Asthma and Pest Control Study: Demonstrating Return-on-Investment for In-Home Pest Control for Children With Persistent Asthma

The New York City Department of Health and Mental Hygiene (DOHMH) and Montefiore Medical
Center, with the Fund for Public Health of New York, DOHMH's fiscal agent, have partnered on
a study to evaluate the feasibility, health outcomes and return-on-investment of a single
integrated pest management (IPM) intervention for Bronx, Harlem and Northern Manhattan
children aged 5 to 12 with persistent asthma who are living in homes with pests. Principal
Investigator (PI) Daniel Kass, MSPH, Deputy Commissioner of the DOHMH Division of
Environmental Health, has extensive experience overseeing evaluation of program and policy
initiatives, and co-PI Marina Reznik, MD, MS, Associate Professor of Pediatrics at
Montefiore, has conducted research on evaluating the impact of a home-based asthma
intervention on asthma-related outcomes in children with persistent asthma recruited from
Montefiore clinics.

Asthma is the most common childhood disease in New York City, and both prevalence and
hospitalization rates are highest in high-poverty neighborhoods. The greatest individual and
community-level factor associated with asthma disparities is varying exposure to triggers in
the home, most notably cockroaches and mice. Asthma health care costs are significant, and
prevention efforts to reduce triggers could result in improved outcomes and significant cost
savings. Unlike traditional pest control, which relies solely on pesticides, IPM eliminates
pests and prevents re-infestation by addressing housing conditions conducive to pests and
with safe, targeted use of pesticides.

The specific goals of the project are to:

- Demonstrate the feasibility of implementing a basic IPM intervention in the homes of
children aged 5-12 years with persistent asthma or current prescription for controller
medication and past-year history of asthma-related urgent care visits living in
households with pest problems.

- Evaluate changes in asthma outcomes and asthma-related health system utilization
associated with the IPM intervention.

- Assess the costs and return-on-investment (ROI) for the IPM intervention.

- Report findings and support policies to adopt insurance reimbursement for basic IPM
interventions embedded in health service delivery to prevent asthma exacerbations due to
pest triggers in the home.

HealthFirst and Affinity, among the largest insurers of pediatric patients in the Bronx, are
collaborating with the research team, providing support in recruitment and use of their data
on health outcomes among study participants for the evaluation. The research team is also
working with pest control experts to establish a well-priced and replicable protocol for IPM
best practice. The protocol will build upon DOHMH's prior work to evaluate IPM in public
housing, which demonstrated significant reductions in pest populations and allergens in
kitchens and bedrooms, with sustained effects. The study aims to contribute to a
best-practice model for one-time IPM service in the home that is not only effective in
reducing asthma triggers but also practical and readily adoptable in the pest control
industry, replacing the current pesticides-only approach. This groundwork is critical to
efforts to scale up to meet demand, should IPM intervention become a reimbursable service in
asthma care for high-risk children.

This two-year research project will employ a prospective, randomized controlled study design
with the random assignment of 400 participants to two groups: intervention and control.
Participants in both groups will be followed for a 12-month period with three assessments: at
baseline (when recruited), 6 months, and 12 months after-recruitment. The intervention group
will receive the IPM service within 2-4 weeks of completion of the baseline assessment. In
addition to the intervention, the family will be provided with basic information about good
pest-control practices, such as appropriate food storage, and be given a set of food storage
containers. The control group will be provided basic pest control information at baseline and
will be offered the equivalent intervention, information, and food storage containers after
completion of their 12-month assessment. The primary clinical outcome measures will be:
asthma-related urgent care (unscheduled ambulatory) visits, asthma-related emergency
department (ED) visits, and asthma-related hospitalizations.

The evaluation of this proposed initiative will assess the intervention implementation and
costs, its impact on health outcomes, healthcare cost savings or ROI.

This project targets low-income children with the potential to significantly improve their
health and well-being. The study has been designed to evaluate an inexpensive and scalable
environmental intervention for asthma that can be replicated in other New York City
neighborhoods and incorporated into any urban healthcare setting in New York State and
nationwide. By demonstrating cost effectiveness, this study could provide the basis for
health insurance coverage of an IPM visit embedded in clinical treatment plans for high-risk
asthma patients living with pests.

Inclusion Criteria:

1. Current residence in the Bronx, Harlem and Northern Manhattan with no plans to move
within the recruitment period (3 months) outside the Bronx, Harlem or Northern
Manhattan

a. Families with plans to move within the recruitment period to another location in
the Bronx, Harlem, or Northern Manhattan will be placed on list to be called at the
end of the recruitment period to reassess eligibility at that time, if the sample size
has not yet been achieved.

2. Age: 5-12 years

3. Persistent asthma or currently prescribed inhaled corticosteroids/other prevention
medication

Persistent asthma (including mild, moderate or severe), according to National Heart
Lung and Blood Institute (NHLBI) criteria:

i. Experiencing symptoms more than 2 days per week in past month ii. Awaking at night
due to symptoms more than 2 times per month iii. Use of SABA meds (i.e., albuterol)
for symptom control (not prevention) more than 2 days per week in past month iv. Any
interference with daily activity v. Having exacerbations requiring oral systemic
corticosteroids 2 or more time per year

4. Any past-year urgent care visits for asthma:

1. ED visits

2. Hospitalizations

5. Parent-reported pest infestation - cockroaches or mice - in the home

6. Have a working phone

7. Caregiver primary language of English or Spanish

Exclusion Criteria:

1. Child living in foster care

2. Current residence in shelter or other similar temporary accommodation in the Bronx,
Harlem, or Northern Manhattan