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. 2019 Sep;74(9):849-857.
doi: 10.1136/thoraxjnl-2018-212979. Epub 2019 Aug 14.

Damp mouldy housing and early childhood hospital admissions for acute respiratory infection: a case control study

Tristram Ingham  1 , Michael Keall  2 , Bernadette Jones  3 , Daniel R T Aldridge  3 , Anthony C Dowell  4 , Cheryl Davies  5 , Julian Crane  3 , Jessica Barbara Draper  3   5 , Lauren Olivia Bailey  3 , Helen Viggers  2 , Thorsten Villiers Stanley  6   7 , Philip Leadbitter  8 , Mereana Latimer  5 , Philippa Howden-Chapman  2
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Damp mouldy housing and early childhood hospital admissions for acute respiratory infection: a case control study

Tristram Ingham et al. Thorax. 2019 Sep.

Abstract

Introduction: A gap exists in the literature regarding dose-response associations of objectively assessed housing quality measures, particularly dampness and mould, with hospitalisation for acute respiratory infection (ARI) among children.

Methods: A prospective, unmatched case-control study was conducted in two paediatric wards and five general practice clinics in Wellington, New Zealand, over winter/spring 2011-2013. Children aged <2 years who were hospitalised for ARI (cases), and either seen in general practice with ARI not requiring admission or for routine immunisation (controls) were included in the study. Objective housing quality was assessed by independent building assessors, with the assessors blinded to outcome status, using the Respiratory Hazard Index (RHI), a 13-item scale of household quality factors, including an 8-item damp-mould subscale. The main outcome was case-control status. Adjusted ORs (aORs) of the association of housing quality measures with case-control status were estimated, along with the population attributable risk of eliminating dampness-mould on hospitalisation for ARI among New Zealand children.

Results: 188 cases and 454 controls were studied. Higher levels of RHI were associated with elevated odds of hospitalisation (OR 1.11/unit increase (95% CI 1.01 to 1.21)), which weakened after adjustment for season, housing tenure, socioeconomic status and crowding (aOR 1.04/unit increase (95% CI 0.94 to 1.15)). The damp-mould index had a significant, adjusted dose-response relationship with ARI admission (aOR 1.15/unit increase (95% CI 1.02 to 1.30)). By addressing these harmful housing exposures, the rate of admission for ARI would be reduced by 19% or 1700 fewer admissions annually.

Conclusions: A dose-response relationship exists between housing quality measures, particularly dampness-mould, and young children's ARI hospitalisation rates. Initiatives to improve housing quality and to reduce dampness-mould would have a large impact on ARI hospitalisation.

Keywords: acute respiratory infections; child health; dampness; housing quality; mould; public health policy.

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Conflict of interest statement

Competing interests: All authors have completed the International Committee of Medical Journal Editors uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare the following: TI reports grants from the Health Research Council of New Zealand during the conduct of the study, grants from Janssen Research and Development, and others from AstraZeneca outside the submitted work. MK, CD, JC, HV and ML report grants from the Health Research Council of New Zealand during the conduct of the study. BJ, DRTA, JBD and LOB report grants from the Health Research Council of New Zealand during the conduct of the study and grants from Janssen Research and Development outside the submitted work. ACD, TVS and PI report that they have nothing to disclose. PH-C reports grants from the Health Research Council of New Zealand and the Ministry of Business, Innovation and Employment during the conduct of the study. The lead author affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

Figures

Figure 1
Figure 1
Recruitment flow diagram. HHI, Healthy Housing Index.
Figure 2
Figure 2
DAG demonstrating causal relationships and potential biasing pathways affecting the association between housing quality and ARI hospitalisation (produced using DAGitty V.2.3 software). In this conceptual diagram, each circle represents an individual exposure (‘node’) of theoretical relevance to this hypothesis; each node is interconnected by directional arrows (‘edges’) that represent theoretical associations based on the researchers’ assessment of a priori literature and determination of biological plausibility. Housing quality (RHI and/or Damp–Mould index as proxy) is the exposure of interest (green node with black border), with ARI hospitalisation (blue node with black border) as the outcome of interest. The association of interest, therefore, is the edge represented by the green arrow connecting the exposure and outcome. Age, gender, secondhand smoke exposure and BMI (blue nodes with blue borders) are theoretically causally associated with (ie, ancestors of) the outcome alone. In this instance, all the other exposures (‘nodes’) are theoretically causally associated with (ie, ancestors of) both the exposure and the outcome. To adjust for confounding in the association of interest, it is necessary to close all ‘backdoor pathways’ between the exposure and outcome (ie, any pathway (consisting of a series of one or more edges and nodes) that provides an alternate route between the exposure and outcome); this is accomplished by adjusting for at least one node on that path. The minimally sufficient adjustment set is the combination of the fewest nodes that, being ancestors of both the exposure and outcome, if selected, effectively block all backdoor pathways between the exposure and the outcome (white nodes with black borders). These ‘adjusted variables’ are then introduced into the multivariate modelling as potential confounders. No other ancestors (blue, red or green nodes) are necessary (or appropriate) to include in the model as potential confounders. ARI, acute respiratory infection; BMI, body mass index; CNOS, Canadian National Occupancy Standard; DAG, directed acyclic graph; NZiDep, New Zealand Index of Socioeconomic Deprivation; RHI, Respiratory Hazard Index.
See this image and copyright information in PMC

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