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The implementation of policies to reduce environmental allergic triggers can be an important adjunct to optimal patient care for allergic rhinitis and allergic asthma. Policies at the local level in schools and other public as well as private buildings can make an impact on disease morbidity. Occupational exposures for allergens have not yet been met with the same rigorous policy standards applied for exposures to toxicants by Occupational Safety and Health Administration. Further benefit may be obtained through policies by local, county, state, and national governments, and possibly through international cooperative agreements. The reduction of allergenic exposures can and should be affected by policies with strong scientific, evidence-based derivation. However, a judicious application of the precautionary principle may be needed in circumstances where the health effect of inaction could lead to more serious threats to vulnerable populations with allergic disease. This commentary covers the scientific basis, current implementation, knowledge gaps, and pro/con views on policy issues in reducing environmental allergic triggers.

I Paciencia, J Cavaleiro Rufo, D Silva. Allergy . 2019;74(7):1277–1291 The goal of this study was to examine the role of specific indoor air contaminants identified as endocrine-disrupting chemicals (EDCs) in the prevalence of asthma and other respiratory symptoms and obesity. A cross-sectional analysis was used with 815 participants from 20 schools in Porto, Portugal, corresponding to a total of 71 classroom assessments. Respiratory symptoms were assessed, lung function and airway reversibility …

Indoor environmental exposures, particularly allergens and pollutants, are major contributors to asthma morbidity in children; environmental control practices aimed at reducing these exposures are an integral component of asthma management. Some individually tailored environmental control practices that have been shown to reduce asthma symptoms and exacerbations are similar in efficacy and cost to controller medications. As a part of developing tailored strategies regarding environmental control measures, an environmental history can be obtained to evaluate the key indoor environmental exposures that are known to trigger asthma symptoms and exacerbations, including both indoor pollutants and allergens. An environmental history includes questions regarding the presence of pets or pests or evidence of pests in the home, as well as knowledge regarding whether the climatic characteristics in the community favor dust mites. In addition, the history focuses on sources of indoor air pollution, including the presence of smokers who live in the home or care for children and the use of gas stoves and appliances in the home. Serum allergen-specific immunoglobulin E antibody tests can be performed or the patient can be referred for allergy skin testing to identify indoor allergens that are most likely to be clinically relevant. Environmental control strategies are tailored to each potentially relevant indoor exposure and are based on knowledge of the sources and underlying characteristics of the exposure. Strategies include source removal, source control, and mitigation strategies, such as high-efficiency particulate air purifiers and allergen-proof mattress and pillow encasements, as well as education, which can be delivered by primary care pediatricians, allergists, pediatric pulmonologists, other health care workers, or community health workers trained in asthma environmental control and asthma education.

Introduction: The Centers for Disease Control and Prevention report that the number of individuals with asthma in the United States has increased by 4.3 million, or 12.3%, between 2001 and 2009, creating an increasing burden on our health care system. Effective patient education is a key component of asthma management. The National Asthma Educator Certification Board (NAECB) promotes “optimal asthma management and quality of life by advancing excellence in asthma education through the Certified Asthma Educator process.” Methods: Following completion of the asthma educator certification examination, applicants were invited to participate in a voluntary, anonymous Web-based survey. The survey was developed and approved by the Executive and Research Committees of the NAECB, with the objective of reviewing the experience of applicants seeking initial certification and of those seeking recertification. Results: Completed surveys were obtained from 988 applicants. Seventy-six percent of respondents were first-time test takers; the remaining respondents were repeat test takers. Eighty percent reported having passed the examination. Approximately 85% felt that the time allotted for the examination was “just right”; the level of difficulty was “ just right” for 65% of the respondents, and the clarity of the examination questions was rated as “good” or “excellent” by 72% of the respondents. Seventy-two percent responded that the examination reflected the role of the asthma educator and 88.1% would recommend the examination to others interested in asthma education. Open-ended responses highlighted benefits and barriers. Discussion: The asthma educator certification examination is reflective of the professional responsibilities of the asthma educator. Benefits and barriers are discussed in the context of published literature.

