»EPA
Unfted States.
Environmental Protection
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VOLUME 3
ASTHMA & ALLERGY
A PUBLICATION
OF THE OFFICE
OF RADIATION AND
INDOOR AIR
Childhood Asthma: Do you know the causes, signs, and latest statistics?
Trends in Asthma Prevalence by Age
Rate per 1.000 population
80
Five million children, or 11 percent of the U.S. child population,
have asthma—a leading cause of school absenteeism and pediatric
hospital admission. According to The New England Journal of
Medicine, children with asthma miss 10 million school days
each year and spend an estimated 7.3 million days per year
restricted to bed.
Asthma is a chronic respiratory disease that causes the airways
in the lungs to swell and constrict, usually in what is called an
asthma "episode." An asthma episode occurs due to the
inflamation in the lining of the respiratory tract, tightening of
the muscle, and increased secretion of mucus in the airway,
resulting in narrowed airways and breathing difficulty. Common
asthma symptoms include chest tightness, wheezing, and
coughing.
Asthma rates have increased drastically during the past 20 years.
In fact, the number of asthmatics in the U.S. has more than
doubled since 1980, from 6.7|million to about 15 million. A
study conducted by the Johns Hopkins University School of
Public Health estimates that, if asthma rates continue to rise
(continued on page 11)
Asthma Triggers Commonly Found in School Buildings
70
60 -
50 -
40 -
30 -
20 .
10
1980
1981-83 1984-86 1987-89 1990-92
« 0-4 B 5-14 i 15-34 O 35-64 X 65+
Source: National Health Interview Survey. National Center for Health Statistics
1993-94
The most successful technique for
managing asthma in the school
environment is avoiding "triggers," which
are substances that can cause 'an asthma
episode or allergic reaction. When
children with allergies come in contact with
irritants or triggers, they may experience
congestion, a runny or itchy nose, and
watery eyes. Children with asthma may
cough, wheeze, or experience shortness
of breath and chest tightness.
A recent study by the American Academy
of Allergy, Asthma, and Immunology
(AAAAI) found that 41 percent of the
children with asthma surveyed had as many
as three asthma episodes each month at
school. Untreated or unrecognized asthma
and allergy symptoms sparked by
classroom triggers can interfere with
participation in sports, school trips,
physical education classes, and play
activities. They can also interfere with a
child's energy level, concentration,
attention span, cognitive functioning, and
peer relations. Parents should make school
personnel aware of their child's asthma
or allergy condition so that school officials
can work to help the child avoid triggers.
The most common asthma and allergy
triggers found in schools come from living
organisms such as trees, plants, fungus,
insects, or animals. Cockroaches, dust
mites, mold, animal dander, and
secondhand smoke can aggravate a
student's allergies or asthma. Pollen and
ozone have also been shown to trigger
asthma episodes. Chemicals such as
formaldehyde and nitrous oxides can be
respiratory tract irritants.
The article, "10 Ways to Manage Asthma
in Schools," included in this Bulletin on
pages 2-3 is a helpful resource for asthma
trigger management. For more detailed
information on these asthma and allergy
triggers, consult your IAQ TfS Kit or visit
EPA's Indoor Air Quality Tools for Schools
Web site at www.epa.gov/iaq/schools.
2
4
Asthma Management in Schools
Mold Management Just Got Easier
Montgomery County Asthma Improvement 7
School Nurses Proponents of IAQ Program 8
Asthma Activities for the Classroom
Kate Horter Interview
IAQ Tools for Schools Bulletin -
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10 Ways to Manage Asthma in Schools
Asthma is a manageable disease. If students and staff are proactive about assessing the school indoor environment
and identifying potential asthma triggers, they can reduce incidences of asthma episodes. EPA's Indoor Air Quality
Tools for Schools (IAQ TfS) Kit is a great resource for identifying pollutants in schools which may exacerbate asthma.
Following are 10 tips for managing asthma in schools. For more information on each, consult your IAQ TfS Kit or the
links provided.
1. Use EPA's Indoor Air Quality
Tools for Schools Kit.The£lQ235Kit
helps school personnel identify, solve, and
prevent indoor air quality problems in the
school environment. Improving your
school's indoor air quality will aid children
with asthma by reducing school allergen
levels and exposures, improving classroom
comfort, and promoting asthma awareness.
The checklists included in the Kit help assess
the school buildings ventilation system,
maintenance procedures, classrooms, and
food service areas. Students and school staff
can play an integral role in the success of a
school's IAQ. program. See page 7 in this
Bulletin for ideas on classroom activities diat
promote IAQ and asthma awareness among
students and staff.
2. Control Animal Allergens. Proteins
that act as allergens in the dander, urine,
and saliva of warm-blooded animals can
trigger allergic reactions and asthma
episodes. Children with asthma and
allergies are especially susceptible to animal
allergens. To decrease the chances of
allergic reactions or asthma episodes, pets
should be removed from the classroom.
If this is not possible, try to locate animals
away from sensitive students and the
classroom's ventilation system. In addition,
the animal's cage and the classroom must
be cleaned frequently. Once pets are
removed, and even after extensive
cleaning, pet allergens may remain in the
indoor environment for several months.
3. Control Cockroach Allergens.
Cockroach saliva and waste contain
proteins that can act as allergens, causing
allergic reactions or triggering asthma
episodes. Integrated Pest Management
(IPM) practices help prevent and manage
cockroach and other pest problems. Four
key IPM methods for reducing exposure
to pests in the school setting include
(1) looking for signs of pests; (2) not
leaving food, water, or garbage exposed;
(3) removing pest padiways and shelters; and
(4) using pest control products such as
poison baits, traps, and pesticide sprays as
needed.
