Division II:
Asthma & Children's Environmental Health Outreach

Division II

Co-Directors: Edward Brooks and Sharon Petronella

Sharon Petronella, MS, PhD, and Edward G. Brooks, MD, are both NIEHS center investigators in the Asthma Pathogenesis Core and the co-directors of the Asthma Division of the UTMB NIEHS COEC. A major focus of their work has been translational or integrative research, i.e., building interfaces between and among research, education, and community health. Two examples of this emphasis include the Management of Indoor Air Quality in Schools for Respiratory Health program (MANIAQS-RH) and the Gulf Coast Study of Urban Air Pollution & Respiratory Function. Both of these projects were initiated as environmental research projects for the Asthma Pathogenesis Core that developed into educational and policy interventions implemented as part of the COEC. Asthma surveillance projects in which Petronella and Brooks are involved include a statewide initiative to determine the scope and burden of asthma among Texas schoolchildren and the Texas Emergency Department Asthma Surveillance Project (TEDAS). Communities Organized Against Asthma & Lead (COAL) is an NIEHS-funded Environmental Justice: Partnerships for Communication consortium that unites the efforts of North Houston social services provider, de Madres a Madres, a Harris County health care provider, Casa de Amigos, and the UTMB NIEHS Center. Recent initiatives include expansion of the original Asthma: Integrated Management in Schools (AIMS) program geared toward addressing asthma in schools as identified through surveillance efforts.

Programs

   1. MANIAQS-RH: MANagement of Indoor Air Quality in Schools for Respiratory Health

   Funding:  Constance Schafer Endowment

As part of a cooperative education program, the UTMB COEC's Children's Asthma Team has developed a partnership with the Galveston Independent School District to provide important information to schools regarding the relationship between asthma and air pollution, while also providing students the chance to experience science through hands-on research projects. One such project, Clearing the Air, utilized the U.S. Environmental Protection Agency's Tools for Schools Indoor Air Quality Kit as a basis for identifying indoor air quality problems, while a second project, APPLE (Air Pollution PoLiciEs for Texas Schools), focused upon quantifying the effects of exposure to air pollution upon lung function. These two studies have since been incorporated into a comprehensive asthma intervention module, Asthma: Integrated Management in Schools. The successful implementation of these pilot programs has led to invitations to present the projects at national air quality management conferences, local grants for expansion of the studies throughout the school district and the potential for funding at the national level to develop a standardized model for school indoor air quality management in public schools. Continued interdisciplinary collaboration, involving laboratory science, epidemiology and cooperative education, is expected to lead to more successful ventures with respect to the study of childhood respiratory diseases and the management of symptoms, as well as indoor and outdoor air quality management.

   2. COAST: Coastal Ozone Action Strategies for Texas

   Funding: UTMB NIEHS Center and Sealy Center for Environmental Health Sciences

Any lifeguard could tell you that a mere six seconds can mean the difference between life and death for a swimmer in serious trouble. For the Galveston County Beach Patrol, however, six seconds is not only a matter of life, but breath. To assist with development of evidenced-based decisions regarding ozone policy, the Beach Patrol participated in a study to assess lung function among athletes exercising outdoors under conditions of low pollution and high pollution. As the occupational cohort for "COAST: Coastal Ozone Action Strategies for Texas," the lifeguards of the Galveston County Beach Patrol underwent a daily series of three lung function tests, each requiring approximately six seconds to complete. This environmental study was designed to identify and evaluate exposure to and effects of air pollutants and weather conditions on human health.

Our data has included more than 100 subjects, aged 16-27, and more than 1500 spirometric studies have been collected. Using univariate regression analyses, our data have shown a significant decrease in FVC and FEV1 after exposure to increasing levels of PM 2.5 for several hours. We have not seen a similar effect with ozone, NO_x, or SO₂. Our data suggest a decrease in total lung volume (preserved FEV1/FVC ratio) rather than typical patterns of airway obstruction due to brochospasm typically seen in asthma exacerbations (FEV1 reduced more than FVC).

