Association Between Allergen Exposure in Inner-City Schools and Asthma Morbidity Among Students | Allergy and Clinical Immunology | JAMA Pediatrics | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Centers for Disease Control and Prevention (CDC).  Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001-2009.  MMWR Morb Mortal Wkly Rep. 2011;60(17):547-552.PubMedGoogle Scholar
Hasegawa  K, Tsugawa  Y, Brown  DF, Camargo  CA  Jr.  Childhood asthma hospitalizations in the United States, 2000-2009.  J Pediatr. 2013;163(4):1127-1133.e3.PubMedGoogle ScholarCrossref
Beck  AF, Huang  B, Simmons  JM,  et al.  Role of financial and social hardships in asthma racial disparities.  Pediatrics. 2014;133(3):431-439.PubMedGoogle ScholarCrossref
Rosenstreich  DL, Eggleston  P, Kattan  M,  et al.  The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma.  N Engl J Med. 1997;336(19):1356-1363.PubMedGoogle ScholarCrossref
Morgan  WJ, Crain  EF, Gruchalla  RS,  et al; Inner-City Asthma Study Group.  Results of a home-based environmental intervention among urban children with asthma.  N Engl J Med. 2004;351(11):1068-1080.PubMedGoogle ScholarCrossref
Permaul  P, Hoffman  E, Fu  C,  et al.  Allergens in urban schools and homes of children with asthma.  Pediatr Allergy Immunol. 2012;23(6):543-549.PubMedGoogle ScholarCrossref
Sheehan  WJ, Rangsithienchai  PA, Muilenberg  ML,  et al.  Mouse allergens in urban elementary schools and homes of children with asthma.  Ann Allergy Asthma Immunol. 2009;102(2):125-130.PubMedGoogle ScholarCrossref
Abramson  SL, Turner-Henson  A, Anderson  L,  et al.  Allergens in school settings: results of environmental assessments in 3 city school systems.  J Sch Health. 2006;76(6):246-249.PubMedGoogle ScholarCrossref
Chew  GL, Correa  JC, Perzanowski  MS.  Mouse and cockroach allergens in the dust and air in northeastern United States inner-city public high schools.  Indoor Air. 2005;15(4):228-234.PubMedGoogle ScholarCrossref
Berge  M, Munir  AK, Dreborg  S.  Concentrations of cat (Fel d1), dog (Can f1) and mite (Der f1 and Der p1) allergens in the clothing and school environment of Swedish schoolchildren with and without pets at home.  Pediatr Allergy Immunol. 1998;9(1):25-30.PubMedGoogle ScholarCrossref
Munir  AK, Einarsson  R, Schou  C, Dreborg  SK.  Allergens in school dust, I: the amount of the major cat (Fel d I) and dog (Can f I) allergens in dust from Swedish schools is high enough to probably cause perennial symptoms in most children with asthma who are sensitized to cat and dog.  J Allergy Clin Immunol. 1993;91(5):1067-1074.PubMedGoogle ScholarCrossref
Almqvist  C, Wickman  M, Perfetti  L,  et al.  Worsening of asthma in children allergic to cats, after indirect exposure to cat at school.  Am J Respir Crit Care Med. 2001;163(3, pt 1):694-698.PubMedGoogle ScholarCrossref
Salo  PM, Sever  ML, Zeldin  DC.  Indoor allergens in school and day care environments.  J Allergy Clin Immunol. 2009;124(2):185-194.e181-e189.PubMedGoogle ScholarCrossref
Phipatanakul  W, Bailey  A, Hoffman  EB,  et al.  The School Inner-City Asthma Study: design, methods, and lessons learned.  J Asthma. 2011;48(10):1007-1014.PubMedGoogle ScholarCrossref
Mitchell  H, Senturia  Y, Gergen  P,  et al.  Design and methods of the National Cooperative Inner-City Asthma Study.  Pediatr Pulmonol. 1997;24(4):237-252.PubMedGoogle ScholarCrossref
Redline  S, Gruchalla  RS, Wolf  RL,  et al.  Development and validation of school-based asthma and allergy screening questionnaires in a 4-city study.  Ann Allergy Asthma Immunol. 2004;93(1):36-48.PubMedGoogle ScholarCrossref
Miller  MR, Hankinson  J, Brusasco  V,  et al; ATS/ERS Task Force.  Standardisation of spirometry.  Eur Respir J. 2005;26(2):319-338.PubMedGoogle ScholarCrossref
Smedje  G, Norbäck  D, Edling  C.  Asthma among secondary schoolchildren in relation to the school environment.  Clin Exp Allergy. 1997;27(11):1270-1278.PubMedGoogle ScholarCrossref