Examples of
other
effective
techniques
include
relocating
dumpsters
away from
school
buildings,
reviewing
food
handling
and storage procedures in food preparation
areas, and fixing plumbing leaks and other
moisture problems. Look to the IAQ TJSKit
for more information on cockroach allergens
and IPM.
4. Clean Up Mold and Control
Moisture. Molds reproduce by emitting
tiny spores that travel through the air and
grow when they land on damp surfaces.
Mold growth in a; school building can
cause allergic reactions and asthma
episodes. While no practical method exists
to eliminate aji mold and mold spores in
a school building, controlling and
minimizing mold growth can greatly
improve the health of sensitive students
and staff. Moisture problems in schools—
roof, window, and plumbing leaks,
condensation, and;excess humidity—are
often the source of mold growth. To
prevent mold growth, fix moisture
problems and thoroughly dry all wet areas
within 24 to 48 hours. Should mold
growth occur on hard surfaces, clean with
water and detergent and dry thoroughly.
Venting showers and other moisture
sources within the school will help reduce
indoor humidity. The school building
should be inspected for moldy odors and
water stains, especially under sinks, on
ceiling tiles, in bathrooms, and in air
conditioner or refrigerator drip pans.
Adding insulation to cold surfaces such as
windows, piping, exterior walls, and die roof
can reduce the potential for condensation.
5. Eliminate Secondhand Smoke
Exposure. Secondhand smoke causes a
number of serious health effects in young
children, including coughing and
wheezing, bronchitis and pneumonia, ear
infections, reduced lung function, and
increased frequency of asthma episodes.
EPA estimates that between 200,000 and
1 million children witli asthma have their
condition made worse by exposure to
secondhand smoke. Research also
suggests that secondhand smoke may cause
asthma in pre-school children. Most
schools in die United States have banned
smoking. Despite the ban, smoking
sometimes still occurs in school
bathrooms, lounges, and on school
grounds. Even if smoking is confined to
specific rooms or the outdoors, smoke
can travel through the ventilation system,
exposing others in the school to the fumes.
Enforcing smoking bans is important
because secondhand smoke exposure can
cause problems for students and staff with
asthma.
6. Reduce Dust Mite Exposure. Dust
mite allergens may trigger an allergic
reaction or an asthma episode in sensitive
individuals. Evidence shows that dust
mite exposure may lead to the
development of asthma in children.
Although too small to be seen, dust mites
are found in homes, schools, and buildings
diroughout the U. S. In schools, they live in
carpets,
upholstered
furniture,
clothes,
pillows, and
stuffed toys
where they
feed on dead
skin flakes. To reduce dust mite exposure in
the school building, choose washable stuffed
-------
toys, and clean them often in hot water. Cover classroom pillows
with dust-proof, zipped covers. Dust hard surfaces often with a damp
cloth, and vacuum carpet and upholstered furniture to reduce dust
accumulation. Classrooms should be cleaned thoroughly on a regular
basis and during non-school hours as vacuuming often releases dust
into the air.
t
7. Develop an Asthma Management Plan in Your
School. Schools can support students with asthma and help
them manage their condition by developing an asthma
management plan. The plan should include school policies on
inhaler and other asthma medication use, as well as emergency
procedures to guide school staff on what to do if a student has
an asthma episode. The plan can also encourage asthmatic
students and their parents to provide the school with a completed
student asthma action card. The National Asthma Education
and Prevention Program's Managing Asthma: A Guide for Schools
is another helpful resource to use in developing your school's
management plan. Check http://www.nhlbi.nih.gov for details.
8. Provide School-Based Asthma Education
Programs. Your school can empower students, staff, and
parents to take control of asthma management by providing
school-based asthma education programs. An excellent example
of such a program is the American Lung Association's (ALA)
Open Airways for Schools program. This program teaches students
how to manage their asthma by recognizing asthma triggers in
their environment, reducing their exposure to these triggers,
and using their asthma medication correcdy. Open Airways for
Schools is composed of six lessons, designed for children aged 8
to 11. The 40-minute lessons can be taught by school staff or
trained volunteers. Program results have been extremely positive
for students—improved school performance, more confidence
in their ability to manage asthma, greater influence on their
parents' asthma management decisions, fewer episodes of asthma,
and more active management of their asthma. For more
information on this program, contact your local Lung Association
at 800-LUNG-USA or visit the ALA web site at www.lungusa.org.
9. File Student Asthma Action Cards. Your school can
require students with asthma to pbtain and submit asthma action
cards to die school nurse and classroom teachers. These cards
encourage students to manage their asthma by identifying and
recording asthma triggers. The card also benefits school staff
and officials as it provides the ^students' medical information,
identified asthma triggers, emergency procedures, and phone
numbers. The Asthma and Allergy Foundation of America has
developed a sample card, . available at www.aafa.org/
healthprofessionals/programsandmaterials/
student_asthma_card.pdf.
10. Gather Additional Asthma Information and
Resources. Establishing a file of asthma and allergy information
and related resources will be a helpful reference to school staff
dealing with asthma issues in the school environment. Helpful
sources of information include:
• Allergy and Asthma Network/Mothers of Asthmatics
(800) 878-4403
www.aanma.org
Ask about obtaining their school information packet.
• American Lung Association
(800) LUNG-USA
www.ala.org
Ask about the Open Airways for Schools program.
