Bernstein J, Grimes C, Miller JD, Seltzer J. Environmental assessmentt/practice parameters: Rodents Ann Allergy Asthma Immunol. 2012 Dec;109(6):375-87

• Portnoy J, Chew GL, Phipatanakul W, Williams PB, Grimes C, Kennedy K, Matsui EC, Miller JD, Bernstein D, Blessing-Moore J, Cox L, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D, Seltzer J, Sublett J. Environmental assessment cockroaches , Practice Parameters J Allergy Clin Immunol. 2013; Oct;132(4):802-808

• Portnoy J, Miller JD, Williams PB, Chew GL, Miller JD, Zaitoun F, Phipatanakul W, Kennedy K, Barnes C, Grimes C, Larenas-Linnemann D, Sublett J, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D.“Environmental Assessment and Exposure Control: Dust Mites: A practice parameter.” Annals Allergy, Asthma, Immunology 2013; 111(6):465-507.

• Portnoy J, Miller JD, Williams PB, Chew GL, Miller JD, Zaitoun F, Phipatanakul W, Kennedy K, Barnes C, Grimes C, Larenas-Linnemann D, Sublett J, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D.“Environmental Assessment and Exposure Control: Dust Mites: A practice parameter.” Annals Allergy, Asthma, Immunology 2013; 111(6):465-507.

References: Rostrums • Sublett JL, Seltzer J Brukhead R, William PB, Wedner HJ, Phipatanakul W; American Academy

of Allergy, Asthma & Immunology Indoor Allergen Committee. “Air filters and air cleaners: Rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee.” Journal of Allergy and Clinical Immunology 2010; 125(1):32-38 American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee. “Air filters and air cleaners: Rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee.” Journal of Allergy and Clinical Immunology 2010; 125(1):

• Sheehan WJ, Rangsithienchai PA, Wood RA, Rivard D, Chinratanapisit S, Persanowski MS, Chew GL, Seltzer JM, Matsui EC and Phipatanakul W. “Pest and Allergen Exposure and Abatement in Inner-City Asthma: A Work Group Report of the American Academy of Allergy, Asthma & Immunology Indoor Allergy/Air Pollution Committee.” Journal of Allergy and Clinical Immunology 2010;125(3):575-81. PMCID: PMC2862381

• Eggleston, P. A. (2007). "The environment and asthma in US inner cities." Chest 132(5 Suppl): 782S-788S.

References Delfino RJ, Staimer N, Tjoa T. Personal endotoxin exposure in a panel study of school children with asthma. Environ Health. 2011;10:69. Pa¨ ivi M. Salo, PhD, Michelle L. Sever, MSPH, and Darryl C. Zeldin, Indoor allergens in school and day care environments. J Allergy Clin Immunol 2009;124:185-92