Arbes  SJ  Jr, Sever  M, Vaughn  B,  et al.  Feasibility of using subject-collected dust samples in epidemiologic and clinical studies of indoor allergens.  Environ Health Perspect. 2005;113(6):665-669.PubMedGoogle ScholarCrossref
King  EM, Filep  S, Smith  B,  et al.  A multi-center ring trial of allergen analysis using fluorescent multiplex array technology.  J Immunol Methods. 2013;387(1-2):89-95.PubMedGoogle ScholarCrossref
Gruchalla  RS, Pongracic  J, Plaut  M,  et al.  Inner City Asthma Study: relationships among sensitivity, allergen exposure, and asthma morbidity.  J Allergy Clin Immunol. 2005;115(3):478-485.PubMedGoogle ScholarCrossref
Ownby  DR, Johnson  CC, Peterson  EL.  Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age.  JAMA. 2002;288(8):963-972.PubMedGoogle ScholarCrossref
Ingram  JM, Sporik  R, Rose  G, Honsinger  R, Chapman  MD, Platts-Mills  TA.  Quantitative assessment of exposure to dog (Can f 1) and cat (Fel d 1) allergens: relation to sensitization and asthma among children living in Los Alamos, New Mexico.  J Allergy Clin Immunol. 1995;96(4):449-456.PubMedGoogle ScholarCrossref
Perzanowski  MS, Rönmark  E, Nold  B, Lundbäck  B, Platts-Mills  TA.  Relevance of allergens from cats and dogs to asthma in the northernmost province of Sweden: schools as a major site of exposure.  J Allergy Clin Immunol. 1999;103(6):1018-1024.PubMedGoogle ScholarCrossref
Sporik  R, Squillace  SP, Ingram  JM, Rakes  G, Honsinger  RW, Platts-Mills  TA.  Mite, cat, and cockroach exposure, allergen sensitisation, and asthma in children: a case-control study of three schools.  Thorax. 1999;54(8):675-680.PubMedGoogle ScholarCrossref
Ownby  DR.  Will the real inner-city allergen please stand up?  J Allergy Clin Immunol. 2013;132(4):836-837.PubMedGoogle ScholarCrossref
Ahluwalia  SK, Peng  RD, Breysse  PN,  et al.  Mouse allergen is the major allergen of public health relevance in Baltimore City.  J Allergy Clin Immunol. 2013;132(4):830-835.e1-2.PubMedGoogle ScholarCrossref
Matsui  EC, Eggleston  PA, Buckley  TJ,  et al.  Household mouse allergen exposure and asthma morbidity in inner-city preschool children.  Ann Allergy Asthma Immunol. 2006;97(4):514-520.PubMedGoogle ScholarCrossref
Pongracic  JA, Visness  CM, Gruchalla  RS, Evans  R  III, Mitchell  HE.  Effect of mouse allergen and rodent environmental intervention on asthma in inner-city children.  Ann Allergy Asthma Immunol. 2008;101(1):35-41.PubMedGoogle ScholarCrossref
Kattan  M, Stearns  SC, Crain  EF,  et al.  Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma.  J Allergy Clin Immunol. 2005;116(5):1058-1063.PubMedGoogle ScholarCrossref
Busse  WW, Morgan  WJ, Gergen  PJ,  et al.  Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children.  N Engl J Med. 2011;364(11):1005-1015.PubMedGoogle ScholarCrossref
Pacheco  KA, McCammon  C, Liu  AH,  et al.  Airborne endotoxin predicts symptoms in non–mouse-sensitized technicians and research scientists exposed to laboratory mice.  Am J Respir Crit Care Med. 2003;167(7):983-990.PubMedGoogle ScholarCrossref
Rabito  FA, Carlson  J, Holt  EW, Iqbal  S, James  MA.  Cockroach exposure independent of sensitization status and association with hospitalizations for asthma in inner-city children.  Ann Allergy Asthma Immunol. 2011;106(2):103-109.PubMedGoogle ScholarCrossref
Gautrin  D, Ghezzo  H, Infante-Rivard  C, Malo  JL.  Natural history of sensitization, symptoms and occupational diseases in apprentices exposed to laboratory animals.  Eur Respir J. 2001;17(5):904-908.PubMedGoogle ScholarCrossref
Trompette  A, Divanovic  S, Visintin  A,  et al.  Allergenicity resulting from functional mimicry of a Toll-like receptor complex protein.  Nature. 2009;457(7229):585-588.PubMedGoogle ScholarCrossref
Herre  J, Grönlund  H, Brooks  H,  et al.  Allergens as immunomodulatory proteins: the cat dander protein Fel d 1 enhances TLR activation by lipid ligands.  J Immunol. 2013;191(4):1529-1535.PubMedGoogle ScholarCrossref
Original Investigation
Journal Club
January 2017