• Asthma and Allergy Foundation of America
(800) 7-ASTHMA
www.aafa.org
Ask about the Asthma Management at School presentation
for parents and school staff.
• Center for Disease Control and Prevention
(770) 488-7320
www.cdc.gov
Read more on their Asthma Prevention Program.
• National Integrated Pest Management (IPM) Network
http://schoolipm.ifas.ufl.edu/
Find out more about IPM.
• U.S. Environmental Protection Agency
www.epa.gov/pesticides/ipm
Find out more about implementing IPM in schools.
• U.S. Environmental Protection Agency
www.epa.gov/iaq/schools
Download the IAQ TfS Kit.
lAQ ToolsforSchools Bulletin _. ^_ _ _ -.._'! -•--_•_ iT V^_ j :-'_ '_ - ^ -il_ :v ;_ t "L _"_ -" Paee3
-------
Mold Management Just Got Easier
EPA releases new document: Mold Remediation in Schools and Commercial Buildings
Mo! J Remediation
In
Mold. You've seen it growing on your shower curtain
or on the month-old bagels in your bread basket. You've
probably eaten a form of it in bleu cheese or taken it
as part of a penicillin prescription. And you've
definitely inhaled it—mold spores are abundant in
outdoor environments, especially during die spring
and fall. But, what exactly is mold? According to
Barbara Spark, a staff member in EPA's Region 9
California office, "Saving mold' is like saying 'animal'—
there are many different kinds widi very different
characteristics."
Some scientists estimate that there are more dian
100,000 types of mold. Molds can produce allergens
that trigger reactions in people with allergies and
asthma. Molds produce irritants that can affect the
respiratory system of those exposed. Some can also be
toxic. Therefore, exposure to indoor mold should be
avoided.
Building occupants may report a variety of health
problems due to moisture and mold growth in schools,
including headaches, breathing difficulties, skin
irritation, and aggravation of asdima symptoms. "In
fact," according to Laura Kolb of EPA, "if you see mold,
you need to get rid of it, period."
Molds can be hard to find; levels fluctuate in any
building depending on how air is moving through the
building, and how the mold is releasing its spores. Mold
is a living organism, and just like humans don't yawn
or sneeze on a regular schedule, molds don't release
spores at a constant rate. In schools, mold can grow
almost anywhere if diere is a moisture problem—
hidden within die walls of a classroom, on ceiling tiles,
in unit ventilators, or behind blackboards, file cabinets,
or vinyl wallpaper.
Mold requires moisture to grow; so buildings should
be kept dry. If moisture problems occur in a school,
they need to be addressed immediately. Mold may
grow on materials that remain wet for more than 48
hours, regardless of die climate. And, it is not enough
to merely disinfect and dry the area; killing mold does
not decrease the health effects associated with
exposure because people are allergic to the dead mold
as well. Instead, material saturated with mold should
be completely removed from the building using safe
handling techniques.
EPA released a document to help facility
managers, teachers, parents, school officials, or
anyone else interested in combating the issue
of mold in schools or commercial buildings.
Mold Remediation in Schools and Commercial
Buildings is a guide that offers accurate, clear,
and manageable advice for dealing widi mold and
clean water problems. This publication covers
remediation guidelines, health effects, personal
protective equipment, and much more.
Checklists for mold remediation, a glossary of
key terms, other resources, and communication
strategies are also included. You can download
Mold Remediation in Schools and Commercial
Buildings from www.epa.gov/iaq/molds or call
800-438-4318 to request a free copy.
If you find or suspect a water or mold problem in
your school building, don't wait. By acting early you
can prevent damage to the building materials and
furnishings, save money, and avoid potential health
risks.
The cost of asdima in 1998 was estimated to be $12.6 billion.
Many asdimatic children are more likely to have an attack during the winter than they are during
die summer. This is at least partly attributable to die fact that they spend more time inside during
!i p winter months, where airborne pollutant concentration is generally much higher than it is outside.
Asthma tends to run in families. People with a parent or sibling with asthma are more likely to develop asthma them-
selves.
An estimated 40 to 50 million Americans suffer from allergies. Allergies are the most frequently reported chronic
condition in children, limiting activities for more than 40 percent.
Reference: American Academy of Allergy, Asthma, and Immunology (AAAAI) at www.aaaai.org
IAQ Tools for Schools Bulletin
-------
Montgomery County Asthma Improvement Resources (AIR) Coalition
A collaborative approach to changing the face of asthma awareness and management in schools.
Education is a high priority for Montgomery County, Maryland;
more than half of the county's budget is devoted to public
education. Among the various initiatives through which the
county and the school district work together is one to improve
asthma management among school-aged children. Asthma is a
leading cause of children's school absenteeism and hospitalization
in Montgomery County and nationwide. Efforts to reduce these
outcomes and improve quality of life are occurring through a
collaborative of Montgomery County Public Schools, the
Department of Health and Human Services (DHHS), and
community, public, and private organizations. Montgomery
Asthma Improvement Resources (AIR), a community wide
coalition to raise asthma awareness and improve asthma
management in schools, and the Indoor Air Quality/Preventative
Maintenance Team are moving the county in the right direction.
Background ;
Montgomery AIR was initiated in 1997 under the leadership of the
County's Health Officer, Dr. Carol Garvey, and with die support of
other health, education, and community leaders. Its membership
has grown to include many health care organizations, die American
Lung Association (ALA), Asthma and Allergy Foundation of America
(AAFA), Montgomery County Medical Society, National Asthma
Education and Prevention Program (NAEPP), Montgomery County
Public Schools (MCPS), Montgomery County Department of the
Environment, county hospitals, and coalitions such as die African-
American and Latino Initiatives.
