Kevin Kennedy

Environmental assessment and exposure control of dust mites: a practice parameter

Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD *; J. David Miller, PhD; Fares Zaitoun, MD; Wanda Phipatanakul, MD, MS; Kevin Kennedy, MPH; Charles Barnes, PhD; Carl Grimes, CIEC; Desiree Larenas-Linnemann, MD; James Sublett, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD* Members of the Joint Taskforce on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD

Environmental assessment and exposure control: a practice parameter—furry animals

Members of the Joint Task Force onPractice Parameters:David Bernstein,MD, Joann Blessing-Moore,MD, Linda Cox,MD, David Khan,MD, David Lang,MD, RichardNicklas, MD, John Oppenheimer, MD, Jay Portnoy, MD, Christopher Randolph, MD, Diane Schuller, MD, Sheldon Spector, MD, Stephen A. Tilles, MD, Dana Wallace, MD Practice ParameterWork Group: James Sublett, MD, cochair, Kevin Kennedy, MPH, cochair, Charles Barnes, PhD, David Bernstein, MD, Jonathan Bernstein, MD, Carl Grimes, Elizabeth Matsui, MD, Jeffrey D. Miller, MD, J. David Miller, PhD, Wanda Phipatanakul, MD, MS, James Seltzer, MD, P. Brock Williams, PhD Invited Reviewers: Jack Armstrong, Hans Gr×nlund, PhD, Kraig W. Jacobson, MD, Jill A. Poole, MD, Matthew A Rank, MD, Megan Taylor, MD This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthmaand Immunology, and the Joint Council of Allergy, Asthmaand Immunology. The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “Environmental Assessment and Remediation: A Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changingenvironment, andnotall recommendationswillbeappropriate forallpatients.Because thisdocument incorporatedtheeffortsofmanyparticipants,nosingle individual, including thosewhoservedontheJointTaskForce, isauthorizedtoprovideanofficialAAAAIorACAAIinterpretationofthesepracticeparameters.Anyrequestforinformationaboutoraninterpretation of these practice parameters by the AAAAI or ACAAI should be directed to the executive offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use bypharmaceutical companies in drugpromotion. Reprints: Joint Council of Allergy, Asthmaand Immunology, 50NBrockway St, #3-3 Palatine, IL 60067. Disclosures: The following is a summaryof interests disclosedonWorkGroupmembers’ Conflict of InterestDisclosure Statements (not including information concerning familymember interests). Completed Conflict of Interest Disclosure Statements are available on request. Dr. Sublett is the owner of AllergyZone. Dr. Portnoy is a speaker and consultant for ThermoFisher (Phadia). Dr. Barnes is a consultant for and has received research funding from Clorox Corporation. Mr. Grimes is the owner of Healthy Habitats LLC. Dr. Matsui is speaker for Indoor BioTechnologies.Dr.Miller is theownerofMission:Allergy Inc.Dr. Seltzer is thePresident of JamesM. Seltzer, Assoc. TheotherWorkGroupmembershaveno conflicts todisclose. The Joint Task Force recognizes that experts in a field are likely to have interests that could come into conflictwith development of a completely unbiased and objective practice parameter. To take advantage of that expertise, a process has beendeveloped to prevent potential conflicts from influencing thefinal document in a negativeway. At theworkgroup level,memberswhohaveapotential conflictof interest eitherdonotparticipate indiscussions concerning topics related to thepotential conflictor, if theywrite a section onthattopic, theworkgroupcompletelyrewritesitwithouttheir involvementtoremovepotentialbias. Inaddition,theentiredocumentisreviewedbytheJointTaskForce,andanyapparent bias is removedat that level. Finally, thepracticeparameter is sent for reviewbothby invited reviewersandbyanyonewithan interest in the topicbyposting thedocumenton thewebsites of theACAAI and theAAAAI. In particular, the 2 owners of companies