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Randomized Controlled Trial
. 2021 Sep 7;326(9):839-850.
doi: 10.1001/jama.2021.11559.

Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma: A Randomized Clinical Trial

Wanda Phipatanakul  1   2 , Petros Koutrakis  3 , Brent A Coull  3   4 , Carter R Petty  5 , Jonathan M Gaffin  2   6 , William J Sheehan  1   7 , Peggy S Lai  2   8 , Lisa M Bartnikas  1   2 , Choong-Min Kang  3 , Jack M Wolfson  3 , Mihail Samnaliev  5 , Amparito Cunningham  1 , Sachin N Baxi  1   2 , Perdita Permaul  9   10 , Marissa Hauptman  2   11 , Michelle Trivedi  12 , Margee Louisias  13 , Liming Liang  4 , Peter S Thorne  14 , Nervana Metwali  14 , Gary Adamkiewicz  3 , Elliot Israel  3   15 , Andrea A Baccarelli  16 , Diane R Gold  2   3   17 ; School Inner-City Asthma Intervention study team
Collaborators, Affiliations
Randomized Controlled Trial

Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma: A Randomized Clinical Trial

Wanda Phipatanakul et al. JAMA. .

Abstract

Importance: School and classroom allergens and particles are associated with asthma morbidity, but the benefit of environmental remediation is not known.

Objective: To determine whether use of a school-wide integrated pest management (IPM) program or high-efficiency particulate air (HEPA) filter purifiers in the classrooms improve asthma symptoms in students with active asthma.

Design, setting, and participants: Factorial randomized clinical trial of a school-wide IPM program and HEPA filter purifiers in the classrooms was conducted from 2015 to 2020 (School Inner-City Asthma Intervention Study). There were 236 students with active asthma attending 41 participating urban elementary schools located in the Northeastern US who were randomized to IPM by school and HEPA filter purifiers by classroom. The date of final follow-up was June 20, 2020.

Interventions: The school-wide IPM program consisted of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for school staff. Infestation was assessed every 3 months, with additional treatments as needed. Control schools received no IPM, cleaning, or education. Classroom portable HEPA filter purifiers were deployed and the filters were changed every 3 months. Control classrooms received sham HEPA filters that looked and sounded like active HEPA filter purifiers. Randomization was done independently (split-plot design), with matching by the number of enrolled students to ensure a nearly exact 1:1 student ratio for each intervention with 118 students randomized to each group. Participants, investigators, and those assessing outcomes were blinded to the interventions.

Main outcomes and measures: The primary outcome was the number of symptom-days with asthma during a 2-week period. Symptom-days were assessed every 2 months during the 10 months after randomization.

Results: Among the 236 students who were randomized (mean age, 8.1 [SD, 2.0] years; 113 [48%] female), all completed the trial. At baseline, the 2-week mean was 2.2 (SD, 3.9) symptom-days with asthma and 98% of the classrooms had detectable levels of mouse allergen. The results were pooled because there was no statistically significant difference between the 2 interventions (P = .18 for interaction). During a 2-week period, the mean was 1.5 symptom-days with asthma after use of the school-wide IPM program vs 1.9 symptom-days after no IPM across the school year (incidence rate ratio, 0.71 [95% CI, 0.38-1.33]), which was not statistically significantly different. During a 2-week period, the mean was 1.6 symptom-days with asthma after use of HEPA filter purifiers in the classrooms vs 1.8 symptom-days after use of sham HEPA filter purifiers across the school year (incidence rate ratio, 1.47 [95% CI, 0.79-2.75]), which was not statistically significantly different. There were no intervention-related adverse events.

Conclusions and relevance: Among children with active asthma, use of a school-wide IPM program or classroom HEPA filter purifiers did not significantly reduce symptom-days with asthma. However, interpretation of the study findings may need to consider allergen levels, particle exposures, and asthma symptoms at baseline.

Trial registration: ClinicalTrials.gov Identifier: NCT02291302.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Phipatanakul reported receiving nonfinancial support from Coway Co Ltd (provided HEPA filter intervention), ALK-Abelló (provided skin testing reagents), and Monaghen (provided aerochambers); receiving grants from Thermo Fisher and the National Institutes of Health; receiving consulting fees from Genentech/Novartis, Regeneron/Sanofi, and GlaxoSmithKline; receiving funding, clinical trial support, and medications from Genentech/Novartis, Regeneron/Sanofi, and GlaxoSmithKline; and receiving clinical trial medication support from Bohringer Ingelheim, AstraZeneca, Merck, and CSL Behring. Dr Coull reported receiving grants from Apple Inc. Dr Sheehan reported receiving consulting fees from GlaxoSmithKline for serving on an advisory board. Dr Louisias reported receiving grants from the Brigham and Women’s Hospital Nesson Fellowship. Dr Israel reported receiving personal fees from the National Asthma Education and Prevention Program for serving on the coordinating committee, which advises on the asthma guidelines for the US. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow of Students in the School Inner-City Asthma Intervention Study
All students who were randomized received an intervention throughout the school year.
Figure 2.
Figure 2.. Integrated Pest Management vs No Integrated Pest Management During the School Year for the Primary Outcome of Symptom-Days With Asthma
Data were collected from 2015 through 2020. IRR indicates incidence rate ratio.
See this image and copyright information in PMC

Comment in

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