The Montgomery AIR Coalition's mission is to promote optimal
asthma management and to reduce asthma morbidity and mortality
among children. This is especially important among minorities
because a greater proportion of African-American children are
visiting the emergency room for asthma difficulties than are children
of other races.
Montgomery AIR's Initiatives
The Montgomery Air Coalition, co-facilitated by Judy Lichty,
Adventist Health Care, and Ann Yeamans, DHHS, developed a
strategic plan to target schools, parents, caregivers, healthcare
providers, and practitioners. Based on a cross analysis of data
collected from hospitals and emergency departments in
Montgomery County, DHHS s school and community nurses and
health technicians focus efforts on identifying, implementing, and
supporting "best practices" for IAQ and asthma management in
schools. Emergency department data, which distinguishes
emergency room patients by age, race, and zip code, served as
the primary indicator of county regions that were most in need
of an asthma management program. Nurses from the 19 schools
identified in the "high-need" zip codes were trained on indoor
air quality issues and asthma management in conjunction with
ALA's Open Airways program. DHHS nurses and health room
technicians, who work in MCPS schools, provide critical support
to parents and school staff to educate them about best asthma
practices and teach them to help students learn about and
manage their asthma.
School nurses in die district were surveyed to determine how many
students use action plans and peak flow meters (a device that
measures how fast the user can move air out of die lungs) as part of
their asthma management. Two letters were also sent out to
encourage families of known asthmatic students to use the school
nurse as an asthma management resource and to urge families to
create an asthma action plan for their children and share it widi the
school. The second letter laid out Montgomery AIR's expectation
that the students' healthcare practitioners follow the National Institute
of Health's (NIH) protocol for asdima, which was distributed with
the letter. Asdima management plans received by die school are
tracked. Another survey will be conducted at the end of the year to
measure the efFectiveness of the coalitions outreach efforts. Through
a state grant, the coalition will be able to provide schools with peak
flow meters with disposable mouthpieces. This is an important asset
to schools because not all students keep peak flow meters at school.
Disposable mouthpieces will also allow the county to better regulate
asthma management in schools because the school can track asthma
reactions according to their inventory of disposable mouthpieces.
If fewer disposable mouthpieces are used, one can deduct diat fewer
asthma attacks have occurred.
A Focus on Indoor Air Quality
Montgomery AIR's initiatives also target county pre-school children
(infant to 4 years). The preschool population is actually the most
susceptible to asthma problems stemming from IAQ issues and have
the most frequent asthma-related emergency room visits. Through
AIR, community- and school-based nurses train in preschool staff
and implement the Head Start program, a child development
program to increase the school readiness of children from low-income
families. Community nurses provide asthma education to pregnant
women and new mothers through home visiting programs.
Montgomery County also seeks to make die link between asthma
management and indoor air quality. In 1997, the Indoor Air Quality
Process Action Team, a work group of Montgomery County health
officials, parents, employee associations, and school staff, met to
evaluate school IAQ issues. The Team developed recommendations
to ensure that good IAQ practices are utilized in existing MCPS
facilities. In response to these recommendations, a pilot program
was funded in 2000 to improve lAQin older schools. An IAQ team
of mechanical system technicians/specialists, headed by an
occupational safety specialist, is funded through the District's
operating budget and building improvements are funded through
die capital budget. The primary goal of the pilot program is to ensure
that mechanical equipment performs at optimal operating levels by
addressing deferred maintenance repairs, implementing preventative
maintenance (PM) plans, and training building staff on IAQ
maintenance procedures for one-third of the existing MCPS facilities
constructed or modernized before 1998. The pilot is being
implemented to determine the effectiveness of the program and to
guide future funding requests to expand the program to all MCPS
facilities. The Team surveyed the heating and ventilation systems in
all of the County's schools to determine dieir age, design, and
maintenance and cleaning schedules.
(continued on page 11)
IAQ Tools for Schools Bulletin
-------
jffljllffaG^^
18s?
School Nurses as Strong Proponents of IAQ Programs
Dr. Barbara Sattler, PH, RN, Associate Professor at the
University of Maryland School of Medicine and School of
Nursing and Director of the Environmental Health Education
Center at the University of Maryland, spoke with us about
the role of school nurses in establishing indoor air quality
as an Important issue for schools.
School nurses are in the unique
position of being responsible for the
health of students and staff when
they are at school. As a trusted ;
source of information about health
and health risks, school nurses can
play a major role in gaining school
board or administrative buy-in for ;
indoor air quality (IAQ) programs
in a school or across an entire;
school district. Good IAQ:
contributes to a favorable learning i
environment for students,
productivity for staff, and a sense of comfort, health and well- ;
being for everyone in the school. If school nurses make a strong ,
case for IAQ as a critical health issue for students and staff,
officials should realize the need for a proactive IAQ program.