These decreases in lung function are present even at relatively low levels of PM 2.5. While federal air quality standards list PM 2.5 levels of greater than 65mg/m³ as unhealthy, we have seen average lung volumes decrease by as much as 0.5 liters (5-30%) with particulate matter concentrations of only 38 mg/m³.

This research has led to two new efforts for the Asthma Team, the first being a study to assess the role of genetic susceptibility in individual responses to air pollution, called the Gulf Coast Study of Urban air pollution and Respiratory Function (GC-SURF). The second new effort, in collaboration with the Galveston Beach Patrol, entails establishment of an environmental awareness program implemented on Galveston beaches in spring 2006. This has included both a policy change at the local level and establishment of an environmental educational intervention to apprise residents and visitors of environmental conditions and appropriate responses.

   3. Gulf Coast Study of Urban air pollution and Respiratory Function (GC-SURF)

   Funding: UTMB NIEHS Center and Sealy Center for Environmental Health Sciences

As COAST data suggested that decrements in lung function are due to decreased lung volume, the collection of breath condensate and buccal cell samples was added to the study in order to measure biochemical indicators of inflammation. Genetic testing suggests that certain polymorphisms in GSTM1, GSTT1, and GSTP1 genes may correlate with airway inflammation induced by air pollution. However, this study is still on-going and results are still being analyzed. Preliminary results have shown that EBC pH may be a marker not only for airway inflammation, but also for silent gastroesophageal reflux.

   4. Environmental Awareness Flag System

   Funding: UTMB NIEHS Center and Sealy Center for Environmental Health Sciences

Petronella and Brooks’ collaborative research with the Galveston County Beach Patrol to assess the effects of ambient air quality upon lung function (GC-SURF) has evolved into a model for translating a community-based scientific study into public health and safety interventions and policies. As of spring 2006, Galveston beaches will include in their public notification flag system an “environmental alert.” The Beach Patrol will implement this system, providing public education brochures and notifications via website related to the specific environmental condition of concern, e.g., heavy levels of particulates or ozone affecting air quality, and/or biological water contaminants, including red tide or unsafe levels of e. coli. This long and mutually beneficial collaborative relationship with the Galveston County Beach Patrol prompted an invitation to present this work at a meeting held in Galveston to commemorate the 40th anniversary of the inception of the US Lifesaving Association, headlined by Surgeon General Richard Carmona.

   5. Addressing Asthma in Texas: Assessing Asthma Prevalence among Elementary School Children

   Funding: Texas Department of Health & the Centers for Disease Control and Prevention

Petronella recently completed a four-year study in conjunction with the Texas Department of State Health Services to develop and implement a statewide school-based asthma surveillance program, funded by the Centers for Disease Control and Prevention. In the past two years, this program has conducted surveillance with over 100,000 children in the Texas Education Agency’s Region IV. The program was subsequently peer reviewed by the CDC, which approved it for implementation statewide, which would make Texas the first state in the nation to conduct school-based surveillance. Over time, this program will provide the basis for guiding future public health outreach and education, based upon identified needs.

   6. TEDAS

   Funding: Robert Woods Johnson Foundationn
   Collaborators: Texas Children’s Hospital; Ben Taub Hospital; LBJ Hospital

TEDAS is an innovative project that is a collaborative effort of UTMB, Texas Children’s Hospital, Ben Taub Hospital, and LBJ Hospital. The project entails development of a linked database that enables tracking of asthma emergency department visits from each of the four hospitals and tests an ED-based educational intervention program. The educational intervention includes patient, staff and provider components to encourage preventive behavior and prospective management. Uniquely placed to impact the high morbidity of asthma, ED physicians traditionally avoid implementing long-term management into their therapeutic paradigm. However, the potential payoff is great, as ED physicians are often the most frequent contact in the medical community for high morbidity, low Socio-Economic Status (SES) patients. As the rate of insurance coverage lessens, more and more patients turn to the ED for care in crises. Transforming that crisis visit into an educational and therapeutic opportunity for preventive self-management holds great promise. Additionally, preliminary outcomes measurements indicate that the majority of asthma patients visiting the EDs in the Houston/Galveston region are classified in the lowest severity, i.e., mild intermittent asthma, with 58% of patients in that category. This is a group traditionally not referred for intensive education and specialist care, so the education component of the TEDAS project will target a population not currently addressed by existing guidelines. In addition, the mild/intermittent population also represents the group of asthmatics with the highest number of uninsured children in the study. These results may explain the dependence of this group on ED care, as these children traditionally represent a group with poor access to chronic care services.

