United States
Environmental Protection
                                                                                                  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

                                       Rste f*i ' .Vf. |v.|-,, hi -.n
 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

 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 7 7j

Asthma Triggers  Commonly  Found  in  School Buildings
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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 lAQTfS Kit or visit
EPA's Indoor Air Quality Tools for Schools
Web site at www.epa.gov/iaq/schools.
                                       N s l  D E
                                 THIS   ISSUE
 2  Asthma Management in Schools    5  Montgomery County Asthma Improvement   7  Asthma Activities for the Classroom
 4  Mold Management Just Got Easier  6  School Nurses Proponents of IAQ Program  8  Kate Horter Interview

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 IAQ TfS Kit
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 building's 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 that
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 pathways and shelters; and
(4) using pest control products such as
poison baits, traps, and pesticide sprays as
                         Examples of
                         away from
and storage procedures in food preparation
areas, and fixing plumbing leaks and other
moisture problems. Look to the IAQ TfS Kit
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 a]l 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 the 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 with 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 the 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

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
throughout the U. S. In schools, they live in
pillows, and
stuffed toys
where they
feed on dead
skin flakes. To reduce dust mite exposure in
the school building, choose washable stuffed

           INDOOR    AIR     QUALITY    TOOL
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.

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 correctly. 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 obtain and submit asthma action
cards to the 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/
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:

i  Allergy and Asthma Network/Mothers of Asthmatics
   (800) 878-4403
   Ask about obtaining their school information packet.

i  American Lung Association
   (800) LUNG-USA
   Ask about the Open Airways for Schools program.

i  Asthma and Allergy Foundation of America
   (800) 7-ASTHMA
   Ask about the Asthma Management at School presentation
   for parents and school staff.

i  Center for Disease Control and Prevention
   (770) 488-7320
   Read more on their Asthma Prevention Program.

i  National Integrated Pest Management (IPM) Network
   Find out more about IPM.

i  U.S. Environmental Protection Agency
   Find out more about implementing IPM in schools.

i  U.S. Environmental Protection Agency
   Download the IAQ TfS Kit.
                                                                 1 ^>

                      Mold  Management Just Got Easier
                      EPA releases new document: Mold Remediation in Schools and Commercial Buildings
Mold Remediatjon
in Sch&ols and
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 the spring
and fall. But, what exactly is mold? According to
Barbara Spark, a staff member in EPA's Region 9
California office, "Saying 'mold' is like saying 'animal'—
there are many different kinds with very different

Some scientists estimate that there  are more than
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

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 asthma 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 there is a moisture problem—
hidden within the 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 the 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 with 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
                          The cost of asthma in 1998 was estimated to be $12.6 billion.

                          Many asthmatic children are more likely to have an attack during the winter than they are during
                          the summer. This is at least partly attributable to the fact that they spend more time inside during
                          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-

    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

           INDOOR    AIR    QUALITY     TOOL
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.

Montgomery AIR was initiated in 1997 under the leadership of the
County's Health Officer, Dr. Carol  Garvey, and with the support of
other health, education, and community leaders. Its membership
has grown to include many health care organizations, the 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 the 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 the 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 the 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 with 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 asthma, which was distributed with
the letter. Asthma management plans received by the school are
tracked. Another survey will be conducted at the end of the year to
measure the effectiveness of the coalition's 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 that 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 the 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 IAQ in 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
the 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 their age, design, and
maintenance and cleaning schedules.
                                                                                                  (continued on page 7 7j
                                                        -•   •.  m.  jr-x:  a.  •.  -ar

    School Nurses  as Strong Proponents of  IAQ  Programs
  Dr. Barbara Saltier, 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
                        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
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
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.

           INDOOR    AIR     QUALITY    TOOL
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
  incorporate into your lesson?

  Did you know....

  4  Your right lung is slightly larger
     than the left?

  4  Hairs in your nose help to clean
     and warm the air you breathe so
     that your lungs don't get infected?

  4  The highest recorded "Sneeze
     Speed" is 102.5 miles per hour?

  4  The surface area of your lungs is
     about the same size as a tennis

  4  You lose half a liter of water each
     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"


                                                              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-

                        Kate Horter,  Chairperson  for Health and
                        Environmental Issues, Howard  County, MD
                        School Environments Team (SET)
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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 consistently
   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 (IAQ
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

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 Jeff Klenk of the Howard County Public School
System's Safety and  Environmental Risk
Management Office on walkthroughs 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

           INDOOR    AIR    QUALITY    TOOL
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
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 school's team. The team
submits a list of issues identified with the
relevant department within the school
district (e.g., electrical office, carpentry). We
are currently 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

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 the 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."

            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 importantly, (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

Do you have any tips for school districts
looking to implement similar programs?
One of the greatest things 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.
                                             ^_ j  -.  JT- JT- •.  *.

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
the 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 health, 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
researchers at Columbia University's College of Physicians and
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;
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 took more steps
to manage their asthma. Since ALA began the program in 1996,
282,215 children and 17,348 volunteers have been trained, and
28,438 kits have been distributed. The OAS program has been
carried out in  24,687 schools including 1,256 private and 23,431
public schools. For more information on OAS call 800-LUNG-USA
or visit www.lungusa.org.

Asthma Resources at Your Fingertips
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,
nurses, maintenance and facilities staff, food service workers, bus
drivers, etc.) working with grades K-l 2. 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
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/aces!40.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

           INDOOR    AIR    QUALITY    TOOLS
Montgomery County AIR Coalition  (continued from page 5)

They also examined school carpets and mold levels. In 2000, the IAQ Team developed
a proactive maintenance plan through which 53 schools will be evaluated for IAQ over
three years. With $1.3 million in their budget last year, the  IAQ Team 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 (IAQ
TfS) Program into all 191 schools  in Montgomery County and train staff on the
Program. IAQ Team 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 IAQ Team 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 and 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 11
     Information  Resources

     To order the Indoor Air Quality Took
     for SchoolsKit:
     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/

     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

     Contact Information

     Send Bulletin submissions to:

     Michele Guarneiri


     For Additional Information About
     Articles in this Issue:

     EPA Indoor Air  Quality Hotline:
     (800) 438-4318.
     EPA Product Number
     EPA 402-F-01-019
     EPA Indoor Air  Quality  Tools for
     Schools Web site: www.epa.gov/iaq/
    This publication is a product of the Office of Radiation
    and Indoor Air, Indoor Environments Division, Mail
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.
                                            ^_ j  -. JT- JT- •.  *.

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