Kimberly Gray: Good afternoon, everyone, and welcome to the Partnerships for Environmental Public Health Webinar, entitled Children’s Environmental Health. My name is Kimberly Gray, and I’m the Program Director for the Children’s Environmental Health at the National Institute of Environmental Health Science, Division of Extramural Research and Training, in Research Triangle Park, North Carolina. I’ll be the Moderator for today’s session. I’m very pleased to introduce our presenters for today. Dr. Sheela Sathyanarayana of the University of Washington and Seattle Children’s Research Institute, Dr. Toby Lewis and Dr. Stuart Batterman of the University of Michigan. The first presentation will be given by Sheela. She is a pediatrician and environmental health specialist at the University of Washington and the Seattle Children’s Research Institute. Her research focuses on early life exposures to endocrine disrupting chemicals and childhood health outcomes. She sees patients at Harborview Medical Center and the University of Washington Newborn Nursery, and is the Co-Director of the University of Washington Pediatric Environmental Health Specialty Unit. She recently received a Young Investigator Award from the University of Washington’s Center for Ecogenetics in the Environmental Health. Welcome, Sheela. Sheela Sathyanarayana: Thanks, everybody, and thanks to you for inviting me to present today. So the title of my talk is Endocrine Disrupting Chemicals, Translation from Research to Prevention. And what I really want to do is talk about how research questions are derived from the clinical realm and then how that research translates to potential interventions to reduce exposures. So the clinical realm that I’m going to talk about is the Pediatric Environmental Health Specialty Unit where we do environmental health consults, and then how that relates to research that we have done, including the TIDES Environmental Study, it’s the Infant Development and Environment Study, which is sponsored by NIEHS, and then how the TIDES study has led to potential interventions to reduce exposures in the general population. So the Pediatric Environmental Health Specialty Units are a national network of environmental health specialists, including industrial hygienists, practitioners, and epidemiologists. It’s sponsored by the ATSDR and EPA, and in this capacity we perform environmental health consults for providers, patients and families and government entities. For patients and families we may talk to them about a specific child environmental health issue. For providers we may talk to them about how to counsel their patients on reducing environmental exposures. And then for government entities a lot of times we’re consulted based on mass contaminations or air quality within a school on how to communicate those health issues to the entire population and what actions to take on the potential health harm. But the majority of our consults end with families and providers really wanting to know how chemicals can harm their children and what actions they can take to protect their children from these harmful exposures. And for those of us who work in environmental health we know how hard it is to translate the research. It’s very hard to say a certain level of a chemical will lead to potential health outcomes, and that has led to specific research questions that we would like answered. And the other part of the environmental health specialty units is when we have important topics that come up again and again, we create handouts for the public, as well as healthcare providers, which I’ll talk about in just a second. So phthalates and bisphenol A are endocrine disrupting chemicals that have commanded a lot of media attention, as well as scientific and government attention, and so I wanted to go into potential sources of these chemicals and then potential health harm. So the traditional sources of phthalates and BPA that we learned about several years ago were flexible plastic tubing, vinyl flooring, and soft squeezy toys, and those are specifics versus a phthalate exposure, but on the bottom here were these water bottles and baby bottles that you may have heard a lot about for bisphenol A exposure. Now those were the traditional sources of exposure that we learned about, but we’re learning more and more that probably the largest single source of exposure to phthalates and BPA is through diet, and so this is really more of our current thinking. And here are cans, and the reason that cans are here are because can linings can contain very high concentrations of bisphenol A. And on the right-hand side, our first slide here, you can see processed foods, and processed foods, as well as meats and dairy can contain high concentrations of phthalates. On the bottom is not a food specifically, but we’ve recently learned that carbonless paper receipts contain very high concentrations of bisphenol A, as well. So I just wanted to touch a little a bit more upon phthalates in the food supply. This is a very busy slide, and I’ll just bring your attention to a couple of main points. First, on the left-hand side are a number of foods. And here are carbohydrates, dairy and animal meats. And on the right-hand side is DEHP, that’s Di(2-ethylhexyl)phthalate, and this is one of the most toxic phthalates in animal and human studies. And you can see here that there are detectable concentrations of Di(2-ethylhexyl)phthalate in almost all of these foods. And they are very low concentrations. So the idea here is not that you’re going to get a high exposure from any one of these foods, but that you’re eating these foods every single day and so you have chronic exposures over time. And how are phthalates getting into the food supply? It’s thought that there’s — it’s through processing of plastic products in the actual food production process, so conveyor belts, lids to glass jars, big plastic tubes that store foods in factories, gloves, plastic packaging in storage, and then paper packaging that has plastic lining. And just like phthalates are in the food supply, bisphenol A has also been found to be in the food supply. And this is a table showing bisphenol A in a variety of foods, and you can see here that it’s in green beans, a variety of soups and chilis in higher concentrations. So both bisphenol A and phthalates have been found in a variety of different food products, specifically bisphenol A in canned foods. So why are we so concerned about these chemicals? And I haven’t put citations on this slide because the statements here really reflect numerous studies in the literature that talk about phthalate and bisphenol A exposures and potential health harms. So for phthalates we know that they’re anti-androgens, and prenatal exposures to these chemicals are associated with male reproductive tract abnormalities, including a smaller anogenital distance, smaller penile width, and reduced testicular descent. And then prenatal exposure is also associated with neurodevelopmental changes in young children. Bisphenol A is a known synthetic estrogen, and low doses in the prenatal period are associated with development of tumors in the breast and prostate glands, that’s also associated with bisphenol exposure in adult life, as well, obesity and metabolism changes, and then they have found significant impacts on neurodevelopment. For bisphenol A specifically there’s not as much epidemiologic literature out there yet, but in humans we have found that prenatal exposure is associated with neurodevelopmental changes in children. So this is a lot of jargony information and we’re still left with, well, what exposure leads to what health outcome and how can we translate that? And that has led to a research study that we’ve been working on for several