that produce products discussed in this practice parameter are Jeffrey D. Miller, MD, and James Sublett, MD. DrMiller wrote an initial section on mattress encasings. This section was then completely rewritten by other members of the work groupwithout his participation. Dr Sublett wrote a preliminary draft of the section on air filtration. That sectionwas also subsequently rewritten by othermembers of thework groupwithout his participation. Neither participant provided subsequent input into those sections. The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions ismade subsequently. Work Group Cochairs: James Sublett,MD, FamilyAllergy andAsthma, Louisville, Kentucky; KevinKennedy,MPH, Center for EnvironmentalHealth, Children’sMercyHospitals C JointTaskForceLiaison:JayM.Portnoy,MD,SectionofAllergy,Asthma& Immunology, TheChildren’sMercyHospitalsC JointTaskForceMembers:David I. Bernstein,MD,DepartmentofClinical,MedicineandEnvironmentalHealth,Division ofAllergy/Immunology,UniversityofCincinnati,CollegeofMedicine,Cincinnati,Ohio; JoannBlessing-Moore,MD,Departmentof Immunology,StanfordUniversityMedicalCenter,PaloAlto, California; Linda Cox, MD, Department of Medicine, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida; David A. Khan, MD, Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, Texas; David M. Lang, MD, Allergy/Immunology Section, Division of Medicine, Allergy and Immunology Fellowship Training Program, Cleveland Clinic Foundation, Cleveland, Ohio; Richard A. Nicklas, MD, Department of Medicine, George Washington Medical Center, Washington, DC; John Oppenheimer, MD, Departmentof InternalMedicine,NewJerseyMedicalSchool,PulmonaryandAllergyAssociates,Morristown,NewJersey; JayM.Portnoy,MD,SectionofAllergy,AsthmaI Christopher C. Randolph, Department of Pediatrics,YaleAffiliatedHospitals,Center forAllergy,Asthma,IDianeE.Schuller,MD,DepartmentofPediatrics,PennsylvaniaStateUniversityMilton S.HersheyMedical College,Hershey, Pennsylvania; SheldonL. Spector,MD,DepartmentofMedicine,UCLASchool ofMedicine, LosAngeles, California; StephenA. Tilles,MD,Departmentof Medicine,UniversityofWashington,SchoolofMedicine,Redmond,Washington;DanaWallaceMD,DepartmentofMedicine,NovaSoutheasternUniversityCollegeofOsteopathicMedicine, Davie, Florida;ParameterWorkGroupMembers:CharlesBarnes,PhD,AllergyResearch,TheChildren’sMercyHospitalsCDavid I.Bernstein,MD,Department of Clinical Medicine, Division of Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Jonathan A. Bernstein, MD, Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio; Carl Grimes, CIEC, Healthy Habitats LLC, Denver, Colorado; Elizabeth Matsui, MD, MHS, Department of Pediatrics, Johns Hopkins School ofMedicine, Baltimore,Maryland; Jeffrey D.Miller, MD, Department of Pediatrics, NewYorkMedical College, Valhalla, NewYork; J. David Miller,PhD,DepartmentofBiochemistry,CarltonUniversity,Ottawa,Ontario,Canada;WandaPhipatanakul,MD,MS,DepartmentofPediatrics,DivisionofAllergyandImmunology,Harvard Medical School, Children’s Hospital Boston, Boston, Massachusetts; JamesM. Seltzer, MD, RelianceMedical Group, Department of Allergy and Immunology,Worcester, Massachusetts; P. BrockWilliams,PhD,DepartmentofAllergy/Immunology,UniversityofMissouri–KansasCitySchoolofMedicineandTheChildren’sMercyHospitalsC Invited Reviewers: Jack Armstrong, MD, Medical Arts Allergy, P.C., Carlisle, Pennsylvania; Hans Gr×nlund, PhD, Department of Immunology, Clinical Immunology and Allergy Unit Karolinska Institute,Stockholm,Sweden;KraigW.Jacobson,MD,CPI,OregonAllergyAssociates,AllergyandAsthmaResearchGroup,Eugene,Oregon;JillA.Poole,MD,DepartmentofMedicine,Division ofAllergy, Asthma& Immunology,University ofNebraskaMedical Center,Omaha,Nebraska;MatthewARank,MD,DivisionofAllergicDiseases,MayoClinic, Rochester,Minnesota;Megan Taylor,MD, Allergy&AsthmaCare, Jenkintown, Pennsylvania.