HM Wolsk, BL Chawes, NV Folsgaard. Allergy. 2016;71(6);820–828 To determine whether having siblings affects the airway immune response in healthy neonates, a characteristic that could be attributed to an underlying immune modulatory pathway. Five hundred seventy-one 1-month-old, asymptomatic neonates from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) birth cohort were studied. Unstimulated airway mucosal lining fluid was sampled via the nose at 1 month …

Asthma and related respiratory tract allergic diseases are among the most common chronic diseases of adults and children. Despite their importance, disease course cannot be predicted and treatment remains non-specific and potentially hazardous, with no means for cure. Improved clinical management of asthma will require an improved understanding of the fundamental factors that initiate allergic inflammation, especially T helper type 2 (T(H)2) cell induction.In this review, we explore the Proteinase Hypothesis of allergic airway disease, considering specifically how organismal proteinases contribute to the expression of allergic disease and potentially important proteinase signaling pathways.Proteinases from diverse sources (bacteria, fungi, plants) may cause occupational asthma by acting as immune adjuvant factors that specifically elicit T(H)2 cell-dependent allergic inflammation. However, more conventional allergic airway diseases (asthma, allergic sinusitis) are more likely to arise from contained fungal or viral infections of the airway in which proteinases are produced and serve as major virulence factors. Proteinases may elicit allergic disease by disrupting numerous cellular proteins, potentially including Toll like receptor (TLR) 4, but critical proteinase-activated signaling pathways remain largely unknown.Clarification of how proteinases cause allergic disease, specifically confirming an infectious basis for airway proteinase exposure, will likely radically advance how asthma and related respiratory tract disorders are diagnosed and treated. This article is part of a Special Issue entitled Biochemistry of Asthma.

Allergic asthma is an obstructive lung disease linked to environmental exposures that elicit allergic airway inflammation and characteristic antigen-specific immunoglobulin reactions termed atopy. Analyses of asthma pathogenesis using experimental models have shown that T helper cells, especially T helper type 2 (Th2) cells and Th2 cytokines such as interleukin 4 (IL-4) and IL-13, are critical mediators of airway obstruction following allergen challenge, but the environmental initiators of lung Th2 responses are less defined. Our studies demonstrate that fungal-derived proteinases that are commonly found in home environments are requisite immune adjuvants capable of eliciting robust Th2 responses and allergic lung disease in mice. We have further shown that common household fungi readily infect the mouse respiratory tract and induce both asthma-like disease and atopy to otherwise innocuous bystander antigens through the secretion of proteinases. These findings support the possibility that asthma and atopy represent a reaction to respiratory tract fungal infection, suggesting novel means for diagnosis and therapy of diverse allergic disorders.

Active fungal proteinases are powerful allergens that induce experimental allergic lung disease strongly resembling atopic asthma, but the precise relationship between proteinases and asthma remains unknown. Here, we analyzed dust collected from the homes of asthmatic children for the presence and sources of active proteinases to further explore the relationship between active proteinases, atopy, and asthma. Active proteinases were present in all houses and many were derived from fungi, especially Aspergillus niger. Proteinase-active dust extracts were alone insufficient to initiate asthma-like disease in mice, but conidia of A. niger readily established a contained airway mucosal infection, allergic lung disease, and atopy to an innocuous bystander antigen. Proteinase produced by A. niger enhanced fungal clearance from lung and was required for robust allergic disease. Interleukin 13 (IL-13) and IL-5 were required for optimal clearance of lung fungal infection and eosinophils showed potent anti-fungal activity in vitro. Thus, asthma and atopy may both represent a protective response against contained airway infection due to ubiquitous proteinase-producing fungi.

In the United States, the prevalence of asthma is greater in urban African American children than their white counterparts, but data for Hispanic children are not consistent. Prevalence of asthma in “Hispanic ” children may be dependent on one or more factors such as of socioeconomic status, geographic location, and country of origin. We screened a predominately African American and Mexican American population of poor children in a large city for self-reported symptoms that might suggest asthma and then asked their parents about both symptoms and diagnosis of asthma. A video-guided yes/no questionnaire was administered in the fall of 1997 to 21,852 children in grades 1–4 (ages 6–10) in 60 schools; a questionnaire was then sent to the parents of the 10,454 children who reported at least one asthma symptom. Asthma had already been diagnosed in 8.16%. However, 51% of the children whose parents reported daytime wheezing (10.46%) had not received a diagnosis of asthma. Percentages of wheeze ranged from 5% of A...

Clinical guidelines can assist in the management of asthma. Decision support systems (DSSs) can enhance adherence to clinical guidelines but tend not to provide clinicians with cues for behavioral change strategies to promote patient self-management. The Stop Asthma Clinical System (SACS) is a DSS designed for this purpose. To assess feasibility, seven clinicians used SACS to guide well visits with 26 predominantly persistent pediatric asthma patients. Data were collected via survey and in-depth semi-structured interviews. SACS improved assessment of asthma severity and control, classification of and intervention in medicine and environmental trigger management problems, and development of an action plan (all p< 0.05). Clinician-patient communication was enhanced. The primary challenge was that SACS increased clinic visit time. SACS can enhance clinician behavior to improve patient asthma self-management, but more studies are indicated to mitigate temporal constraints and evaluate impact on clinician and patient communication and behavior as well as clinical outcomes.

