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Background Students spend a large portion of their day in classrooms which may be a source of mold exposure. We examined the diversity and concentrations of molds in inner-city schools and described differences between classrooms within the same school. Methods Classroom airborne mold spores, collected over a 2 day period, were measured twice during the school year by direct microscopy. Results There were 180 classroom air samples collected from 12 schools. Mold was present in 100% of classrooms. Classrooms within the same school had differing mold levels and mold diversity scores. The total mold per classroom was 176.6 ± 4.2 spores/m3 (geometric mean ± standard deviation) and ranged from 11.2 to 16,288.5 spores/m3. Mold diversity scores for classroom samples ranged from 1 to 19 (7.7 ± 3.5). The classroom accounted for the majority of variance (62%) in the total mold count, and for the majority of variance (56%) in the mold diversity score versus the school. The species with the highest concentrations and found most commonly included Cladosporium (29.3 ± 4.2 spores/m3), Penicillium/Aspergillus (15.0 ± 5.4 spores/m3), smut spores (12.6 ± 4.0 spores/m3), and basidiospores (6.6 ± 7.1 spores/m3). Conclusions Our study found that the school is a source of mold exposure, but particularly the classroom microenvironment varies in quantity of spores and species among classrooms within the same school. We also verified that visible mold may be a predictor for higher mold spore counts. Further studies are needed to determine the clinical significance of mold exposure relative to asthma morbidity in sensitized and non-sensitized asthmatic children.

Background Most studies of indoor allergens have focused on the home environment. However, schools may be an important site of allergen exposure for children with asthma. We compared school allergen exposure to home exposure in a cohort of children with asthma. Correlations between settled dust and airborne allergen levels in classrooms were examined.

Background Endotoxins are stimulators of the immune system and, despite their potential to protect against allergy, have been associated with early wheezing and asthma morbidity. Objective To compare inner-city school endotoxin exposure with home endotoxin exposure in children with asthma. Methods Students with asthma were recruited from 12 urban elementary schools. Settled and airborne dust samples, linked to enrolled students, were collected from school classrooms, gymnasiums, and cafeterias twice during the academic year. For comparison, settled dust was collected once from the bedrooms of students with asthma. Results Two hundred twenty-nine school settled dust samples and 118 bedroom settled dust samples were collected and analyzed for endotoxin. The median endotoxin concentration for school samples was 13.4 EU/mg (range, 0.7–360.7 EU/mg) and for home samples was 7.0 EU/mg (range = LLOD–843.0 EU/mg). The median concentration within each individual school varied from 6.6 EU/mg to 24.0 EU/mg. One hundred four students with asthma had matched classroom and bedroom endotoxin exposure measurements performed in the same season and demonstrated significantly higher concentrations of endotoxin in the students' classrooms (mean log value, 1.13 vs 0.99, P = .04). The median of the classrooms was 12.5 EU/mg compared with their bedrooms, with a median of 7.0 EU/mg. Within the school environment, no significant difference was seen between the fall and spring samples (mean log value 1.14 vs 1.09; P = .35). Conclusion Inner-city children with asthma were exposed to higher concentrations of endotoxin in their classrooms as compared with their bedrooms. Further studies are needed to evaluate school endotoxin exposure as a factor in asthma morbidity.

Children spend a significant amount of time in school. Little is known about the role of allergen exposure in school environments and asthma morbidity.The School Inner-City Asthma Study (SICAS) is a National Institutes of Health (NIH)-funded prospective study evaluating the school/classroom-specific risk factors and asthma morbidity among urban children.This article describes the design, methods, and important lessons learned from this extensive investigation. A single center is recruiting 500 elementary school-aged children, all of whom attend inner-city metropolitan schools. The primary hypothesis is that exposure to common indoor allergens in the classroom will increase the risk of asthma morbidity in children with asthma, even after controlling for home allergen exposures. The protocol includes screening surveys of entire schools and baseline eligibility assessments obtained in the spring prior to the academic year. Extensive baseline clinical visits are being conducted among eligible children with asthma during the summer prior to the academic school year. Environmental classroom/school assessments including settled dust and air sampling for allergen, mold, air pollution, and inspection data are collected twice during the academic school year and one home dust sample linked to the enrolled student. Clinical outcomes are measured every 3 months during the academic school year.The overall goal of SICAS is to complete the first study of its kind to better understand school-specific urban environmental factors on childhood asthma morbidity. We also discuss the unique challenges related to school-based urban research and lessons being learned from recruiting such a cohort.

The association between allergens in schools and childhood asthma has not been well studied, particularly in the United States.To investigate allergen exposure in schools compared with homes with a specific focus on children with asthma.Dust samples were collected from 46 rooms in 4 urban elementary schools (northeastern United States) and from 38 student bedrooms. Samples were analyzed for cat (Fel d 1), dog (Can f 1), cockroach (Bla g 2), dust mites (Der f 1/Der p 1), and mouse urinary protein (MUP). Questionnaires identified students with physician-diagnosed asthma.Cat and dog allergens were detectable in most school samples (96% and 78%, respectively), but at low levels. Cockroach allergen was detectable in only 11% of school samples. Mouse allergen was detectable in 89% of school samples, with 68% having MUP levels greater than 0.5 microg/g. In contrast, MUP was detectable in only 26% of bedroom samples. Matched classroom and home samples from 23 asthmatic students showed higher geometric mean MUP levels in the classroom vs the home (6.45 microg/g vs 0.44 microg/g, P.001). However, there were lower geometric mean dust mite (Der f 1) levels in the classroom vs the home (0.04 microg/g vs 0.66 microg/g, P.001).There are significantly higher levels of MUP but lower levels of Der f 1 in schools vs homes. It is important to recognize that children with asthma may encounter varying levels of allergens in environments outside the home, such as schools.

