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Original Research: Asthma |

School Endotoxin Exposure and Asthma Morbidity in Inner-city ChildrenInner-city School Endotoxin and Asthma

Peggy S. Lai, MD, MPH; William J. Sheehan, MD; Jonathan M. Gaffin, MD, MMSc; Carter R. Petty, MA; Brent A. Coull, PhD; Diane R. Gold, MD, MPH; Wanda Phipatanakul, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care (Dr Lai), Massachusetts General Hospital; Department of Environmental Health (Drs Lai and Gold), and Department of Biostatistics (Dr Coull), Harvard School of Public Health; Harvard Medical School (Drs Lai, Sheehan, Gaffin, Gold, and Phipatanakul); Boston Children’s Hospital (Drs Sheehan, Gaffin, Gold, and Phipatanakul, and Mr Petty); and Channing Laboratory (Dr Gold), Brigham and Women’s Hospital, Boston, MA.

CORRESPONDENCE TO: Wanda Phipatanakul, MD, Division of Immunology and Allergy, Boston Children’s Hospital, 300 Longwood Ave, Fegan 6, Boston, MA 02115; e-mail: wanda.phipatanakul@childrens.harvard.edu


This study was previously published in abstract form (Lai PS, Sheehan WJ, Petty CR, et al. Am J Respir Crit Care Med. 2014;189:A2288).

FUNDING/SUPPORT: This study was funded by US National Institutes of Health (NIH) National Institute of Allergy and Infectious Diseases [U01 AI 110397, R01 AI 073964, K24 AI 106822, K23 AI104780, and K23 AI106945] and NIH National Institute of Environmental Health Sciences [K23ES023700 and P30 ES000002]. This work was also conducted with support from Harvard Catalyst/The Harvard Clinical and Translational Science Center [NIH award 8UL1TR000170]; American College of Allergy, Asthma, and Immunology Young Faculty Award; Division of Immunology Clinical Research Advisory Group Research Grant; American Lung Association/American Academy of Allergy, Asthma, and Immunology Respiratory Diseases Faculty Award; and the Deborah Munroe Noonan Memorial Award.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(5):1251-1258. doi:10.1378/chest.15-0098
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BACKGROUND:  Endotoxin exposure is associated with airway inflammation. Children spend 6 to 8 h/d in school, yet the effect of school-specific endotoxin exposure on asthma morbidity is not well understood.

METHODS:  In this longitudinal cohort study, 248 students with asthma, from 38 inner-city schools, underwent baseline phenotyping and follow-up. Clinical outcomes were evaluated throughout the academic school year and linked to classroom-specific dust and air endotoxin levels as well as home dust endotoxin levels. The primary outcome was maximum asthma symptom-days per 2-week period.

RESULTS:  Classrooms had higher settled dust endotoxin levels compared with homes (14.3 endotoxin unit/mg vs 11.3 endotoxin unit/mg; P = .02). Airborne endotoxin levels exceeding recommended occupational exposure limits for adults were recorded in 22.0% of classrooms. Classroom air endotoxin levels were independently associated with increased maximum symptom-days in children with nonatopic asthma, but not in those with atopic asthma (interaction P = .03). Adjusting for home exposures, classroom endotoxin exposure was independently associated with a dose-dependent increase in asthma symptom-days for children with nonatopic asthma (adjusted incidence rate ratio, 1.16 [95% CI, 1.03-1.31]; P = .02). In these subjects, maximum symptom-days increased by 1.3 days for each 14-day period when comparing students in classrooms with the lowest endotoxin levels compared with average measured levels.

CONCLUSIONS:  Inner-city children with asthma are exposed to high levels of airborne endotoxin at school, resulting in increased asthma symptoms in children with nonatopic asthma. Mitigation of school-related exposures may represent a strategy to decrease asthma morbidity in this population.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01756391; URL: www.clinicaltrials.gov

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