Because they offer a varied curriculum, schools have many
potential sources of pollutants—art supplies and kilns,.
photography laboratories, cosmetology centers, and wood and
metal shops, to name a few. In the workplace, these areas are,
regulated by Occupational Safety and Health Administration
(OSHA) standards. Schools, too, are workplaces and, at the;
very least, should establish and maintain equivalent health and
safety standards for students and staff. Nurses might argue that
schools should aim for even higher standards because children
are generally more vulnerable to health effects from indoor air
pollutants than adults. ;
Many IAQ problems in schools also trigger asthma attacks, a
serious health condition that is dramatically increasing among
children. By monitoring and tracking asthma episodes within a
school, including where the episodes are most common, the
school nurse can help identify an IAQ problem for the
administration. Prevalence of asthma episodes in a certain area;
of the school often indicates an indoor air quality issue. Priscilla
Santiago, the School Nurse at Little Harbour School in,
Portsmouth, New Hampshire, tracked student asthma episodes i
to determine the effectiveness of IAQ upgrades that were taking:
place in the school. She found a significant decrease in both
asthma episodes and in asthma medication and inhaler use for
a severe asthmatic who attended the school. To learn more about
Priscilla's work at Little Harbour, read the case study at
www.epa.gov/iaq/schools/casestudies.html.
School nurses have the power to leverage their health knowledge
to persuade school officials to form an IAQ Team and promote
good indoor air quality to everyone's benefit.
A number of resources are available to school nurses looking to
improve IAQ practices in their schools. EPA's Indoor Air Quality
Tools for Schools program is a useful IAQ implementation guide.
In addition, EPA's Office of Children's Health Protection and
the American Nurses Association (ANA) are reaching out to the
2.6 million registered nurses in the United States, urging them
to promote the importance of IAQ maintenance in schools. EPA
and ANA are developing a set of continuing education courses,
to be available online and as a printed insert in ANA's newsletter.
The first course will address indoor air quality issues in schools.
The National Association of School Nurses (NASN) has created
a "Managing Asthma Triggers Training Manual," to increase
awareness of potential asthma triggers and irritants in the school
environment. Using this manual, NASN is conducting state and
regional workshops to train school nurses to facilitate the
formation of an IAQ program within their school system. The
training modules, funded through an EPA grant, provide school
nurses with tools for informing school staff, parents, and students
of asthma triggers and IAQ issues within the school. Nurses can
present this information at staff meetings, PTA meetings, or as
enhancements to classroom curricula. Many of the modules are
built upon topics identified in EPA's Indoor Air Quality Tools for
Schools Kit. With an estimated 33,000 school nurses nationwide,
NASN encourages them to become agents of change by
facilitating the convening of facilities manager, teachers, school
officials, and parents in order to discuss and implement an indoor
air quality program within the school. For more information,
visit NASN's Web site at www.nasn.org.
IAQ Tools for Schools 'Bulletin
-------
Asthma and Allergy Activities for the Classroom
Involving students in asthma and allergy
awareness activities can be a great asset to
your classroom and school's health. There
are many ways to accomplish this.
Lung biology and function can be taught in
a science lesson. Students can learn how
asthma affects the respiratory system, what
provokes asthma episodes, and why it is
important to remove these asthma triggers
from the classroom.
Students can then break into groups and
investigate the classroom, looking for
potential asthma triggers. Have them list the
"culprits" they identify, then facilitate a
discussion of why these things trigger asthma
and what can be done to help students with
asthma avoid these triggers.
Here are two classroom activities to help you
teach students about asthma:
Lesson 1: What does an asthma
attack feel like?
You will need thin straws like those used for
stirring coffee. Direct the students to take a
long deep breath to feel the air fill their
lungs. Then instruct them to run in place
for 1 minute, stop, hold their nose, and
breath through a straw . After completing
the exercise, ask students how they feel.
Common comments are, "I felt dizzy,"
or "I couldn't get enough air into my
lungs!" Asthma attacks often feel similar
to this exercise. Explain to students about
lung function, asthma maintenance, and
asthma episodes.
Lesson 2: Involve children with
asthma in the lesson:
Is there a child in your class with asthma?
The answer is most likely "Yes!" with
asthma rates in the U.S. at 1 in 13 school-
aged children. Talk to this child after class.
Discuss possible ways of eliminating the
identified asthma triggers from the
classroom. Ask if he/she would be
interested in helping to teach the class
about asthma management. The child
could tell students what it feels like to have
an asthma attack, how he/she monitors
and avoids asthma triggers, and about
asthma management. The child could
demonstrate the use of his/her peak flow
meter, a hand-held device that measures
how fast the user can move air out of the
lungs. This meter is often used to monitor
lung function and as a guide in
administering asthma medication. The
school nurse or a parent could speak to
the class to demonstrate the use of an
asthma inhaler.
-.. Need some fun facts to
ji incorporate into your lesson?
U- Did you know....
" • Your right lung is slightly larger
r than the left?
: • Hairs in your nose help to clean
and warm the air you breathe so
•s- - that your lungs don't get infected?
:...• The highest recorded "Sneeze
J Speed" is 102.5 miles per hour?
£- i/ The surface area of your lungs is
»-: about the same size as a tennis
.;. court?
p • You lose half a liter of water each
P" day by breathing?
Visit the National Asthma Education
Prevention Program (NAEPP), part of the
National Heart, Lung, and Blood Institute,
online at http://hin.nhlbi.nih.gov/
as_frameset.htm for more ideas or to
download materials, activity sheets, and
sample lessons for your class.
National "No Attacks"
Campaign
EPA released a childhood asthma media campaign
aimed at preventing asthma attacks among child
populations. The national campaign includes Public
Service Announcements (PSAs) in English and Spanish
for television, radio, newsprint, and transit ads. The
media campaign targets high population inner-city
markets. Ads are to be displayed on transit and bus
shelters and on outdoor buildings. The campaign
encourages people to call 1-866-NOATTACKS or visit
the Web site at www.NOATTACKS.org. For
additional information on asthma management,
callers can speak with an asthma consultant through
a companion hotline operated by the Allergy and
Asthma Network Mothers of Asthmatics, Inc. at 1-
800-315-8056.