H Tachimoto, H Mezawa, T Segawa, N Akiyama, H Ida, M Urashima. Allergy. 2016;71(7):1001–1009 To assess whether low-dose, short-term vitamin D supplementation in addition to standard treatment improved control of childhood asthma. Eighty-nine Japanese schoolchildren ages 6–15 years who had a diagnosis of asthma based on GINA criteria and spirometry were randomly assigned to receive vitamin D ( n = 54) or a placebo ( n = 35). Ninety-four percent of subjects were using either an inhaled corticosteroid or a leukotriene …

MI Muniz-Junqueira, SM Barbosa-Marques, LF Junqueira Jr. Allergy. 2013;68(7):911–920 The goal of this study was to determine if morphologic changes in blood eosinophils can be used for early identification of the severity of an acute asthma exacerbation in children. Children were selected sequentially in an emergency care unit or asthma outpatient clinic. They comprised a group of 15 healthy children (5 girls and 10 boys; ages 4–14 years) without asthma or a personal of familial history of allergy, a group of 15 asthmatic children with variable disease severity (3 girls and 12 boys; ages 2–12 years) seen at a symptom-free …

There is concern regarding the underdiagnosis and undertreatment of asthma in children. This pilot study was designed to determine the specificity, sensitivity, and feasibility of using a two-part (child + parent questionnaire) case finding tool (Video-guided Asthma Screening for Children-School Age, VASC-SA) to identify elementary school children with asthma. The child checklist includes two practice items and nine items asking about asthma symptoms and diagnosis. The items are visually cued using a 10-min videotape using split-screen vignettes, one corresponding to a no response (most children do not...) and one to a yes response (some children...). Three case definition algorithms were examined (all included inhaled medication, or current diagnosis, or wheeze with 0, 1, or 2 other symptoms). The VASC-SA was administered to English-speaking children in grades 1-4 from one school. All parents were sent a written asthma questionnaire. Positive screens were compared with diagnosis obtained from physician r...

Objective: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education. Design: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation. Results: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found ( P = 0.55); children using the program scored significantly higher ( P < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater selfefficacy ( P < 0.05) and more efficacy building attribution classification of asthma self-management behaviors ( P < 0.05) than those children who did not use the program. Conclusion: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

To determine the efficacy of high doses of intravenous gammaglobulin (IVIG) for the treatment of severe, steroid-dependent asthma in patients between 6 and 68 years of age, a randomized, double-blind, placebo-controlled multicenter clinical trial was conducted in private and university hospitals in the United States. Patients were randomized to one of three treatment arms: 2 g IVIG/kg/month (16 patients); 1 g IVIG/kg/month (9 patients); or 2 g iv albumin (placebo)/kg/month (15 patients). The treatment consisted of seven monthly infusions followed by a posttreatment observation period. The primary outcome measurement was mean daily prednisone-equivalent dose requirements, determined during the observation month preceding initiation of treatment and compared to the month preceding the seventh infusion. Secondary clinical endpoints measured were pulmonary function, frequency of emergency room visits or hospitalizations, and number of days absent from school or work. When adjusted for body weight, the mean dose requirements fell by 33, 39, and 33% in the placebo, IVIG (1 g/kg), and IVIG (2 g/kg) treatment arms, respectively. The differences between therapies were not statistically different (P = 0.9728). The mean percentage-of-predicted FEV1 fell in all three treatment groups during the treatment period but there was no significant difference between treatment groups (P = 0.8291). There was also no significant difference in the percentage of subjects requiring emergency room visits or hospitalizations or missing days of work/school, among the three treatment groups. The trial was terminated prematurely after interim analysis determined the adverse experience rate was different between the three groups. Three patients, all randomized to the 2-g/kg IVIG dose group, were hospitalized with symptoms consistent with aseptic meningitis. In summary, in this randomized, double-blind, placebo-controlled multicenter study, high doses of IVIG did not demonstrate a clinically or statistically significant advantage over placebo (albumin) infusions for the treatment of corticosteroid-dependent asthma. Subgroup analysis failed to identify markers predicting responsiveness. High-dose IVIG can also be associated with a significant incidence of serious adverse events.

Asthma, a major cause of school absenteeism, can be triggered by allergens and irritants in the child's environment. A new measurement tool, the Environmental Observation Checklist (EOC), was developed and piloted for qualitative assessment of indoor asthma triggers (allergens and irritants), adequacy of ventilation, and existing environmental control practices. Seventy-five classrooms in 20 schools from two large urban school districts in Texas were surveyed using the EOC. A Q-TRAK Air Quality Monitor was used to assess indoor carbon dioxide, temperature, and relative humidity, concurrently. The EOC appears to be a useful screening tool for identifying schools in need of intervention.

