A Community-Based Participatory Research Approach to Hurricane Katrina: When Disasters, Environmental Health Threats, and Disparities Collide.

In 2005, Hurricane Katrina resulted in long-term flooding of 80% of New Orleans, Louisiana. Mold-infested homes gave rise to concerns about increased childhood asthma. To address these concerns, a diverse community-academic partnership used a community-based participatory research (CBPR) approach to implement the Head-off Environmental Asthma in Louisiana (HEAL) study in 2007.The study examined the relationship between post-Katrina mold and other environmental exposures and asthma morbidity, while testing an asthma counselor (AC) intervention. Both the AC intervention and the CBPR approach were effectively implemented in the postdisaster setting. However, homes had lower levels of mold and other allergens than expected, possibly because of the timing of environmental sampling. Also, HEAL illustrated the vulnerability of the study community, especially to the interconnected threats of health disparities, environmental health stressors, and disasters.We examine the implications of these threats for public health science, policy, and practice, not only through the lens of Hurricane Katrina but also for future disasters faced by communities in the Gulf Coast and nationally.

Decreased pulmonary function measured in children exposed to high environmental relative moldiness index homes.

BACKGROUND: Exposures to water-damaged homes/buildings has been linked to deficits in respiratory health. However, accurately quantifying this linkage has been difficult because of the methods used to assess water damage and respiratory health. PURPOSE: The goal of this analysis was to determine the correlation between the water-damage, as defined by the Environmental Relative Moldiness Index (ERMI) value in an asthmatic child's home, and the child's pulmonary function measured by spirometry, "forced expiratory volume in one second, percent predicted" or FEV1%. METHODS: This analysis utilized data obtained from the "Heads-off Environmental Asthma in Louisiana" (HEAL) study. The children (n= 109), 6 to 12 years of age, who had completed at least one spirometry evaluation and a dust sample collected for ERMI analysis from the home at approximately the same time as the spirometry testing, were included in the analysis. Statistical evaluation of the correlation between ERMI values and FEV1% was performed using the Spearman's Rank Correlation analysis. The relationship between ERMI values and FEV1% was performed using B-spline regression. RESULTS: The average ERMI value in the HEAL study homes was 7.3. For homes with ERMI values between 2.5 and 15, there was a significant inverse correlation with the child's lung function or FEV1% measurement (Spearman's rho -0.23; p= 0.03), i.e. as the ERMI value increased, the FEV1% value decreased. CONCLUSIONS: Measures of water-damage (the ERMI) and clinical assessments of lung function (FEV1%) provided a quantitative assessment of the impact of water-damaged home exposures on children's respiratory health.

Implementation of evidence-based asthma interventions in post-Katrina New Orleans: the Head-off Environmental Asthma in Louisiana (HEAL) study.

BACKGROUND: Childhood asthma morbidity and mortality in New Orleans, Louisiana, is among the highest in the nation. In August 2005, Hurricane Katrina created an environmental disaster that led to high levels of mold and other allergens and disrupted health care for children with asthma. OBJECTIVES: We implemented a unique hybrid asthma counselor and environmental intervention based on successful National Institutes of Health asthma interventions from the National Cooperative Inner City Asthma (NCICAS) and Inner-City Asthma (ICAS) Studies with the goal of reducing asthma symptoms in New Orleans children after Hurricane Katrina. METHODS: Children (4-12 years old) with moderate-to-severe asthma (n = 182) received asthma counseling and environmental intervention for approximately 1 year. HEAL was evaluated employing several analytical approaches including a pre-post evaluation of symptom changes over the entire year, an analysis of symptoms according to the timing of asthma counselor contact, and a comparison to previous evidence-based interventions. RESULTS: Asthma symptoms during the previous 2 weeks decreased from 6.5 days at enrollment to 3.6 days at the 12-month symptom assessment (a 45% reduction, p < 0.001), consistent with changes observed after NCICAS and ICAS interventions (35% and 62% reductions in symptom days, respectively). Children whose families had contact with a HEAL asthma counselor by 6 months showed a 4.09-day decrease [95% confidence interval (CI): 3.25 to 4.94-day decrease] in symptom days, compared with a 1.79-day decrease (95% CI: 0.90, 2.67) among those who had not yet seen an asthma counselor (p < 0.001). CONCLUSIONS: The novel combination of evidence-based asthma interventions was associated with improved asthma symptoms among children in post-Katrina New Orleans. Post-intervention changes in symptoms were consistent with previous randomized trials of NCICAS and ICAS interventions.

Indoor environmental exposures for children with asthma enrolled in the HEAL study, post-Katrina New Orleans.