Association Between Allergen Exposure in Inner-City Schools and Asthma Morbidity Among Students

Journal Club PowerPoint Slide Download
Author Affiliations
  • 1Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston
  • 4Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
  • 5Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
  • 6Division of Respiratory Diseases, Boston Children’s Hospital, Boston, Massachusetts
  • 7Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston
  • 8Channing Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Pediatr. 2017;171(1):31-38. doi:10.1001/jamapediatrics.2016.2543
Key Points

Question  What is the effect of school-specific aeroallergen exposures on students’ asthma morbidity?

Findings  In this cohort study evaluating students with asthma, higher mouse allergen exposure at school was significantly associated with both increased asthma symptoms and lower lung function, independent of allergic sensitization and allergen exposure in the home.

Meaning  The school environment is an important contributor to childhood asthma morbidity, and future school-based environmental interventions may benefit all children with asthma.


Importance  Home aeroallergen exposure is associated with increased asthma morbidity in children, yet little is known about the contribution of school aeroallergen exposures to such morbidity.

Objective  To evaluate the effect of school-specific aeroallergen exposures on asthma morbidity among students, adjusting for home exposures.

Design, Setting, and Participants  The School Inner-City Asthma Study was a prospective cohort study evaluating 284 students aged 4 to 13 years with asthma who were enrolled from 37 inner-city elementary schools in the northeastern United States between March 1, 2008, and August 31, 2013. Enrolled students underwent baseline clinical evaluations before the school year started and were then observed clinically for 1 year. During that same school year, classroom and home dust samples linked to the students were collected and analyzed for common indoor aeroallergens. Associations between school aeroallergen exposure and asthma outcomes during the school year were assessed, adjusting for home exposures.

Exposures  Indoor aeroallergens, including rat, mouse, cockroach, cat, dog, and dust mites, measured in dust samples collected from inner-city schools.

Main Outcomes and Measures  The primary outcome was maximum days in the past 2 weeks with asthma symptoms. Secondary outcomes included well-established markers of asthma morbidity, including asthma-associated health care use and lung function, measured by forced expiratory volume in 1 second.

Results  Among 284 students (median age, 8 years [interquartile range, 6-9 years]; 148 boys and 136 girls), exposure to mouse allergen was detected in 441 (99.5%) of 443 school dust samples, cat allergen in 420 samples (94.8%), and dog allergen in 366 samples (82.6%). Levels of mouse allergen in schools were significantly higher than in students’ homes (median settled dust level, 0.90 vs 0.14 µg/g; P < .001). Exposure to higher levels of mouse allergen in school (comparing 75th with 25th percentile) was associated with increased odds of having an asthma symptom day (odds ratio, 1.27; 95% CI, 1.05-1.54; P = .02) and 4.0 percentage points lower predicted forced expiratory volume in 1 second (95% CI, –6.6 to –1.5; P = .002). This effect was independent of allergic sensitization. None of the other indoor aeroallergens were associated with worsening asthma outcomes.

Conclusions and Relevance  In this study of inner-city students with asthma, exposure to mouse allergen in schools was associated with increased asthma symptoms and decreased lung function. These findings demonstrate that the school environment is an important contributor to childhood asthma morbidity. Future school-based environmental interventions may be beneficial for this important public health problem.