years, it’s called the Infant Development and Environment Study. The PI is Shanna Swan, and I’m the Site PI and Clinical Director for the entire study. It’s a multicenter study at Rochester, Minnesota, UCSF, and here at the University of Washington, and it’s a five-year longitudinal pregnancy cohort study, looking at prenatal phthalate exposures in relation to reproductive outcomes. And as of July we’re happy to report that we have recruited over 750 women and completed over 472 birth exams. And the objectives of this study are to test the hypothesis that prenatal phthalate exposure is associated with reproductive outcomes in male infants. So we’re looking for population-based norms of anogenital distance in these markers and other genital markers, we develop a reliable method for obtaining these measurements, and then we’re testing the hypothesis that ano- genital distance is a long-lasting marker of anti-androgen exposure. So, again, this is really jargony. It’s very scientific, and didactic, and how does it really relate to the general population, and that’s what I struggle with as the Clinical Director of the study and I deal with all of the clinical issues that come up when we’re communicating the study to patients, whether it’s through recruitment or through a birth exam, and all of the questions that families have for us. And so I just wanted to show a little bit of data. In our questionnaire we asked women who were in their first trimester of pregnancy do you think environmental chemicals pose risks? And 73% of them strongly agreed that they do pose risks. And then we also asked, do you consume ecofriendly foods? And there’s a variety of definitions of ecofriendly foods that we put in the questionnaire that I haven’t put on this slide, but about half of them say that they always or usually consume ecofriendly foods and half say sometimes or rarely. But still inevitably whenever I’m in a patient visit or talking with a family I still get this kind of question, if you think the chemicals could be harmful then how can I protect myself and my family from exposures? And that has led to our environmental health specialty units creating these handouts. I said before that we sometimes create handouts on important topics, and this is something we created in 2009 when phthalates and bisphenol A were first coming into the public foray in terms of being potentially harmful, and we talk about what phthalates and bisphenol A are, that these chemicals can leak from plastic products and that scientists and doctors are learning about the health effects that they may have on children. And then we tell people that there are these recycling codes on the bottom of plastic bottles, and these are the safe recycling codes and then these are the ones to avoid. So it’s a pictorial diagram of how to actually reduce your exposures. And then I haven’t put the entire handout on here, it’s two pages, but we also talk about how families can be exposed to phthalates and BPA and what are the potential health impacts of phthalates and BPA. So this is a really nice handout. I personally wrote a lot of it, but we still don’t have any evidence that it actually works, that when we give people these handouts that their exposures are actually reduced. And that is kind of the translation and the art of public health communication that sometimes is missing from our research studies. And right now there’s only been one true intervention study that’s in the published literature to reduce phthalates and BPA, and this is by Ruthann Rudel and her colleagues. And basically what they did was a complete dietary intervention, based on some of the sources of exposure I showed you earlier they took families, measured their urine concentrations during a pre-intervention period, then for five days asked them to eat a complete dietary intervention that they created themselves of fresh foods, I mean non-canned foods, and measure their urine concentrations during that dietary period. And then in a post period they asked them to go back to their regular diets and measure their urine concentrations again, and they found significant reductions in phthalates and BPA. So this study was extremely important in showing that we actually can do things to reduce our daily exposures, but there were some issues and for those of us who have to translate this to patients and families it — there were difficulties in doing that. First is that this is not a practical intervention. I cannot give a patient or a family a complete dietary replacement. There were very few children enrolled in this study, and we do know that children are the most vulnerable, both during in utero development, as well as early childhood because that’s when developmental programming occurs. And then they also couldn’t identify what contributed to the pre-intervention or post-intervention concentrations, so we knew that the dietary replacement helped, but not what was contributing to the original exposures. So still what can people do in their daily lives to reduce exposures to phthalates and BPA? And that led to a study that we did, where we recognized that there are many different guidelines that exist to counsel families to reduce phthalate and BPA exposures for children, but none are really evidence based. So I showed you our environmental health specialty unit handout, but there are a lot of government scientific agencies, state government handouts that also exist to reduce phthalate and BPA exposures. And so our objective was to determine if following these written guidelines to reduce exposures would lead to urinary reductions in BPA & phthalates to a similar extent as a dietary intervention. And so we undertook a very small randomized trial where we screened over 50 families and chose those with the highest potential for phthalate and BPA exposures, and we ended up with 10 families with two kids each, randomized to two different arms. The first arm was a complete dietary replacement that was similar to the Rudel study, which was a catered diet made with fresh organic local foods prepared and stored in non-plastics. And I just want to emphasize that the organic was not an important part of this, it was just what our caterer already did, but the organic was — we did not feel like would contribute to phthalate and BPA exposure. What we did feel like would contribute to those exposures are the fresh diet, as well as the preparation and storage in non-plastics. The second arm of the trial, we provided the families with the pediatric environmental health specialty unit written handouts and asked them to follow those handouts. So this is the study design that we used. We had a pre-intervention period from days one through five, where they’re eating their regular diet and we collected a urine sample on day five. Then we had an intervention period from six to 10, and we collected the urine samples on days nine and 10. And so, again, during this intervention period arm one was eating a complete dietary replacement that we provided, and arm two was following the written handouts. And the idea was to see if they would be — they would produce similar effects. And then we had a post-intevention period, days 11 through 16, where we asked the families to go back to their regular diet and we took a urine sample on day 16. So what did we learn from this? Well, first, we learned that asking families to follow written materials did not reduce phthalate and BPA concentrations during the prevention period, and this may seem a little outrageous while we have these really great handouts, they’re evidence based, and they didn’t lead to reductions in concentrations, but this is something that we see in medicine all the time. We have all sorts of information that we give to patients and