IAQ Tools for Schools Bulletin
-------
Kate Horter, Chairperson for Health and
Environmental Issues, Howard County, MD
School Environments Team (SET)
. ft t
By crying a ",
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Howard County, located in the Washington,
DC metro area, has been one of Maryland's
fastest-growing regions, increasing its
population by 26 percent over the past
decade. During that same time period, the
county's public school system has consistendy
received the top rating from the State of
Maryland. Education is a high priority in
Howard County. To maintain its reputation,
school staff, parents, and students actively seek
to improve the school environment. One
result has been the formation of the School
Environments Team (SET), a committee of
the PTA Council for Howard County. Kate
Horter, Chairperson for Health and
Environmental Issues in Howard County,
spoke about the formation of SET and their
accomplishments thus far.
How was the School Environments Team
started in Howard County? ;
Let me first explain the structure of our system in
Howard County. Each of our 67 public schools has
its own PTA, all of which are members of our PTA
Council for Howard County. The PTA Council has
a Health and Environmental Issues Committee
(HEIC), which I chair. HEIC is composed of PTA
members interested in various school-related issues
including lighting, carpeting, indoor air quality,
cleaning products, and food services. One of our
goals is to be proactive and preventive in our
involvement in school health issues. This led us, in
1997, to the idea for the School Environments Team
(SET)—a group that would work with the PTA,
HEIC, the Howard County Public School System
(HCPSS), and community volunteers. To better
address environmental issues in schools, HEIC
formed three workgroups: Environmental
Education, Integrated Pest Management, and
School Environment (this includes the SET
program). We began with the question, "How can
we make a difference in schools?" We realized that
Howard County was generally "reactive" on
environmental issues in school systems. By creating
a program to identify school maintenance and
environmental problems at an early stage, we could
be more "proactive" about dealing with these issues.
What were some of the proactive programs
that were established?
Using EPA's Indoor Air Quality Tools for Schools (MQ
TfS) Kit as a guide, we created checklists including a
"Master Checklist" and various specialized checklists
for rooms with special considerations, such as a
photography lab, a home economics room, and
relocatable classrooms. Our hope is that the
relocatable classroom checklist will be especially
useful in identifying potential issues, as 50 percent
of the schools in Howard County have at least one
relocatable classroom, totaling 80 units. We are
expanding the use of the relocatable checklist and
would like to use it eventually in all of the relocatables
in the county. The checklists in the Kit were
particularly helpful and easily adaptable to our
needs.
Were there any barriers to the process?
An important consideration in creating the SET
program, of course, was money. Identifying
indoor air quality problems, maintaining
equipment, and performing walkthroughs are
time-consuming processes, particularly if these
tasks are performed in all of the county's schools.
To address this issue, HEIC members designed
the SET program to revolve around school-
specific SET teams. Currently, team participants
are usually parents from PTA and school staff.
However, the SET program is designed to be
flexible to allow for uniqueness in teams. For
example, the team might be entirely composed of
volunteers, thus saving on staff time and school
funds. This flexibility allows us to streamline the
process of problem identification and remediation.
Please describe the Master Checklist.
The Master Checklist is a two-page sheet with a list
of 35 "check" items. To create this Master Checklist,
the HEIC Committee accompanied Ron Miller
and JefFKlenk of die Howard County Public School
System's Safety and Environmental Risk
Management Office on walkdiroughs at two schools
to identify and describe what specific items should
be on the Checklist. Mr. Miller and Mr. Klenk also
helped us develop a school grounds checklist to
watch for situations such as bushes growing over
outdoor vents, open dumpster lids, dumpster
proximity to school buildings, and potential insect
problems.
IAQ Toots for Schools 'Bulletin
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Who is using the checklists'?
Currently, the SET program is underway in
seven pilot schools—one high school, one
middle school, and five elementary schools.
Each school's team decides how the
checklists will be completed. In the high
school, because of its large size,! teachers fill
out the checklists for their own classrooms.
In some of the other schools, however,
checklists are completed during
walkthroughs conducted by the school team
or volunteers, usually parents or teachers.
From our experience, it takes an average of
15 minutes to analyze a regular classroom
and 30 minutes for a portable classroom.
The SET team recommends completing
these checklists twice a year, as seasonal
changes and wear on the classroom could
generate new issues. Our hope is that
subsequent walkthroughs will take less time
than the initial walkthrough, not only
because people will be familiar with the
checklists, but also because the problems are
being solved in the meantime.
What happens to the completed
checklists?
First, we emphasize to the SET team
members performing the walkthroughs that
they are acting as observers—only recording
what they see, rather than inspecting the
school. Once completed, the checklists are
compiled by the schools team. The team
submits a list of issues identified with the
relevant department within the school
district (e.g., electrical office, carpentry). We
are currendy collecting data to determine
how quickly the school system is able to
address the issues raised by the checklists.
Our preliminary data suggest that most
issues are investigated within one or two
weeks.
Has this program been successful in
the school district?
Although the program, has been active in
schools for only one year, we are very happy
with the pilot schools' participation and the
results to date. We are currently collecting
information on response time and student
and teacher satisfaction, which we will
analyze to ensure the success of the SET
program in die future.
Do you have a success story that you
could share?