BACKGROUND: Rain and flooding from Hurricane Katrina resulted in widespread growth of mold and bacteria and production of allergens in New Orleans, Louisiana, which may have led to increased exposures and morbidity in children with asthma. OBJECTIVES: The goal of the Head-off Environmental Asthma in Louisiana (HEAL) study was to characterize post-Katrina exposures to mold and allergens in children with asthma. METHODS: The homes of 182 children with asthma in New Orleans and surrounding parishes were evaluated by visual inspection, temperature and moisture measurements, and air and dust sampling. Air was collected using vacuum-pump spore traps and analyzed for > 30 mold taxa using bright field microscopy. Dust was collected from the children's beds and bedroom floors and analyzed for mouse (Mus m 1), dust mite (Der p 1), cockroach (Bla g 1), and mold (Alternaria mix) allergens using ELISA. RESULTS: More than half (62%) of the children were living in homes that had been damaged by rain, flooding, or both. Geometric mean indoor and outdoor airborne mold levels were 501 and 3,958 spores/m3, respectively. Alternaria antigen was detected in dust from 98% of homes, with 58% having concentrations > 10 µg/g. Mus m 1, Der p 1, and Bla g 1 were detected in 60%, 35%, and 20% of homes, respectively, at low mean concentrations. CONCLUSIONS: Except for Alternaria antigen in dust, concentrations of airborne mold (ratio of indoor to outdoor mold) and dust allergens in the homes of HEAL children were lower than measurements found in other studies, possibly because of extensive post-Katrina mold remediation and renovations, or because children moved into cleaner homes upon returning to New Orleans.

The Head-off Environmental Asthma in Louisiana (HEAL) study--methods and study population.

BACKGROUND: In the city of New Orleans, Louisiana, and surrounding parishes (NOLA), children with asthma were perilously impacted by Hurricane Katrina as a result of disrupted health care, high home mold and allergen levels, and high stress. OBJECTIVES: The Head-off Environmental Asthma in Louisiana (HEAL) study was conducted to examine relationships between the post-Katrina environment and childhood asthma in NOLA and assess a novel asthma counselor intervention that provided case management and guidance for reducing home mold and allergen levels. METHODS: Children (4-12 years old) with moderate-to-severe asthma were recruited from NOLA schools. Over 1 year, they received two clinical evaluations, three home environmental evaluations, and the asthma intervention. Quarterly end points included symptom days, medication use, and unscheduled emergency department or clinic visits. A community advisory group was assembled and informed HEAL at all phases. RESULTS: Of the children (n = 182) enrolled in HEAL, 67% were African American, and 25% came from households with annual incomes < $15,000. HEAL children were symptomatic, averaging 6.6 symptom days in the 2 weeks before baseline, and had frequent unscheduled visits to clinics or emergency departments (76% had at least one unscheduled visit in the preceding 3 months). In this report, we describe study design and baseline characteristics of HEAL children. CONCLUSIONS: Despite numerous challenges faced by investigators, study staff, and participants, including destroyed infrastructure, disrupted lives, and lost jobs, HEAL was successful in terms of recruitment and retention, the high quality of data collected that will provide insight into asthma-allergen relationships, and the asthma intervention. This success was attributable to using an adaptive approach and refining processes as needed.

Exposure matrices of endotoxin, (1→3)-ß-d-glucan, fungi, and dust mite allergens in flood-affected homes of New Orleans.

This study examined: (i) biocontaminant levels in flooded homes of New Orleans two years after the flooding; (ii) seasonal changes in biocontaminant levels, and (iii) correlations between biocontaminant levels obtained by different environmental monitoring methods. Endotoxin, (1→3)-ß-d-glucan, fungal spores, and dust mite allergens were measured in 35 homes during summer and winter. A combination of dust sampling, aerosolization-based microbial source assessment, and long-term inhalable bioaerosol sampling aided in understanding exposure matrices. On average, endotoxin found in the aerosolized fraction accounted for <2% of that measured in the floor dust, suggesting that vacuuming could overestimate inhalation exposures. In contrast, the (1→3)-ß-d-glucan levels in the floor dust and aerosolized fractions were mostly comparable, and 25% of the homes showed aerosolizable levels even higher than the dust-borne levels. The seasonal patterns for endotoxin in dust and the aerosolizable fraction were different from those found for (1→3)-ß-d-glucan, reflecting the temperature and humidity effects on bacterial and fungal contamination. While the concentration of airborne endotoxin followed the same seasonal trend as endotoxin aerosolized from surfaces, no significant seasonal difference was identified for the concentrations of airborne (1→3)-ß-d-glucan and fungal spores. This was attributed to the difference in the particle size; smaller endotoxin-containing particles can remain airborne for longer time than larger fungal spores or (1→3)-ß-d-glucan-containing particles. It is also possible that fungal aerosolization in home environments did not reach its full potential. Detectable dust mite allergens were found only in dust samples, and more commonly in occupied homes. Levels of endotoxin, (1→3)-ß-d-glucan, and fungi in air had decreased during the two-year period following the flooding as compared to immediate measurements; however, the dust-borne endotoxin and (1→3)-ß-d-glucan levels remained elevated. No conclusive correlations were found between the three environmental monitoring methods. The findings support the use of multiple methods when assessing exposure to microbial contaminants.