families and they either don’t follow those guidelines or it just doesn’t work. So although we have scientific studies that show that we can reduce the exposures and that the evidence that we’re putting on those handouts does work in our research study, it does not work in the field and it does not work practically in the general population. We also learned that a well-controlled dietary intervention led to an unexpected increase in DEHP metabolite concentrations, and that contamination through food sources may be difficult to avoid even with careful control of food procurement, storage and preparation. I’ll just say that I think that what happened in this study with the contamination, with the spices, is really a fluke. And that’s because when you look at the NHANES data, so the National Health and Nutrition Examination Survey, which does general population exposures the concentrations seen in our participants were much higher than even the highest concentrations seen in that study and, therefore, I think that we just happened to get a batch of spices that was contaminated but is not in general circulation nationally. But, of course, that can’t be proven, and I actually have a phone call with the Pew Charitable Trust on food toxicity next week to kind of talk about how that could have happened. In terms of the future, federal regulation may be the only manner to completely control contaminants in the food supply, and that is not just specific to phthalates and bisphenol A, we learn about all sorts of toxicants in our food supply. And in the recent past we’ve learned about arsenic and we are learning about more and more contaminants as time goes on. But in the setting where government regulation does not exist we still need interventions to be developed that are evidence based, practical and generalizable. And so what we are going to do over the next two years is do an intervention that is targeted for low-income, underserved children, ages zero to three. We’re partnering with the Washington State Department of Health to receive a CDC grant to conduct environmental biomonitoring within the state, and we’re going to develop a practical intervention, and we’ll set up a study design in the field with home visits at baseline intervention and post-intervention periods. And it will be designed to work with families to identify what methods work best — paper pamphlets and education, personally I don’t think works very well, Internet based interactive education, or in-person education. And the entire idea is really to move towards a paradigm of evidence based prevention that is really generalizable for endocrine disrupting chemicals so that we have really good evidence based information to communicate to our patients and families and constituents. So, with that, I will just do my acknowledgements. First, I want to acknowledge all of our study participants — our Research Assistant, Gary, Brian Saelens is a Co-Investigator, and Bruce Lanphear is a Co-Investigator, the Pediatric Environmental Health Specialty Units, and then the University of Washington Center for Ecogenetics and Environmental Health who supported the pilot study and, of course, NIEHS for supporting TIDES and future studies. Thanks. Kimberly Gray: Thanks, Sheela, that was a really a great talk. It’s the first time I’ve actually seen it all pulled together, and there’s some good questions here, so we’re just going to take a few of the questions that are posed and save the rest for later, if we don’t get to them, so we can get to the next talk, and then if there’s some additional time at the end we’ll get to all of the questions. So I apologize if I don’t get to your question immediately. But first question is when you ask your patients about their diets how do you define ecofriendly foods? Did you find that people had different preconceived notions of what ecofriendly foods are, example, organic versus local versus canned versus fresh — is that a difficult concept to get across? Sheela Sathyanarayana: It absolutely is. I think to a lot of people ecofriendly foods means organic and that’s it, but it’s a very clear distinction organic or not. And I think to others it does mean fresh and local, as well. But for most people it was organic versus not organic. And what’s interesting about that is that organic really does relate to pesticides, but it doesn’t necessarily relate to other contaminants that we’re talking about. Just to get at how we asked about it, we — in the questionnaire we actually had different boxes that they marked about what they consider to be ecofriendly or not, and there were different distinctions, fresh versus local, fresh versus not fresh, local versus imported or transported over a long distance, and then organic versus not organic. Kimberly Gray: Okay, this question is really to help explain to the audience the difference between BPA and phthalates, and the question is what do you estimate — if you know this, Sheela — the contribution of BPA and phthalates’ exposure from using plastic containers versus glass. Sheela Sathyanarayana: Yes, that’s a really good question, and it gets at a lot of little nuances. So, first, those handouts were created in 2008-9 before we knew that food was likely the biggest source of contamination, and so it was created during a time when we were mostly focused on plastics. Personally, now going or having more experience in this field and learning more about phthalates and BPA, I don’t think that the plastic containers are nearly as big of a contributor as just the general food supply, but it’s nuanced in the sense that in the food supply it is related to plastics, it’s just not plastics you can control, it’s plastics and processing and production. When the foods come to your home or whatever is inside your home then there’s plastic storage and plastics used in preparation. And I personally don’t feel like that is a major contributor, I think it’s more what has happened to those foods before they come into your home. Kimberly Gray: Okay, and the last question that we’ll take and then, again, we’ll come back to the other ones — the comment coming from one of the participants is I’ve heard studies on organic versus nonorganic in which there was very little difference in the terms of nutrition. Organic has become very premium and poses high cost for many of these families. What do you think of this, are we dealing with fashion label foods and vegetables and fruits by the label organic? Sheela Sathyanarayana: Well, so I think that’s a little — it’s a little farther afield from what I just presented, but in general with organic I think what we do know factually, we know that organic foods are lower in pesticides as compared to conventional foods. So if you’re concerned about pesticide exposure and potential health impacts on pesticides you will reduce that risk by eating organic. In terms of whether there’s more nutritional value, that definitely has not been proven, so that is true, that there’s not necessarily more nutritional value from organic foods but there’s certainly is more ecological value. So when you think about organic foods I think you need to think about it in terms of an ecological framework, not just a health based framework. In terms of costs of organic foods versus not, this is something that I talk about a lot and talk about with my colleagues here who are obesity researchers, it’s very — if something was considered very or it’s very accepted in the general dialogue that organic, eating organic or eating fresh is going to be more expensive than not, and it is just not the case. And we have shown it again and again, and it’s been shown here at the University of Washington with obesity studies that eating a fresh foods diet is actually not more expensive