Vol. 11 •Issue 9 • Page 28
Creative Approaches to Control Asthma Triggers in the Home
The first step clinicians tell their asthma patients to take is to decrease or remove major allergens in the home. However, this is easier said than done.
Patients often have trouble finding practical methods to control insects, pet dander and secondhand smoke. Three recent studies reveal some novel home-based interventions that have demonstrated positive results.
The lead abatement program called “supercleaning” inspired one approach to cockroach allergen management. While extermination and pesticides can help, there is no rapid method to eliminate the preexisting allergen, said Steven G. Kelsen, MD, professor of medicine in the division of pulmonary, allergy and critical care at Temple University Hospital in Philadelphia.
“So, we developed this cleaning approach which uses a nontoxic medical grade detergent to clean all the surfaces in the apartment, followed by hot water steam washing and vacuuming of the surfaces with a HEPA filter,” Dr. Kelsen said.
Professional cleaners used alconox (the same detergent used to clean surgical instruments and medical labs) to clean five low-income apartments in Philadelphia. The apartments were then treated for insect abatement with nontoxic sprays that kill insects and repel new ones from entering.
Over a six-month period, the researchers monitored the amount of allergen present in dust on the apartment floors. Looking at two types of cockroach allergen proteins, Dr. Kelsen found the allergen levels were lowered dramatically in the five intervention apartments, and the levels rose slowly over the six months following the cleaning.
In contrast, the allergen levels in the five controlled apartments, located in the same apartment building, didn’t drop and in fact, rose progressively over the six months.
“We couldn’t keep the level down, which is a problem. But, at least the cleaning had a major impact,” Dr. Kelsen reported. “Supercleaning got rid of 90-plus percent of allergens, but we have to come up with better ways to keep the allergen level down over time.”
One possible reason for the rise in allergen levels is that the allergen redistributes itself from areas that weren’t cleaned, including fabric furniture, bedding and light fixtures. Dr. Kelsen said his group is continuing the study and introducing a second cleaning treatment, in addition to cleaning the soft surfaces and reservoirs not cleaned initially.
“We are also looking at the health consequences of lowering the allergen level in cockroach allergen sensitive asthmatics and see if we make a difference in the severity of their asthma,” he stated. The results of this study won’t be completed for a few years.
Dr. Kelsen cautioned that his research was part of a pilot study, with professional cleaners washing the apartments. So, he advocated patients continue the standard tried-and-true recommendations for good home hygiene.
Another project took a family-oriented, community-based approach to educating low-income families about state-of-the-art ways to manage exposure to asthma triggers. The Seattle-King County Healthy Homes initiative emphasized collaboration.
Researchers and the community developed a program that they ultimately felt was culturally acceptable, appropriate and wanted. “That was important to us because we want this work sustained, and the only way to do that is if it is desired by the community that it would benefit,” said James Krieger, MD, MPH, lead researcher.
The Healthy Homes researchers recruited low-income Spanish, English and Vietnamese-speaking people who knew their communities well, were good communicators, were respected by their neighbors and had experience with asthma, either personally or through a family member.
“We put them through an extensive training program to teach them about asthma and to educate them on how to give good patient education,” Dr. Krieger explained.
In the initial visit, the community health workers walked through study families’ homes with structured checklists, evaluated homes for various asthma triggers, and asked families questions concerning smoking at home, pets, cleaning methods and ventilation.
The outreach workers entered the information into a computerized database that produced a step-wise action plan for participants. They then sat down with families and discussed what they could help with over the next year and any referrals that might be necessary for further attention, such as smoking cessation programs.
All of the families rented their homes, half had incomes at the poverty level, half had incomes less than poverty, and all had asthmatic children between the ages of 4 and 12.
The high-intensity group (138 families) received an average of seven visits by the community workers during the year, as well as bedding covers and low-emission vacuum cleaners. The low-intensity group (136 families) received one visit and bedding covers.
“We didn’t have a pure control group because we all agreed that it probably .wasn’t ethical because bedding covers have been shown effective in controlling allergy symptoms,” Dr. Krieger said.
The outreach workers provided feedback, and when families encountered barriers, they helped solve them.
“The workers can develop a trusting relationship with the family so they feel empowered and confident,” Dr. Krieger said. “That’s hard to make happen in a 15-minute office visit,” adding that he views this technique as a complement to clinical services.
The high-intensity group went from 8.0 days with symptoms out of the last 14 to 3.2 days; the low-intensity group went from 7.8 symptom days to 3.9 days. At baseline, 23 percent of the high-intensity group reported having an urgent health care visit in the two months prior, which decreased to 8 percent by the study’s end. The low-intensity group went from 20 percent to 16 percent.
“So, it appears to us that the intervention had a significant effect. Benefit was seen in both groups, but there was more improvement in the high-intensity group,” Dr. Krieger concluded.
The study was funded initially in 1997 with a four-year National Institutes of Health grant that has since been extended another five .years for a second study. The Healthy Homes II .project involves instructing community health workers to teach families proper use of metered dose inhalers, asthma medications, peak flow meters and asthma action plans as well as continuing to help families reduce exposure to asthma triggers. It will be linked with primary care providers, who will receive reports from the outreach workers about how the families are doing, he reported.
A National Heart, Lung, and Blood Institute-funded study by Ana P. Martinez-Donate, PhD, used another strategy to combat home asthma triggers. The Center for Behavioral Epidemiology and Community Health (CBEACH) conducted a clinical trial to test the effectiveness of an intervention to reduce environmental tobacco smoke among 192 Latino asthmatic children in California living with at least one smoker.
The researchers examined the children’s environmental tobacco smoke exposure through maternal-report diaries and urine-cotinine levels. Then researchers assessed how enforcement of home-smoking bans influenced the children’s asthma symptoms, pulmonary function and use of medical care.
Overall, a complete ban on home smoking was associated with a 43 percent decrease in the median reported daily level of exposure at home, said Dr. Martinez-Donate, senior research associate at CBEACH and adjunct professor at the Graduate School of Public Health at San Diego State University. Moreover, the children whose mothers reported having a policy completely or partially banning indoor smoking presented a 20 percent higher FVC than children living with no household restrictions on smoking. In addition, having a total or partial home smoking ban was associated with significant lower number of days in which asthma symptoms interfered with children’s activities, with less use of medical care and better pulmonary function.
“This reduction is likely to improve patients asthma severity,” she concluded, yet added that additional research is needed to determine the best way to establish and enforce a home policy in smoking among specific populations.
Diehl is a free-lance writer in Gettysburg, Pa.