Practice parameterEnvironmental assessment and exposure control of dust mites: a practice parameter

Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD *; J. David Miller, PhD; Fares Zaitoun, MD; Wanda Phipatanakul, MD, MS; Kevin Kennedy, MPH; Charles Barnes, PhD; Carl Grimes, CIEC; Desiree Larenas-Linnemann, MD; James Sublett, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD* Members of the Joint Taskforce on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD

Exposure and Health Effects of Fungi on Humans

Fungi are ubiquitous microorganisms that are present in outdoor and indoor environments. Previous research has found relationships between environmental fungal exposures and human health effects. We reviewed recent articles focused on fungal exposure and dampness as risk factors for respiratory disease development, symptoms, and hypersensitivity. In particular, we reviewed the evidence suggesting that early exposure to dampness or fungi is associated with the development of asthma and increased asthma morbidity. Although outdoor exposure to high concentrations of spores can cause health effects such as asthma attacks in association with thunderstorms, most people appear to be relatively unaffected unless they are sensitized to specific genera. Indoor exposure and dampness, however, appears to be associated with an increased risk of developing asthma in young children and asthma morbidity in individuals who have asthma. These are important issues because they provide a rationale for interventions that might be considered for homes and buildings in which there is increased fungal exposure. In addition to rhinitis and asthma, fungus exposure is associated with a number of other illnesses including allergic bronchopulmonary mycoses, allergic fungal sinusitis, and hypersensitivity pneumonitis. Additional research is necessary to establish causality and evaluate interventions for fungal- and dampness-related health effects.

Higher Environmental Relative Moldiness Index (ERMI) Values Measured in Homes of Asthmatic Children in Boston, Kansas City, and San Diego

Objective. Mold in water-damaged homes has been linked to asthma. Our objective was to test a new metric to quantify mold exposures in asthmatic children’s homes in three widely dispersed cities in the United States. Methods. The Environmental Relative Moldiness Index (ERMI) metric was created by the US Environmental Protection Agency, with assistance by the Department of Housing and Urban Development (HUD), to quantify mold contamination in US homes. The ERMI values in homes of asthmatic children were determined for the three widely dispersed cities of Boston, Kansas City, and San Diego. Results. Asthmatic children in Boston (n = 76), Kansas City (n = 60), and San Diego (n = 93) were found to be living in homes with significantly higher ERMI values than were found in homes randomly selected during the 2006 HUD American Healthy Homes Survey (AHHS) from the same geographic areas (n = 34, 22, and 28, respectively). Taken together, the average ERMI value in the homes with an asthmatic child was 8.73 compared to 3.87 for the AHHS homes. In addition, Kansas City homes of children with “Mild, Moderate, or Severe Persistent Asthma” had average ERMI value of 12.4 compared to 7.9 for homes of children with only “Mild Intermittent Asthma.” Aspergillus niger was the only mold of the 36 tested which was measured in significantly greater concentration in the homes of asthmatic children in all three cities. Conclusion. High ERMI values were associated with homes of asthmatic children in three widely dispersed cities in the United States.

The impact of home cleaning on quality of life for homes with asthmatic children

Treatment with common household bleach containing hypochlorite destroys dust mites and denatures protein allergens. The purpose of this study was to determine if home use of hypochlorite products results in lowered exposure to bacteria, fungi, and protein allergens and improved quality of life (QOL) for asthmatic persons in the home. Asthmatic and nonasthmatic households containing at least three persons (between 2 and 17 years of age) were recruited. Households were supplied one of three sets of cleaning products (regular products, some containing hypochlorite; regular products plus three additional products with dilute hypochlorite; control, no products). Participants were supplied with cleaning instructions and asthma education. The control group was instructed to clean as usual. Participants completed general health and QOL questionnaires. Asthmatic participants completed an additional asthma QOL questionnaire. Families participated in the study for 8 weeks and completed the full set of questions every 2 weeks. Homes were visited at the beginning of the study and twice thereafter at monthly intervals. Samples evaluated were surface bacteria, viable and nonviable airborne spores, and dust antigen content. Reductions in surface bacteria, airborne fungal spores, and dust antigen levels were achieved. Significant improvement in general health parameters was seen for the asthmatic product groups over the control group. Significant improvement in general QOL and asthma-specific QOL was seen in the asthmatic group. Emphasis on cleaning and cleaning education combined with hypochlorite-based cleaning supplies resulted in significantly improved QOL for families with asthmatic children.

Low-cost interventions improve indoor air quality and children's health.