than eating other processed foods. Processed foods can be very, very expensive, but eating a fresh foods diet does lead to needing more time and preparation at home, which is actually the biggest barrier for families here, is knowing what to do with fresh foods. So that’s a very long answer to a short question, but I do think that in terms of thinking about organic food I’ve tried more to focus on fresh foods at home rather than just organic, but organic is nice for certain foods that have very high pesticide concentrations. Kimberly Gray: Thank you very much. Again, we’re going to hold a few questions for the end. So, Sheela, I hope you can stay with us here so at the end we can tackle a few more of these questions. It was a very good talk and stimulating. And I’m going to go now on to Dr. Toby Lewis and Dr. Stuart Batterman from the University of Michigan. Dr. Lewis is a pediatric pulmonologist at the University of Michigan, C.S. Mott Children’s Hospital. She received her medical degree from Cornell and completed her internship and residency in pediatrics at the University of Washington. She went on to complete her fellowship in pediatric pulmonology and her master’s in public health at the University of Washington, as well. At Michigan, the University of Michigan, Dr. Lewis holds a joint appointment as the Associate Professor in the Department of Pediatrics, Division of Pulmonary Medicine, and also the Assistant Research Scientist in the Department of Health Behavior, Health Education. Her research is focused on understanding environmental and social factors that contribute to the development and persistence of asthma in childhood. She’s particularly interested in factors that increase vulnerability to environmental exposures and interventions to reduce the health impact of environmental hazards among vulnerable populations. Dr. Batterman has a bachelor’s in environmental science from Rutgers and a master’s and Ph.D. Degrees in Civil and Environmental Engineering from MIT. He’s currently a Professor of both Environmental Health Sciences and Civil and Environmental Engineering at the University of Michigan. He directs the Michigan Center for Occupational Health and Safety, which is a NIOSH supported P42. He also has appointments in engineering and medicine, respectively, at the University of Coimbra in Portugal and the University of KwaZulu-Natal in Durban, South Africa. Prior to working at Michigan, he’s on Faculty at Texas A&M University, and was a Scientist at the International Institute for Applied Systems Analysis in Laxenberg, Austria. Dr. Batterman’s research focuses on exposure assessment, air quality, and other topics in environmental health sciences and environmental engineering. His applications include environmental, occupational, indoor settings, including bio monitoring, air monitoring, especially VOCs and semi volatiles. He’s an expert in risk assessments, simulation modeling, risk analysis, environmental epidemiology. He serves on a number of advisory committees, including several research centers, journals and NGOs. We welcome both Drs. Lewis and Batterman at this time, and sit back and listen to their talk. Thank you. Toby Lewis: Well, thank you, Kimberly. We’re both very pleased to be here and to have the opportunity to share some of our work. So we’re just going to start by giving a brief overview of how we’re organizing the presentation. I’m going to start by giving some brief background on childhood asthma and health disparity, just to paint the context for our work. Briefly discuss why environmental and partnership approaches to improving asthma health makes sense. Give you a little bit of background about our partnership, which we call Community Action Against Asthma. Talk to you about our partnership, some of the breadth of projects that we work on, as well as how our community partners are involved. But then I’d like to focus in on the part of our research that focuses on home environmental interventions and provide a little data in that area. And then finally conclude by highlighting what we feel are the contributions of the partnership approach to our work. So I always like to start by just reminding everyone what an important public health problem childhood asthma is. Recent estimates are that over almost seven million children in the U.S. have asthma and that this accounts for over three million doctor visits every year, half a million ER visits, many hospitalizations and close to nine million prescription fills. Clearly this is a problem that has a huge economic impact, but it also has a very important human impact. Asthma is the number one chronic illness causing school absence. Asthmatics miss three times more school than non-asthmatics, and 40% of asthmatics have disturbed sleep, so even if a child is not absent from school he or she may have reduced school performance because of sleep disturbances. And obviously when the child is not going to school the parent is not going to work. As with many other health conditions asthma does not affect the population uniformly. There’s variation and disparity, and like many conditions low income folks and people from minority ethnic and racial backgrounds have the largest burden of disease. What I have here is some data from Michigan. The map on the left is showing rates of hospitalization for children under 18 due to asthma by county, and the county that has the most darkly colored shading is Wayne County, which is where Detroit is. And it’s typically quoted that Wayne County has three times the asthma hospitalization rate of the rest of the state, and that’s really driven by the City of Detroit, where the rates of asthma hospitalization are 53 kids per 100,000 population annually. On the right-hand side I have two panels showing health disparity by income, up at the top, and by race, at the bottom. And, again, it’s the lowest income group and African-Americans who bear the largest burden from this disease. This is a cover from Newsweek, and I just learned that Newsweek was going to cease having covers shortly, but this is from about 15 years ago. And I show this as a reminder that asthma is not a new problem, it’s one that we’ve been struggling with for a long time. And it’s a very complex problem, and I think that’s one of the reasons why it lends itself to a partnership approach. No one strategy is going to reduce that morbidity and change that disparity, and if we just approach it from an academic or medical perspective we’re missing a lot of insight on what’s really going on at the ground level. Asthma is triggered by environmental factors, and while there may be several different approaches that you could take to try to reduce asthma morbidity the burden of asthma is going to be impacted tremendously by what people are coming into contact with. And it’s a wide variety of different exposures, everything from air pollution, emissions from both vehicles and industry, as well as biologic exposures, both the family pet but also molds that can be in the environment, as well as certain pests in the indoor air. Physical activity can sometimes trigger asthma and that can be challenging because while we also have an obesity epidemic and we need to be particularly careful for asthmatic kids who may also be obese about how we make recommendations on when, where and how they should be exercising. And, of course, cigarette smoke is a nearly ubiquitous exposure, particularly in urban low income families and remains a very refractory problem and difficult to address. There’s been a lot of work on home environmental interventions in asthma, and I chose to highlight two studies, actually from the ’90s, and the reason I picked these is because they were both seminal studies and also very influential to us as