   7. Asthma Intervention Program for Galveston County Schools

   Funding: NIEHS Center, UTMB

This project is an educational intervention designed for school nurses, coaches and teachers. The curriculum, consisting of a series of targeted seminars, provides an overview of asthma and specifically targets those topics essential to educators dealing with asthmatic children in the classroom, e.g., identifying children with asthma, asthma management in the school setting, medication use and abuse and recognizing a child in danger.

   8. (HEATS ): Houston Exposure to Air Toxics Study

   Funding: The Mickey Leland National Urban Air Toxics Research Center (NUATRC), EPA Region 6, TCEQ

HEATS is a two-year collaborative investigation by UTMB and the UTSPH that investigates symptoms, health effects, and risk perception in two populations living in close proximity to industrial complexes. Sharon Petronella will direct the health component of the project to explore patterns of health symptoms and the participant’s perception of environmental exposures and risk. Maria Morandi, of the UTSPH will link personal exposure data to ambient measurements of a suite of Hazardous Air Pollutants (HAPs) by monitoring residential indoor, outdoor, and personal air concentrations for representative samples of the two communities, both within Harris County, Texas. The long-term aims of the study are to determine the relative impact of outdoor industrial sources of selected HAPs on community concentrations and personal inhalation exposures to these compounds, and to evaluate community health impacts potentially associated with these exposures.

   9. Camp RAD at UTMB: A Specialty Camp for Children with Asthma

Funding: NIEHS Center, GlaxoSmithKline
Collaborators: School of Nursing, Department of Pediatrics, School of Allied Health, Department of Pulmonary Care Services

Camp RAD provides a unique setting to teach self-management skills to children with asthma. The program emphasizes preventive aspects of care and promotes developmentally increasing independence in decision-making. Parents have a critical role in supporting the child’s self-management skills and in forming a partnership in care with the health team.

Camp RAD was begun in 1994 in response to high hospital admission rates for children with asthma. The camp goes beyond simply providing a happy camping experience. The camp is based on the belief that children learn best through interactive, applied teaching strategies that are fun. The heart of the camp is an educationally based children’s asthma curriculum. Important asthma self-management concepts are reinforced in daily camp activities. Creative strategies are used to involve parents in learning and program outcomes are measured.

Camp RAD is a 1-week day camp designed to teach school-age children with asthma self-management skills. The core of the program is a 6-part interactive asthma curriculum. The curriculum was designed by an interdisciplinary team of asthma specialists. Camp activities reinforce asthma self-management concepts in an applied fashion that is fun for the children. Campers highlight their learning for parents in a skit. Evaluation and field testing new asthma education strategies are key components of the program.

Children learn best when teaching methods are interactive and fun. Camp activities are designed to enhance the formal camp curriculum, and provide opportunities for application of self-management concepts. Challenging physical and recreational activities have a significant positive impact on children with asthma, and expand their perception of their own capabilities. Controlled and guided camp activities facilitate the child’s acquisition of new physical and self-care skills, testing of physical limitations, sharing of problems and concerns, enhanced physical fitness, and the development of strategies to deal with everyday problems. Self-image is enhanced through a sense of identity with peers who also live with asthma.

Asthma is a complex, chronic illness. The effectiveness of the camp’s teaching program depends upon professional staff experienced in the care of children and families with chronic illness. Pre-camp education and skill training for the professional staff is essential. Ongoing, systematic evaluation enhances the quality of the camp program. Evaluation provides motivation to the professional staff and stimulates further innovations in the camp design.

Camp RAD has been field tested over a period of 7 years, and significant outcomes have been documented. In the first year of operation a 60% reduction in emergency room visits and 74% reduction in missed school days was achieved. Such outcomes are strong evidence that this program significantly improves children’s asthma self-management skills and decreases the disease’s impact on children who suffer with it.