School-based parent/student screening surveys provide an inexpensive, non-invasive means to identify children at high-risk for asthma1,2. Our goal was to determine parent/student response agreement to an asthma/allergy survey stratified by age and race. We hypothesized that discordance between parent and student responses would increase with age and that ethnicity (particularly generational language differences in Hispanic families) might increase the discordance of parent/student responses. A one page, IRB approved, validated2–6, 20 question parent/student asthma/allergy screening survey available in English and Spanish was distributed to all students in five, northeastern, urban, elementary schools from March to June 2008, as part of the School Inner-City Asthma Study (SICAS). SICAS, a longitudinal school/home environment evaluation of students with asthma and associated morbidity, utilized these surveys to identify potential subjects for the longitudinal study. Students and parents were instructed to fill responses independently. Questions referred to the student’s symptoms including frequency of wheezing, difficulty taking a deep breath, persistent cough, and respiratory problems with activity or at night. Allergy questions focused on frequency of nasal, ocular, or skin symptoms. Response categories were a)never, b)sometimes, c)a lot, d)don’t know. Binary asthma questions ascertained whether there was a previous doctor’s diagnosis of asthma or reactive airway disease, hospitalization for trouble breathing, current asthma medication use and missed days of school due to respiratory problems. Response category options were a)yes, b)no, and c)don’t know. Observations that were missing or answered as “don’t know” were deleted from the analysis. Self-reported race/ethnicity categories were African American, Asian, Hispanic, White, Native American, and Other. Analyses were done using SAS version 9.1 (SAS Institute, Inc., Cary, NC). The percent of agreement was the sum of parent and student responses that agreed divided by the total number of responses. Kappa statistic and McNemar’s test were used to examine agreement beyond expected chance and disagreement, respectively. A test of the difference in proportions was used to determine if there were statistically significant differences between age groups and race. 707 parent/student pair surveys were analyzed. The students’ ages ranged from 5 to 15 years average 8.66±1.96 (standard deviation). The cohort was predominantly Hispanic (54%) and African American (27%). Overall agreement ranged from 81% to 98% for all questions (Kappa of 0.59 to 0.94), except for one. The question, “develops a cough that won’t go away?” had 62% agreement (Kappa of 0.31), demonstrating fair agreement. Table 1 shows the parent/student responses to identical questions by age and race. Direction of disagreement was due to student affirmative responses. Table categories: No/No, No/Yes, Yes/No, and Yes/Yes demonstrate parent/student pairs that responded in this manner. Column 3 (No/No) and column 6 (Yes/Yes) demonstrate parent/student agreement. Column 4 and 5 (No/Yes and Yes/No) demonstrate response disagreement. The kappa statistic decreased and disagreement level increased with age, with similar results by race, but none of these were statistically significant. Table 1 Parent and student responses to survey questions regarding the student’s symptoms. Responses to binary asthma questions demonstrated 93%–97% agreement, with good to excellent Kappa (0.75–0.91). Quantitative asthma symptoms demonstrated 81%–86% agreement, with a moderate to good Kappa (0.59–0.7). Chest tightness or cough after activity or night wakening demonstrated 81%–86% agreement, with a moderate to good Kappa (0.59–0.67). Overall, student responses matched their parents’ regarding quantitative asthma questions. The most concordant response was seen in asthma medication use (97% agreement, 0.91 Kappa), diagnosis of asthma (96% agreement, 0.89 Kappa), hospitalization for respiratory problems (94% agreement, 0.78 Kappa), and missed school days due to breathing problems (93% agreement, 0.75 Kappa), indicating both parents and students have good recognition of the student’s condition. Discordant responses to the question, “develops a cough that won’t go away?” may indicate unclear wording, misinterpretation, or that students may be more in tune with their daily symptoms. Decreased agreement with increasing age may occur due to increased time older students are away from their caregivers. Persistent, indolent symptoms may go unnoticed by the parent, but have significant effects on the child. In contrast, good agreement was seen on hospitalizations or missed school day responses as these likely affect both parties. Parent/student agreement in responses did not differ by race/ethnicity or language of questionnaire (English or Spanish). Our study generally showed good agreement between parent/student responses for asthma. Disagreement was seen most in responses to questions that were more dependent on self-perception of symptoms but these were not statistically significant. Also, no significant racial/ethnic/language differences in parent/student agreement were seen. This study suggests that screening surveys given to either parent or elementary students may be a simple, cost-effective mechanism for identifying children in an urban school population who may need further evaluation.

Objective Visitors to US National Park Service (NPS) units have a unique set of needs in terms of emergency medical care. The purpose of this review is to quantify and characterize emergency medical services (EMS) activities in the NPS to elaborate on its unique aspects, establish trends, and benchmark these data against a sample of national EMS data. Methods The EMS data for calendar years 2012 and 2013 were queried from national NPS reports. Results The EMS responses totaled 40 calls per million visitors in 2012 and 34 calls per million visitors in 2013. Of those, 75% required a basic life support level of care. There were comparable incidences of transported EMS trauma calls (49%) and medical calls (51%). Of a total of 137 sudden cardiac arrest events, 65% of patients received defibrillation and 26% survived to hospital release. There were 262 total fatalities in 2012 and 238 in 2013, with traumatic fatalities occurring approximately twice as often as nontraumatic fatalities. Conclusions Across the country, the NPS responded to a large number of EMS calls each year, but with a relatively low frequency, considering the large number of visitors. This is a challenging setting in which to provide consistent EMS care throughout various NPS administered areas. The typical NPS EMS response provided basic life support level care to visitors with traumatic injuries. The NPS caregivers must be prepared, however, to respond to a varied and diverse range of EMS calls.