we were getting started in our work. The first is called the National Cooperative Inner City Asthma Study, or NCICAS. And this was a multicenter study that enrolled many asthmatics for using a nine-month program that both tried to address medical management, as well as home environmental intervention. And it was a very elaborate intervention, and it was delivered by highly educated, highly skilled practitioners. And they also as part of this addressed cockroach allergy, which is also a difficult problem in the urban setting and used an IPM, which stands for integrated pest management module. There were community advisors, but it wasn’t an integrated partnership model, and it was very effective, I think that was the good news, but there were clearly some places where there was room for further advances. As I mentioned, this was a very intensive, complex program, and it wasn’t really clear which elements were driving the benefit, whether this could be rolled out on a wide scale and whether it could be sustainable. And so that was a challenge to us to see if we could bring something similar to this to Detroit on a local level and make a difference for kids here and perhaps find new ways to deliver the same benefit. We actually looked to the Seattle Healthy Homes Project, which was championed by Jim Krieger. This was a single site study that also used a multifaceted home intervention designed to improve indoor air exposures and health and it was a much shorter program. It did have a steering committee of partners that included leaders in health environment, as well as parents and a scientific advisory group. And, importantly, an important difference in the Seattle program was that they hired people from the community to be their outreach workers. And this we thought was a key feature that we felt was necessary to create a program that could be used widely throughout the country. The Seattle Healthy Home Project showed important improvements in quality of life and urgent healthcare visits, but weren’t able to demonstrate significant improvement in symptoms. And so we started with this base of information and we pulled together a group of community partners who also had interest in environmental asthma issues. Actually should say the community partners got together first and they came to us to say how can we make a difference in our community? What is the latest in the knowledge and how can we apply it here? Our partners have changed somewhat over the years. This is a list of our current partners. It consists of eight community based organizations, and individual community activists, as well as the City of Detroit Department of Health and Wellness promotion, which recently was spun-off into a private, public health institute, but remains a partner with us. Also note that it’s a multidisciplinary effort from the academic side, and I think our strength is that we have a variety of expertise around the table, and everybody brings a little bit different perspective and has something to add as we design our work and as we interpret the results. I’m just going to briefly cover some of our partnership history, trying to get on to the more details of our latest intervention. So we began in ’98 as a spinoff of an earlier partnership and our goal is to develop and implement community based participatory research projects aimed at enhancing the knowledge and role of the environment in asthma and improving asthma health. We do have an environmental focus, but we define environment very broadly, looking at indoor air, outdoor air, as well as the social environment. In our various studies we take a variety of different scientific approaches, including epidemiology, exposure assessments, we have some biologic mechanistic studies, as well as our community intervention studies, which I’m focusing on today. And we have a branch that works on community education and networking. We’ve been fortunate to have been well funded over our 14-year history, and here’s a shout out to NIEHS and EPA, who have provided most of our funding. Focusing in on the role of our partnership, these are — the next few slides have been provided by one of our partners and I think highlight what they feel is some of the important roles that they play. The steering committee helps us develop and conduct our interdisciplinary projects, and allows us to build on the strengths and resources, both within the individual organizations, but also within the community. And even when we don’t have an individual, an organization around the table usually the organizations that aren’t our partnership have networks that they can tap into and bring in additional knowledge and expertise. An important role is that they ensure that the research process is equitable and they help share information back to the community and feel that it’s important that the community that’s most affected by this disease has decision making power and over both how the study is conducted, as well as how the resources are spent. One of our emphases as a partnership is that we promote the hiring of community members as staff, and this is facilitated by our partners who help us writing job descriptions that are both accurate but also will be appealing to local community members. They help us in our interviewing and hiring process, including both what I would call the more interpersonal types of jobs, as well as the technical jobs. When the partners bring technical expertise, they help us with skills training, as well as some additional workforce building and capacity development. Another priority of the partnership is making sure that the information that we develop makes it back to the community. That means getting individual results back to the individuals that participate in our projects, as well as getting study results back to the community so that people understand what the environmental risks are around them, what individuals can do to help protect their kids, as well as to promote activism and advocacy for more policy interventions. All right, focusing in on our home interventions, there was a first study that was conducted between ’99 and 2004, and this was, again, largely designed using what was available at the time, which was that NCICAS study and the Seattle Healthy Homes Project. It was a multifaceted tailored home intervention that was going to be delivered by lay community health workers with the goal of improving asthma community health. As I mentioned, it drew heavily on those earlier studies, but some important differences were that we didn’t necessarily hire people who had prior health experience, but rather people who had good interpersonal skills and who had outreach experience because we felt that getting behavior change really was challenging and it was going to take somebody who could relate to families and families could relate to them to convey the educational messages. While we had multiple different modules addressing different elements of environment, the indoor environments, there was a tailored program where we did an individualized assessment of the home and based on which factors were most prevalent in that home we together with the family prioritized how we were going to work on improving the indoor air for that child. So, for example, if you don’t have a smoker in the house we’re not going to focus on smoking, but if you have cockroaches that may be an area that we’d want to focus on. We also had very extensive measures of indoor air quality, as well as lung function. So just very briefly, we enrolled 300 kids. There was that initial environmental assessment where we were able to give direct feedback to families for development of priorities, and then there were nine standardized modules with additional visits as needed. Here are