In one school, the checklists revealed an
, electrical problem that was quickly
corrected. In another, the walkthrough
helped to identify an insect problem. Three
yellow jacket nests were found during an
initial walkthrough in June, but they had
multiplied to 50 nests by September! It
. turns out that the window frames of the
schools were designed with small holes so that
water could drain out. These holes, however,
were just the right size for yellow jackets to
enter and make nests. The school system used
pesticide-free methods to remove the nests
and installed preventive measures that
should discourage future nest building. The
real success was that parents from the SET
team were able to identify the problem when
it was still small. Had the pilot version of SET
been more successful at identifying the steps
to take when an observation required
additional action, the 50 nests could have
been prevented.
"With teachers and
school facility and
maintenance staff so
pressed for time and
resources, parent
~ involvement has been
a real asset to the
SET program."
~"~~~~ —KateHorfer
Howard County, MD
Where do you see the SET program
going in the next few years?
We'd like to expand SET so that all Howard
County schools have teams and are actively
using the checklists. The purpose of the pilot
is in part to identify where we need to
improve SET materials—and this is
definitely an area in need of attention.
Information gathered from pilot schools is
critical to fine tuning the program. We need
their feedback to help us improve the
checklists and tell us (1) what a realistic
frequency for the program would be, (2)
what resources they need, (3) what needs
better explanation on the checklists, (4) what
team composition and strategy for doing the
walkthroughs was most effective at each
school and, most importandy, (5) whether
the program raises environmental awareness.
The pilot schools deserve tremendous credit.
Our hope is that the data we analyze will
help us refine the program for better, more
efficient implementation in the remaining
schools. We also would like to get more
involved in asthma awareness in the schools.
We have been approached by the American
Lung Association (ALA) to work in
conjunction with their Open Airways
program. My hope is that we will develop
some system to monitor asthma in the
schools.
Do you have any tips for school districts
looking to implement similar programs?
One of die greatest diings about the SET
program is that it gets parents involved. In
fact, in most schools, the SET team relies
heavily on parent involvement. The rewards
for this are threefold: first, it facilitates
parent-teacher and parent-school
administrator interaction; second, it
streamlines the problem identification and
resolution process by taking these initial steps
out of the hands of facilities managers,
allowing them more time to address and
evaluate potential issues; and, third, it
educates parents on indoor air quality issues,
which often results in parents applying these
techniques in their homes, making for a
healthier home life for students. With
teachers and school facility and maintenance
staff so pressed for time and resources,
parent involvement has been a real asset to
the SET program.
IAQ Tools for Schools Bulletin
Page9~_
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New Hampshire is COSHing In Rewards!
The New Hampshire Coalition for Occupational Safety &
Health (NHCOSH) has decided to take an aggressive approach
to counter the increasing asthma rates in New Hampshire school
systems. Sandi Chabot, the NHCOSH Program Coordinator,
visited several school districts in cooperation with a statewide
school asthma pilot program developed by a sub-committee of
die New Hampshire Asthma Educators Coalition. NHCOSH
plans on using EPA's Indoor Air Quality Tools for Schools Kit to
assist schools in forming IAQ teams. If you work in any of the
New Hampshire schools and would like further information,
contact Sandi Chabot at 603-226-0516.
New Year's Resolutions
Constituents of the American Public Health Association (APHA)
have presented draft resolutions regarding indoor air quality,
children's heahh, and childhood asthma rates. These resolutions call
for a national program to monitor and reduce asthma rates and a
commitment to improve indoor school environments. The resolutions
cite the increasing need for new school facilities, the government's
commitment to children's health, and the asthma epidemic in the
U.S. as a few of many convincing reasons to adopt policy to regulate
indoor air quality in schools.
Just Breathe
The American Lung Association's (ALA) Open Airways For Schools
(OAS) is an asthma management program for children, delivered in
! the school setting. It was developed and scientifically evaluated by
i researchers at Columbia University's College of Physicians and
i Surgeons. The long-term goal of the OAS program is to protect lung
\ health through the implementation of the program in all elementary
| schools in the country. Researchers found that children who
; completed the program showed increased school performance;
1 demonstrated more confidence in their ability to manage their
! asthma; exerted greater influence on parents' asthma management
' decisions; had fewer, less severe asthma episodes; and cook more steps
j to manage their asthma. Since ALA began the program in 1996,
i 282,215 children and 17,348 volunteers have been trained, and
! 28,438 kits have been distributed. The OAS program has been
i carried out in 24,687 schools including 1,256 private and 23,431
; public schools. For more information on OAS call 800-LUNG-USA
i orvisitwww.lungusa.org.
!
Asthma Resources at Your Fingertips
i Responding to the growing asthma epidemic, the National
Education Association Health Information Network is developing
'. an "Asthma and Schools" Web site, consolidating information about
asthma-related resources (books, fact sheets, policy statements, videos,
; pamphlets, etc.) for school personnel (teachers, administrators,
1 nurses, maintenance and facilities staff, food service workers, bus
, drivers, etc.) workingwith grades K-12. The Web site is now available.
! To submit information online, go to http://.asthmaandschools.org.
| For a copy of the submission form, please contact Jennie Young at
i 202-822-7481 orjyoung@nea.org.