Mold exposure and health effects following hurricanes Katrina and Rita.

The extensive flooding in the aftermath of Hurricanes Katrina and Rita created conditions ideal for indoor mold growth, raising concerns about the possible adverse health effects associated with indoor mold exposure. Studies evaluating the levels of indoor and outdoor molds in the months following the hurricanes found high levels of mold growth. Homes with greater flood damage, especially those with >3 feet of indoor flooding, demonstrated higher levels of mold growth compared with homes with little or no flooding. Water intrusion due to roof damage was also associated with mold growth. However, no increase in the occurrence of adverse health outcomes has been observed in published reports to date. This article considers reasons why studies of mold exposure after the hurricane do not show a greater health impact.

Aerosolization of fungi, (1-->3)-beta-D glucan, and endotoxin from flood-affected materials collected in New Orleans homes.

Standing water and sediments remaining on flood-affected materials were the breeding ground for many microorganisms in flooded homes following Hurricane Katrina. The purpose of this laboratory study was to examine the aerosolization of culturable and total fungi, (1-->3)-beta-D glucan, and endotoxin from eight flood-affected floor and bedding materials collected in New Orleans homes, following Hurricane Katrina. Aerosolization was examined using the Fungal Spore Source Strength Tester (FSSST) connected to a BioSampler. Dust samples were collected by vacuuming. A two-stage cyclone sampler was used for size-selective analysis of aerosolized glucan and endotoxin. On average, levels of culturable fungi ranged from undetectable (lower limit=8.3 x 10(4)) to 2.6 x 10(5) CFU/m(2); total fungi ranged from 2.07 x 10(5) to 1.6 x 10(6) spores/m(2); (1-->3)-beta-D glucan and endotoxin were 2.0 x 10(3) - 2.9 x 10(4) ng/m(2) and 7.0 x 10(2) - 9.3 x 10(4) EU/m(2), respectively. The results showed that 5-15 min sampling is sufficient for detecting aerosolizable biocontaminants with the FSSST. Smaller particle size fractions (<1.0 and <1.8 microm) have levels of glucan and endotoxin comparable to larger (>1.8 microm) fractions, which raises additional exposure concerns. Vacuuming was found to overestimate inhalation exposure risks by a factor of approximately 10(2) for (1-->3)-beta-D glucan and by 10(3)-10(4) for endotoxin as detected by the FSSST. The information generated from this study is important with respect to restoration and rejuvenation of the flood-affected areas in New Orleans. We believe the findings will be significant during similar disasters in other regions of the world including major coastal floods from tsunamis.

Prevalence of indoor allergen exposures among New Orleans children with asthma.

Studies of inner-city asthmatic children have shown significant regional variation in dust allergen exposures. The home environment of asthmatic children in the Gulf South region of the USA has not been characterized. This study describes indoor dust allergen levels in the homes of 86 asthmatic children in New Orleans and explores regional variability in dust allergen exposure. Data were used from baseline home visits of children in the New Orleans Healthy Homes Initiative. Interview, visual observation, and environmental dust sampling data of 86 children between 4 and 17 years of age were analyzed. Seventy-seven percent of households had moderate (>2.0-9.9 microg/g) or high (> or =10.0 microg/g) levels of either Der p 1 or Der f 1 dust mite allergen and 56.6% had moderate (>2.0-8.0 U/g) or high (>8.0 U/g) levels of cockroach allergen (Bla g 1). The prevalence of high (>10 microg/g) levels of dog (Can f 1) allergen was 26.5%, and few households (6.0%) had high cat allergen (Fel d 1) levels (>8.0 microg/g). Households with average humidity levels >50% were three times more likely to have elevated dust mite levels (odds ratio = 3.2; 95% confidence interval = 1.1, 9.3; p = 0.03). Home ownership and education level were inversely associated with cockroach and dust mite allergen levels, respectively. Our findings reinforce the evidence of regional variability in dust allergen exposure levels. Asthmatic children living in the Gulf South are exposed to multiple indoor allergen exposures and live in a highly allergenic environment.