pictures of two of our community environmental specialists, who actually remain working with our project today, as well as an example of a typical single family house or a two-family house in Detroit, which is our standard housing stock. This is a little bit of a busy slide, but I just want to highlight some of our health outcomes. There’s two outcomes that I have here, one is the need for unscheduled medical care. First, over the last 12 months, and then more short-term measure over the last three months. And we definitely had some improvement in that outcome that reached statistical significance. We also had an indicator of medication use, and we were looking at kids who had frequent symptoms and asking how many of these kids are not on the recommended types of medications, which would be inhaled steroids or other type of controlled meds. And this was not a specific focus over our project, but we did provide general asthma education to our families and prompted them to be more active in how they communicated with their physicians, and we were pleased to see that we also had improvements in those indicators. This table highlights the lung function outcomes for our kids enrolled in our project. The first two outcomes listed here are interday variability, and those should — lower numbers are healthier, the second two are daily nadir lung function values and you want those numbers to be higher. And while the direction of our result went in the desired direction, we really didn’t see improvement in interday variability, but were able to see improvement in daily nadir. So overall we were pretty happy with how that first intervention went, but we were able to see that there were still some gaps. The intervention was well received and appreciated by families, but we found that the integrated pest management module that we had built off of the other projects was very time and labor intensive. And while we were able to make some improvements in allergen concentration in the dust, this was not sustained over the duration of the project. And regretfully we were not able to have an impact on smoking behaviors. And we, while we could see the improvements in lung function parents were not necessarily seeing improvements in symptoms. And we were concerned that the benefits would not be sustained, particularly if we were not impacting on smoking behaviors. So in our second phase, which is our current study, our goal was to build on the successes that we had seen in the first intervention, but also to try to reduce exposure to indoor particulate matter through what I, as a doctor, would call passive means, by using air filters to clean the air. So the idea was to use air filters to reduce indoor particulates and then to enhance the benefit of these air filters by providing air conditioners for use in the summer and this hopefully would allow people to keep their windows closed and allow the air conditioners to do their work, the air filters, excuse me, to do their work more effectively. Again, our hypothesis was that there’s all this stuff in the indoor air in the homes that’s making kids sick. We would like to enhance, clean the air by using air filters plus or minus an air conditioner, hopefully, that will improve the health of kids with asthma. So I’m going to just highlight the important features of this design. We are doing a randomized control trial of air filter, an air filter intervention, which is our standard intervention, and then there’s an enhanced intervention arm that where families will receive the air filter and the air conditioner, as well. We recruited 126 children using community based screening methods, and then children were randomized to one of three groups. Based on the success that we had with our first intervention we felt everybody deserved to get the standard community health worker intervention, so all three groups start with that as the ground work. Group two gets the air filter as our standard intervention, and then group three gets the enhanced intervention with both air filters and air conditioners. People were enrolled for a minimum of six months, for some up to 12 months, and our goal is to evaluate air quality, as well as children’s health. We have some of the environmental data to present today, and I’m going to turn it over to Stuart, who is going to describe a little bit about what we’ve found there. Stuart Batterman: Okay, thanks, Toby. As Toby is saying, one of the goals of this study is that to improve the exposure assessment component there have been a number of air filter studies and we thought we could enhance some of that exposure assessment activity, and so the three panels here show pictures of some equipment that was used in a predecessor study. The center panel is the equipment that we’re using currently, and this involves monitoring particulate matter on a filter, also optical counts of particles so that we can get real-time data, and I’ll show you a picture of this in a second. And, in addition to that, we’re also measuring CO2, VOCs and some environmental tracers for tobacco smoke. The instrumentation that we installed in a child’s bedroom provides in cases real-time measurements, and so what I’m showing in the first trace here, the red line, is the optical particle number concentration. When we deployed our sampling equipment, typically mid-week on a Wednesday and you can see the traces showing particle concentrations in the red line, for the smaller particles, less than one micron. In the blue we have one to five micrometer. Midweek, where this purple line says filter deployed, we placed this freestanding room air filter with a HEPA filter, a high efficiency filter, and you can see quite a dramatic drop in particle concentrations in both size ranges there. One of the enhancements that we put in the system was also to monitor filter usage, and the bottom trace at the bottom shows the speed, the fan speed in the filter ranging from turbo to high to medium to low to off, that the participants actually use the filter. So in this particular example of this household, they mostly use the filter, they shut it off on early Monday or at late Sunday, but they kept it on from medium to high to turbo, as we had instructed and wanted them to do. Some of these results are in several papers, this paper at the top came out last year, there’s two additional papers I believe. So just to give you some quantitative results of what we found here, we saw an average particle concentration of 26 micrograms in the homes that had the no filter, with the filter installed the particle concentration in the child’s room dropped down to 8.4 and this represents a 69% reduction. We saw comparable reductions in the particle counts in both, size fractions, as well. I mentioned that we had tracers that detected whether cigarette smoke was detected, and this table is showing some results that stratify the PM data by the detection. For homes that did not have the ETS tracer detected in no cigarette smoking we had about 27 micrograms, we had 39 micrograms where we did have the tracer detected. So we have about a 13 microgram, about a 50% increase in the child’s bedroom with smokers present. When we had filters, I’m sorry, without filters we had fairly comparable results, and then with filters the concentrations were brought down and yet there was still an increase that was pretty much the same, about 13, 14 micrograms with the smoker being present. So the take home points here are that filters make a difference, they bring down the concentration, whether there are smokers present or not. And the second important point here is that many of the homes that we studied, in fact, did have households and the effect of smoke was seen in the child’s bedroom. Another difference