Indoor Air Pollution and Children With Asthma: An Intervention Trial

We have designed a randomized, double-blind, triple cross-over intervention study to examine
the efficacy of indoor NO2 reduction on reducing asthma severity. Since particles and NO2 are
both byproducts of combustion and associated with gas stove use, the intervention protocol
includes a condition using a filter designed to remove particles also implicated in asthma
exacerbations (e.g., coarse, fine and ultrafine particles including airborne mold spores and
allergens) while leaving NO2 virtually untouched. Primary and secondary aims of the trial
include, respectively, determining whether reducing exposure to NO2 and particles compared to
a "control" (non-filtered) condition results in a clinically significant reduction in asthma
severity measured by a difference in days of symptoms between intervention arms.

Families with asthmatic children age 5-11 will be recruited from selected communities using
a: (1) flyers distributed in elementary schools, (2) postcards send to families from
purchased mailing lists, (3) posters placed in community buildings (libraries, clinics,
etc.), (4) online (Facebook, Craigslist), and (5) letter mailed to families targeted through
Yale Joint Data Analytics Team (JDAT). Volunteers will be screened for preliminary
eligibility based on household characteristics and active asthmatic status. Potentially
eligible families will have homes with a gas cooking stove and seven rooms or fewer.
Potentially eligible children will be aged 5-11; have asthma symptoms and/or medication use
consistent with severity score categories 2 (mild persistent), 3 (moderate), or 4 (severe)
during the previous 12 months; and reside at least 5 days and nights every week in the
eligible home.

Households meeting these preliminary criteria will be asked to participate in passive NO2
sampling. A single Palmes tube will be sent to the home for placement in the main living
space for one week. Families will be called after one week and instructed to cap and return
the NO2 monitor in a pre-paid mailer. Families of children living in homes where the one-week
integrated average NO2 concentration is ≥ 15 ppb will be invited to participate. We will
permit enrollment of more than one eligible child per family. Participating families will be
randomized into one of 6 treatment sequences each requiring 3 periods of 4-weeks preceded by
a 1-week washout period. Randomization will be blocked so that for every 18 subjects
randomized there will be 3 in each sequence. Randomization will be conducted blindly by the
data management department such that each scheduled initial interview/air cleaner
installation is assigned a treatment sequence (referring to machines and filters already on
site). Minimization techniques will be used to balance the randomized allocation as
necessary. Total subject participation time up to 18 weeks.

Inclusion Criteria:

- 5-11 years of age, enrolled in grades K-5 and living in the recruitment area (CT, MA)

- [The screening questionnaire will determine asthma symptoms in the past 12 months
(wheeze, persistent cough, shortness of breath, chest tightness); and asthma
medication use in the past 12 months (short-acting β2-agonists, long-acting
β2-agonists, inhaled steroids, oral steroids, theophylline, cromones, and/or
leukotriene inhibitors). Based on symptoms and medication, asthma severity will be
categorized with a score adapted from the Global Initiative for Asthma guidelines
(1=mild transient, 2=mild persistent, 3=moderate, 4=severe). Only children in
categories 2 (mild persistent, 3 (moderate) or 4 (severe) will be eligible.]

- For potential subjects satisfying these inclusion criteria, a passive NO2 monitor will
be sent to the home for placement in the main living space for one week. Families will
be called after one week and instructed to cap and return the NO2 monitor in a
pre-paid mailer. Families of children living in homes where the one-week integrated
average NO2 concentration is ≥ 15 ppb will be invited to participate. We will permit
the enrollment of more than one eligible child per family.

Exclusion Criteria:

- Using steroid medication for a condition other than asthma

- Chronic respiratory condition other than asthma

- Intention to move or relocate within 6 months