A Deschildre, I Pin, K El Abd. Allergy. 2014;69(6):784–790 The goal of this study was to evaluate asthma control based on Global Initiative for Asthma (GINA) 2006, National Asthma Education and Prevention Program (NAEPP), Childhood Asthma Control Test (C-ACT), and physician’s assessment (PA). This prospective study included 527 asthmatic children aged 4 to 11 years recruited over an 18-month period at an office visit. Children with a chronic illness in addition to asthma were excluded. Both tertiary pediatric pulmonology …

Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

AM Karvonen, A Hyvarinen, H Rintala. Allergy. 2014;69(8):1092–1101 The goal of this study was to identify better ways to characterize microbial exposure early in life as a possible predictor of respiratory symptoms and allergies. A birth cohort of 410 children in Finland was recruited over a 3-year period and followed up until 6 years of age. Asthma, wheezing, cough, and atopic dermatitis were assessed by questionnaires administered during the third trimester and in follow-up at ages 2, …

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.

OBJECTIVE. Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-managment skills. This study tests a tailored self-managment intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months. METHODS. This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child’s acute and chronic severity. RESULTS. To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process. CONCLUSIONS. The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.

OBJECTIVE. Our goal was to teach emergency department (ED) physicians how to use standardized criteria for diagnosing and classifying asthma severity and to describe the patterns of pediatric ED utilization of these criteria for classification of both acute and chronic severity. METHOD. A health care provider education module was developed and implemented in 4 participating EDs in southeast Texas to educate ED physicians and health care providers on the diagnosis and acute and chronic severity classification of pediatric asthma patients. We undertook both retrospective (medical chart extraction) and prospective surveillance over a 2-year period of all children presenting to 1 of 4 EDs with acute asthma. Demographic characteristics, classification of severity, health care resource utilization, and primary physician contact information were collected. RESULTS. The health care provider educational intervention was provided for 84 different physicians. A subset of 16 physicians was randomly tested preintervention and postintervention. Mean mock-scenario scores at 2 weeks showed an improvement of 55.6%, which was sustained at retesting at 6 months. Over the 2-year period, 6222 individual pediatric ED encounters were entered into the surveillance database. The median age of presentation was 5 years. More than 32% of the patients in the study were uninsured. The majority of the patients in each category had asthma of mild severity: mild intermittent chronic (58.7%) and mild acute (53.9%). CONCLUSIONS. Physicians who completed a health care provider education module learned to effectively diagnose asthma and recognize standardized acute and chronic severity classifications. The majority of children with asthma who presented to the Texas Emergency Department Asthma Surveillance project's participating EDs were classified as having mild acute severity and mild intermittent chronic disease. Almost one third of these patients did not have health insurance.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

As part of the Partners in School Asthma Management Program, environmental data were collected from 385 rooms in 60 elementary schools in southeast Texas, using an Environmental Observation Checklist and a Q-TRAK Indoor Air Quality Monitor. Dust samples for allergen analysis were collected from floors, carpets, and area rugs in 80 classrooms in a subset of 20 schools. CO2 levels >1,000 ppm were found in 86% of rooms; 69% had indoor humidity above recommended levels. Der p I dust mite allergen levels >2,000 ng/g were present in 20% of rooms, but only 2.5% of rooms had Der f I mite allergen levels exceeding recommended tolerances. Detectable levels of cockroach allergen (Bla g II) were found in all schools (median 5.5 ng/g), with 10% of rooms over the recommended threshold. Almost two-thirds of classrooms had mold spore counts >10,000 col/g (median, 14,400 col/g; range, 2,000 – 52,000 col/g).

LB van der Aa, WM van Aalderen, HS Heymans; Synbad Study Group. Allergy. 2011;66(2):170–177 Infants with atopic dermatitis (AD) are at high risk of developing asthma. These researchers sought to examine the effect of early intervention with synbiotics, a combination of probiotics and prebiotics, on the prevalence of asthma-like symptoms in infants with AD. Ninety term infants less than 7 months of age with AD were recruited from 2005 to 2007 in the Netherlands. Inclusion criteria included an AD score (Severity Scoring of Atopic Dermatitis [SCORAD]) of …

MT Salam, TM Bastain, EB Rappaport. Allergy. 2011;66(3):412–419 Elevated fractional exhaled nitric oxide (FeNO) has been shown to be a sensitive biomarker for airway inflammation in children with asthma. This study examined whether a relationship could be demonstrated between genetic variants in nitric-oxide synthase and arginase genes and FeNO in asthma. Subjects aged 5 to 7 years were recruited from 13 Southern California communities for a Children's …