compared to previous filter studies is that we monitored filter use and this turned out to be a very important revealing aspect of the study. Here I’m showing the trend for filter use during three periods, week-long periods where we were monitoring concentrations with the equipment that I showed earlier in-house. The baseline week, folks were excited, they used the filters, the usage was very high, 97% of the time filters were on. After a season went by usage dropped by about 20%, 30% to about 68%, and that’s the usage that was maintained during a second follow-up seasonal visit. We also maintained these filters logging during the so-called inter-season periods, and what we found there and somewhat surprising initially but quite logical was that the filter usage dropped to about 26% on average when we weren’t present. And so what we’re seeing here is some changes in filter use in an intervention that we initially thought was quite passive, which turned out to, in fact, not be passive because the caregivers had the ability to turn on or turn off the air filter and, in fact, when we left the homes they often did turn it off. And so this is a potential bias in these types of studies and one that’s probably quite common in the filter studies. We did some follow-up investigation to try to understand what were the factors that affected this use pattern, and since there are some weak predictors that folks mentioned, the perception that it was expensive to run, that it was noisy, or that it produced a draft, but we really weren’t able to quantify these in any kind of strictly speaking quantitative relationship. Toby Lewis: So I think — I don’t have the health data to present today, but that’s — should be coming shortly, but I think we’ve already come away with some key lessons from these studies. So, first of all, parents are very invested in their kids’ health and they perceive asthma as important and they are eager, actually, very excited about our studies and eager for personalized help. The lay outreach model is very well accepted in our community and is something that we would advocate be expanded on a more national basis. We’ve seen the evidence that air filters have the potential to significantly reduce indoor PM and we’re hoping that with the combination of the personalized indoor environmental education from the lay outreach workers that the combination with the air filters will be effective with health. Clearly there are a lot of challenges that these families face, and we have found again and again that the staff characteristics are very important to the success of our interventions, particularly their patience, their persistence and their interpersonal skills. I think ongoing challenges that everyone encounters, that we have certainly seen, is that families have multiple stresses. We did our current study during the most recent recession, and when families are struggling with important basic needs they’re not always able to follow through on medical advice or environmental advice. We did provide a financial stipend for people to cover their electricity bill, but there was some sense that if your rates, if the electricity rates have gone up exponentially even though the stipend is covering your air filter people are still getting their electricity turned off at certain times, and that was certainly something that we encountered. Families also move in these troubling economic times, so that also created some challenges for maintaining environmental intervention effects. And, again, although there are some great strengths using lay outreach workers, you accept that you will need to do additional training and capacity building when you’re starting with people who may bring less experience to the job. I recognize that we’re running a little long, so I think I’m actually probably going to cut it off here. I’m going to just briefly say my acknowledgements. On the left-hand panel I have our organizational supporters, which include our funders, our community partner organizations, the Detroit Urban Research Center, which was our parent partnership, if you will. U of M departments and schools, who have funded parts of our work, as well as collaborative centers here at the University of Michigan, who have provided us with some pilot funds to work on elements of our research. And then on the right-hand side I have the people acknowledgements. First of all, the participating families and kids, which has been close to 600 families since our beginning. The individuals who serve on our steering committee, who spend their time and effort helping us. My colleagues, and particularly our dedicated staff, as well as all the many students, fellows, and volunteers that worked on our project. Thank you. Kimberly Gray: Thank you, that was a very good presentation, and we’re going to take a few questions and then open it up to all three speakers. The first question is some air filters are associated with the generation of ozone, which potentially could exacerbate asthma symptoms. Did you measure ozone in the study and are you certain that the air filters would not generate ozone? Stuart Batterman: Yes, these were filters that used the mechanical filter, basically, an enhanced paper, pleated filter. The questioner is correct there are ionizer units that are sold. There are warnings against their use by the consumer-protection folks and others, and those certainly aren’t the ones that we recommend. Kimberly Gray: Okay, next question is can you do a cost comparison between the operating of the filters or the AC versus the actual cost of a person taking children to the hospital or doctor offices or off work or the $0.50 per mile may be a wash or more expensive for a visit compared to electricity? Toby Lewis: We have not done the calculations, but I can tell you an emergency room visit is a lot more expensive than running these filters. I mean the monthly stipends — Stuart Batterman: The annualized cost of the particular filters that we were using, including filter replacement, is probably on the order of $200 a year. I don’t think that’s takes you very — Toby Lewis: Yes, I mean that’s two doctor visits, that’s a couple of copays of your meds, much less than a missed day of work or a few days of work. So I think it would be a very economic intervention. I think the lesson that I’m taking away from the slide that Stuart showed about filter use is that it’s not enough to just hand somebody a filter and say this is going to be good for the air and for your child’s health, go use it. I think there needs to be a lot of instruction and support in using it, and we had a lot of discussions about you advise people to close the bedroom door so that you get enhanced filtration in the bedroom, where the child is going to be sleeping, but there for different family reasons you may not want the kid behind a closed bedroom door, you may want that door open so you can hear them, particularly if you’re worried about their breathing in the middle of the night. So there is I think the true — for it to be a truly effective intervention there needs to be some support element, ideally in the home where you can see what the individual challenges that that family is going to have will be and help them brainstorm through that. Kimberly Gray: Okay, the next several questions I’m going to kind of combine because there seems to be a lot of interest in these air filters. So one question is what was the recirculation rate for the filters and were they maintained? And was the use of the filters with activated carbon considered? Stuart Batterman: Right. The airflow rate of the filters would depend on the fan speed that people used. These filters were a bit oversized in the sense that they could handle the space of a couple hundred