Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma
Authors: Wanda Phipatanakul, Petros Koutrakis, Brent A. Coull, Carter R. Petty, Jonathan M. Gaffin, William J. Sheehan, Peggy S. Lai, Lisa M. Bartnikas, Choong-Min Kang, Jack M. Wolfson, Mihail Samnaliev, Amparito Cunningham, Sachin N. Baxi, Perdita Permaul, Marissa Hauptman, Michelle Trivedi, Margee Louisias, Liming Liang, Peter S. Thorne, Nervana Metwali, Gary Adamkiewicz, Elliot Israel, Andrea A. Baccarelli, Diane R. Gold, David Kantor, Nicole Akar-Ghibril, Sigfus Gunnlaugsson, Brittany Esty, Elena Crestani, Michelle Maciag, Elizabeth Burke-Roberts, Tina Banzon, Samantha Minnicozzi, Ahmad Sedaghat, Medina Jackson, Nicole Comfort, Edie Weller, Anna Cristina Vasquez-Muniz, Vanessa Konzelman, Giselle Garcia, Sullivan Waskosky, Anna Cristina Ramsey, Ethan Ansel-Kelly, Vaia Bairaktaris, Darin Bell, Nicole Adler, Reid Mathews, Hana B. Ruran, Brian Volonte, John Pacheco, Aiza Zia, Julianne Saia, Alma Castillo-Hernandez, Benjamin Peterson, Jennifer Rooney, Robert Rega, Anne Bailey, Kimberly Greco, Thanaporn Ratchataswan, Stravoula Osganian
Journal: JAMA (2021)

<h3>Importance</h3> School and classroom allergens and particles are associated with asthma morbidity, but the benefit of environmental remediation is not known. <h3>Objective</h3> 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. <h3>Design, Setting, and Participants</h3> 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. <h3>Interventions</h3> 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. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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 (<i>P</i> = .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. <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02291302