UnLEADed, Please
EPA will adopt new standards to help childcare providers and schools identify areas that contain hazardous levels of lead. Lead
exposure, through breathing or ingestion, can cause many adverse health effects, including brain damage, kidney problems, and
learning difficulties. In response to a request from Congress for new standards in 1992, the lead guidelines (some five times more
stringent than those they replace) will give federal, state, and local officials uniform benchmarks for judging potential lead-poison
threats, particularly to children. The rules declare that a hazard exists if there are more than 40 micrograms of lead per square foot
on floors; 250 micrograms of lead per square foot on window sills; 400 parts per million of lead in the soil of a children's play area;
and 1,200 parts per million of lead in soil elsewhere in the yard. The new standards will be available online at www.access.gpo.gov/
su_docs/aces/acesI40.html and for information about lead issues in schools and homes visit www.epa.gov/oia/tips/lead2.htm.
Each year, nearly 5,100 people in the United States die as a result of asthma.
Each day, 14 people die from asthma.
Asthma-related deaths among children have tripled since 1980.
Asthma is the only chronic disease, besides AIDS and tuberculosis, with an increasing death rate.
Asthma has reached epidemic proportions. The prevelence of asthma is higher among children than adults,
and higher among blacks than whites.
! ''
Reference: The Asthma and Allergy Foundation at www.aafa.org
IAQ Tools for Schools Bulletin
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Montgomery County AIR Coalition (continued from page 5)
They also examined school carpets and mold levels. In 2000, the lAQTeam developed
a proactive maintenance plan through which 53 schools will be evaluated for lAQover
three years. With $1.3 million in their budget last year, the lAQTeam evaluated 26
schools, completed IAQ upgrades, and established IAQ school maintenance plans.
This year, a budget of $1.6 million is proposed to complete the project in the 53
schools. The District plans to phase EPA's Indoor Air Quality Tools for Schools (Z4Q
TfS) Program into all 191 schools in Montgomery County and train staff on the
Program. lAQTeam members are also studying new construction and building upgrade
techniques to ensure good indoor air quality in schools. Montgomery County is
beginning to develop regulations to monitor school IAQ in these situations. Members
of the lAQTeam are also members of Montgomery AIR.
Montgomery County nurses are also involved with tracking asthma and indoor air
quality problems in schools. As MCPS sets up the 53 schools with their proactive
IAQ and asthma management plans, one of the pieces will be a system for nurses to
track not only asthma episodes, but other indicators of indoor air quality issues such
as nose bleeds. Though they ;have not found a direct link between the incidence of
asthma episodes and known IAQ problems in schools, the District continues to track
asthma because of the concern about and general awareness of IAQ factors that
impact health.
A Community Program
There are many opportunities, for parents arid families to become involved with MCPS
to support good asthma management. Some members of the Montgomery County
PTA are members of the IAQ Advisory Team. Parent involvement is essential in
developing asthma action plans for their children with asthma. Parents can also
participate in asthma management training by volunteering in the classroom through
the Open Airways program. Through the Head Start outreach, parents will soon have a
greater opportunity to receive asthma management training.
Montgomery AIR has largely been data driven. When confronted with the statistics
that asthma is the leading cause of emergency room visits for children in Montgomery
County and a leading cause: of school absenteeism nationwide, they felt that they
had little choice but to redirect MCPS resources to address this issue.
Montgomery County recommends that other schools or districts looking to create
a similar program make sure' that their plans and approaches are well thought out.
Rushing into a program isn't the answer they say; they recommend addressing
these issues in a staged approach to evaluate what does and doesn't work for the
schools or districts.
Childhood Asthma (continued from page 1) '
Information Resources
To order the Indoor Air Quality Tools
for SchoolsYfa.
To order the Kit free of charge, call
the EPA IAQ Hotline at (800) 438-
4318. The Kit's printed materials are
now available on CD-ROM, or you
can download a text-only version
from our Web site at www.epa.gov/
iaq/schools.
We'd Like to Hear From You!
In future editions of the IAQ_ Tools
for Schools Bulletin, we would like to
share some of your experiences with
indoor air quality issues, successes,
and challenges. Whether you use the
guidance in our Kit, or another means
of improving the air quality in
schools, we would like to hear from
you.
Contact Information
Send Bulletin submissions to:
Michele Guarneiri
Guarneiri.Michele@epa.gov
For Additional Information About
Articles in this Issue:
EPA Indoor Air Quality Hotline:
(800)438-4318.
EPA Product Number ;
EPA402-F-01-019
EPA Indoor Air Quality Tools for
: Schools :Web site: www.epa.gov/iaq/
schools... - -
.This publication is a product of the Office of Radiation
and Indoor Air, Indoor Environments Division, Mail
Code.6609-J. .' : -•'-.•
unabated, a child born 20 years from now will be twice as likely to develop asthma as a child born today. Asthma development may
be associated with genetics and the environment. Scientific evidence links exposure to some allergens (dust mites) and irratants
(second-hand smoke) to the development of asthma in young children. In addition, asthma triggers, factors that exacerbate
asthma, may include colds, stress, emotional factors, biological and chemical triggers, and other environmental factors. In
schools, triggers such as animal dander, cockroach allergens, and molds can cause asthma episodes. Pollen, ozone, and some
chemical products found in schools can also irritate the respiratory system.
Despite the rising asthma rates and the many substances that can trigger an episode, asthma is a manageable disease. Asthma
control is defined as the absence of symptoms and episodes, no use of relief medication, no emergency room visits, normal
activity level, and normal lung function. Recognizing and avoiding asthma triggers, adhering to a physician's prescribed program,
and asthma education are important steps in effective asthma management. To learn how to better control asthma and prevent
asthma episodes in your school system consult "10 Ways to Manage Asthma in Schools" on pages 2-3 of this Bulletin.
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