Intervention in the home environment to reduce asthma triggers theoretically improves health outcomes for asthmatic children. Practical benefit from application of these interventions has proven difficult. This single-blind study tested the effectiveness of simple low-cost home interventions in improving health scores of children with asthma. Families with at least one asthmatic child were recruited. Initial health examination, health, and home assessments were conducted and targeted interventions were implemented. Interventions included dehumidification, air filtration, furnace servicing, and high-efficiency furnace filters. When present, gross fungal contamination was remediated. Asthma education was provided along with education in healthy home practices. Follow-up assessments were conducted after 6 months. Health surveys were completed at enrollment and follow-up. This study enrolled 219 children with asthma. Home inspections and interventions were conducted in 181 homes and 83 families completed all phases. Reduction in asthma and allergy-related health scores was shown in follow-up health surveys. Health improvements were significant for cough when heating, ventilation, and air conditioning (HVAC) service and dehumidification were used. Breathing problems were significantly improved for dehumidification, HVAC service, and room air cleaners. Total dust allergen load was reduced for the dehumidification group (p < 0.05). Mold spore counts were reduced one order of magnitude in 25% of the homes. Indoor spore counts adjusted for outdoor spore levels were reduced overall (p < 0.01). Simple low-cost interventions directed to producing cleaner indoor air coupled with healthy home education improve the indoor air quality and health in asthmatic children.

Innate and Adaptive Immune Response to Fungal Products and Allergens

Exposure to fungi and their products is practically ubiquitous, yet most of this is of little consequence to most healthy individuals. This is because there are a number of elaborate mechanisms to deal with these exposures. Most of these mechanisms are designed to recognize and neutralize such exposures. However, in understanding these mechanisms it has become clear that many of them overlap with our ability to respond to disruptions in tissue function caused by trauma or deterioration. These responses involve the innate and adaptive immune systems usually through the activation of nuclear factor kappa B and the production of cytokines that are considered inflammatory accompanied by other factors that can moderate these reactivities. Depending on different genetic backgrounds and the extent of activation of these mechanisms, various pathologies with resulting symptoms can ensue. Complicating this is the fact that these mechanisms can bias toward type 2 innate and adaptive immune responses. Thus, to understand what we refer to as allergens from fungal sources, we must first understand how they influence these innate mechanisms. In doing so it has become clear that many of the proteins that are described as fungal allergens are essentially homologues of our own proteins that signal or cause tissue disruptions.

Association of tobacco smoke exposure and atopic sensitization

BACKGROUND Forty million children are regularly exposed to environmental tobacco smoke (ETS) each year, increasing their risk for premature death and middle ear and acute respiratory infections. Early life exposure to ETS also is clearly associated with wheezing. However, there is no clear understanding of the influence of ETS on the development of allergic sensitization. OBJECTIVE To determine the association of combined exposure to ETS and indoor allergens on IgE sensitization to aeroallergens in children. METHODS This case-control study enrolled 116 cases and 121 controls from low-income families from Kansas City, Missouri. The adjusted odds ratio was calculated using a logistic model to assess the association between ETS and allergic sensitization using dust allergen levels as a covariate. RESULTS Thirty-six percent of atopic children and 39% of controls were exposed to ETS (P < .05). Unadjusted analyses showed no significant influence of ETS on IgE sensitization to indoor allergens. Logistic regression analyses also showed no significant influence of ETS on sensitization when adjusted for levels of allergens in the home dust and family history of allergic rhinitis. CONCLUSION These data suggest that ETS exposure was not associated with IgE sensitization to indoor allergens, even when home allergen levels were taken into consideration. Further understanding of how components of tobacco smoke influence the immune response is necessary to interpret the disparate findings across studies.

Procedures to Assist Health Care Providers to Determine When Home Assessments for Potential Mold Exposure Are Warranted.

Drawing evidence from epidemiology and exposure assessment studies and recommendations from expert practice, we describe a process to guide health care providers helping their patients who present with symptoms that might be associated with living in damp housing. We present the procedures in the form of a guided 2-part interview. The first part has 5 questions that triage the patient toward a more detailed questionnaire that reflects features of housing conditions known to be reliably associated with exposures to mold and dampness contaminants. We chose the questions based on the conditions associated with moisture problems in homes across the United States and Canada. The goal is to facilitate the clinicians effort to help patients reduce exposure to environmental triggers that elicit symptoms to better manage their disease.