square feet while most of the bedrooms in the community that we looked at were quite small. The flow rate I think is on the order of 100 to 200 cubic feet per hour, cubic meters per hour I believe, and that’s relatively high for that. The second question was? Kimberly Gray: Was the use of the filters in just one room considered to be adequate, and I think you’ve addressed that unless you want to elaborate on that? Stuart Batterman: Yes, yes, so these filters can be dropped in any place you have a plug, a wall outlet, and so that’s one of the reasons why we chose this particular intervention. There are better types of filters to use, if you can filter the house air by putting an enhanced filter in the house’s heating and ventilation air-conditioning system, if you have a forced air furnace, as do most American homes, you would filter the air quite effectively whenever you’re using the heater or the air conditioner, but you wouldn’t be filtering the air if the system is not on, so that’s one down side to that type of filter. Another point here is also important which is that these filters are actually removing particulate matter that comes from both internal sources in the home, like smoking, as well as outdoor air pollution from traffic or industry. The last part of the question was did we consider the use of activated carbon? The filters that we chose had a very thin carbon impregnated fabric in front. I don’t believe that is enough carbon to actually remove much of organics in the way of a deep bed filter. Those are considerably more expensive, however, and they have a higher energy draw, as well, and so in this intervention, which was really focused on looking at particulate matter, we didn’t use those. We did measure VOCs in the homes, which is a pollutant that would be removed by the activated carbon filter, and that’s probably a discussion of some length, but there wasn’t anything extraordinary about the VOC pollution that was found in these older homes for the most part. There are some VOCs that are found at high levels. Kimberly Gray: Another question — Stuart Batterman: Go ahead, Kim? Kimberly Gray: Okay, so other questions were related to did the family members actually get to keep the filters and the filtration units now? Toby Lewis: Yes, they got to keep the air filters and the air conditioners. All families got some basic educational brochures about asthma, as well as a medication valve holding chamber or a spacer, which allows inhaled medicines to be delivered more efficiently, so have to say that the way this child in this screen is taking his medicine is not the way we recommend. And we wanted to make sure that the families that were in the control groups also had some sort of takeaways that they could use ongoing after the study was over. All families also got dust mite encasements for the bedding and a vacuum cleaner to help with household cleaning. Kimberly Gray: Great. I have a question, actually. Toby, so a lot of lessons learned that I’m aware of, too, also come from [Peg Nagelson’s] work and [Pat Brice’s] from Hopkins, trying to implement these cleanup of indoor air through — and it just seems to be very difficult to be sustainable. So are there any attempts to really get to the root of the issues that behaviorally just may be what’s the problem in your area and how to gain success? And I’m wondering what other methods about messaging that may be just more, not more appropriate, you know, I’m looking at health literacy here, because it seems to be a common theme here. We’ve got brochures developed, that we think they’re working. These are health tips that should be sustainable — what do you think the barrier besides cost is for your specific community? Toby Lewis: That’s where I would go back to the multiple competing priorities of the families. I mean I think the fact that you can get improvements in the short run tells me that people can understand the messages that you’re giving and they can actually do it. Now it may require some support in the beginning, but it’s an achievable goal. I think the sustainability factor really just goes to people worried about putting food on the table and keeping a roof over their head, and other family members that get sick, and routines get disrupted and people move, and trying to fit in home environmental measures into the multiple priorities that people have is just really tough. And whether some sort of a sustaining community outreach worker will do the trick, that would be one idea. Having — we have talked about the idea of having sort of public housing based community support groups, like peer support groups, so that you and all the other parents of kids with asthma can get together and talk about things and give each other tips and advice. But I think it’s just hard to, behavior change is hard in general, and doing something that requires multiple different activities over a long haul is just a tough problem. Kimberly Gray: Excellent answer. Sheela, it’s kind of a similar question to you, as well. I mean the PEHSUs have worked very hard through support from EPA and ATSDR to develop those brochures, and was just wondering for a messaging like where phthalates come from, BPA, why they have causes of concern, do you think those brochures and pamphlets, which really have broader implication and outreach to the community, we would hope would be effective, especially for those that don’t have the benefit of having a community advisory board or outreach from their local physicians, what can we do to improve them? Because it really does seem that that’s the model that we need to use so that we have broader outreach. Sheela Sathyanarayana: Yes, I mean I think the handouts in and of themselves are not — they can be really useful, but I think that there needs to be multimodes of education and they need to be given to families and patients with contextualization. So they can’t just be handed out and say take this home and read it, it needs to be handed out in the context of I think this is important or we think this is important for you and your family to prevent these health effects. It’s, and also there needs to be other modes, like maybe Internet based modules or the option for having an in-person education. And a great example of that is the American Lung Association here in Washington State, the Washington Chapter, they will go out to homes and inspect those homes and give families advice on how to create a more healthy environment. And Toby and Stuart probably know a lot about that, but that’s one of the ways that we help our families reduce environmental exposures within their homes, on top of the brochures and the education we give them in the clinical setting. Kimberly Gray: Thank you, all. We’re coming to the end now. We still have a few unanswered questions, but we’ll make sure they get back to the respective speaker and be answered. Again, most of them are pretty generalized, some issues with IPM, difficult to implement some of the issues between organic, nonorganic diet, and pesticides, which I’m sure, Sheela, that those are for you, as well as some more questions about education information on food allergies as it relates to asthma. So we’ll pick up those and have those speakers answer those offline, and I’m just going to do a few little housekeeping here. Thanks, everybody, especially our speakers, for participating in today’s session. And we’d like your feedback. It’s very important. After today’s webinar please take a moment to fill out the short evaluation form. It’s really vital to help Liam and others here who are supporting PEHP to ensure that they’re providing the highest quality speakers and the information to meet your needs, our participants. 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