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5
INDOOR BIOLOGIc Expos u res
I he allergic constituents of indoor air are predominantly bio-
logic in origin (Becher, 1996~. As early as the sixteenth century,
associations between a number of these exposures and asthma
were suspected; however, the scientific data available were un-
able to confirm such an association. Concern in recent years re-
garding the potential health effects of indoor air, as well as the
marked increase in the prevalence of asthma in industrialized
countries, has prompted an influx of scientific data on exposure
to airborne biologic agents and asthma.
The committee was charged with the task of evaluating the
strength of the scientific evidence concerning the possible asso-
ciation between these agents and asthma prevalence and severity.
The committee was also tasked with examining possible means
of mitigating or preventing exposure to these agents. In this chap-
ter the committee evaluates indoor exposure to biologic agents,
addressing the following to the extent permitted by available re-
search:
1. which factors influence exposures to the agent;
2. whether a relationship exists between the agent and asthma
prevalence or severity, taking into account the strength of the sci-
entific evidence and the appropriateness of the methods used to
detect the relationship;
105
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106
CLEARING THE AIR
3. what type of relationship exists between the agent and
asthma;
4. whether there are special considerations regarding the
agent (e.g., subpopulations at risk and interactions with other ex-
posures);
5. which strategies effectively mitigate or prevent exposure
to the agent;
6. whether these strategies only reduce exposures or decrease
the occurrence or exacerbation of asthma; and
7. whether these strategies are reasonable for use by the tar-
get populations.
Each section begins by providing a definition of the agent and
a summary of the factors that influence exposure. The evidence
concerning the possible association between the agent and asthma
is discussed, followed by the committee's conclusions regarding
the health impacts. Where information is available, evidence re-
garding possible means of mitigating or preventing exposure to
the agent is addressed. Each section concludes with any commit-
tee recommendations for areas for which additional research is
needed with respect to the agent. Because there are great differ-
ences in the amount and type of information available on specific
agents, the sections vary in their depth and focus.
ANIMALS
Cats
Definition of the Agent and Means of Exposure
Cats are kept as pets in 27% of U.S. households. The major cat
allergen, Fe! ~ I, is a glycoprotein structured as a heterodimer with
two chains of amino acids, which have been defined by poly-
merase chain reaction (PCR) and subsequent DNA sequencing
(Griffith et al., 1992; Morgenstern et al., 1991; Schou, 1993~. It is
found on cat hair and is produced in cat sebaceous, salivary, and
anal glands (De Andrade et al., 1996~. In male cats, Fe! ~ I glandu-
lar production is under hormonal control and decreases after cas-
tration (Zielonka et al., 1994~. As discussed in the Third Interna
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INDOOR BIOLOGIC EXPOSURES
107
tional Workshop report (Platts-MilIs et al., 1997), the clinical sig-
nificance of this decrease in allergen production is not certain,
since many symptomatic cat-allergic asthmatics in the United
States have neutered cats. Further investigation of hormonal and
genetic control of Fe! ~ I production could be relevant to the con-
tro] of allergen levels in homes with cats. Although 90°/O of pa-
tients allergic to cats make immunogIobulin E (IgE) to Fe! ~ I (de
Groot et al., 1988; Schou, 1993), making Fe! ~ I a marker for the
immune response to cat allergens, at least eight other cat aller-
gens have been identified (Duffort et al., 1987), suggesting that
protection from Fe! ~ I exposure may not be the equivalent of pro-
tection from cat allergen exposure. This conclusion is supported
by the findings that 66% of the histamine-releasing activity of cat
hair and dander extract, and about 60% of the cat dander
radioallergosorbent test (RAST) activity, was carried by Fe! ~ I
(Schou, 1993~.
Touching the cat is only one mode of contact that may result
in airborne suspension of allergen and potential direct hand-to-
nose deposition of allergen-associated particles. In contrast with
cockroach allergen, which is airborne only transiently during the
disturbance of household dust, cat allergen can remain airborne
for long periods of time, in part because Fe! `1 I is associated to a
significant extent with smaller particles of less than 5 ,um
(Custovic et al., 1998b). Particles on which cat allergen is carried,
coming primarily from cat dander, are also very adherent. Conse-
quently cat allergen is spread easily throughout a house, even
when cats are kept out of certain rooms. Moreover, cat allergen is
easily carried from home to home, office, school, or day care cen-
ter by those who touch cats or visit households with cats
(Custovic et al., 1998a; Dybendal and Elsayed, 1994; Warner,
1992~. At trace or small amounts that may be significant for sensi-
tization or exacerbation of disease in sensitized individuals, Fe! `1
I in settled dust is found in most homes without cats (Bollinger et
al., 1996; Chew et al., 1998), although allergen levels are generally
higher in homes with cats. A Baltimore, Maryland, study found
measurable levels of airborne Fe! ~ I in 37 homes with cats (range,
1.8-578 ng/m3; median, 45.9 ng/m3) and in 10 of 40 homes with-
out cats (range for detectable samples, 2.8-88.5 ng/m3; median,
17 ng/m3) (Bollinger et al., 1996~. In 38 of 40 homes without cats,
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108
CLEARING THE AIR
Eel d I was present in the settled dust (range, 39-3,750 ng/g; me-
dian,258 ng/g); dust levels were weakly correlated with airborne
levels. Carpeting, bedding, and upholstered furniture can be res-
ervoirs for deposited cat allergen (Wood et al., 1989~; shaking the
bedding in rooms with cats resuspends cat allergen in the air.
As well as being detected in homes without cats, cat allergen
has also been detected in public places such as hospitals and
schools. In one British study that measured both settled and air-
borne cat allergen in hospitals, the amount of cat allergen in
settled dust in upholstered chairs was as high as in homes with
cats (geometric mean, 23,ug/g dust), but airborne levels were low
(0.22 ng/m3) (Custovic et al., 1998a).
Evidence Regarding Asthma Exacerbation
In cat-sensitized asthmatics, cat allergen can induce allergic
symptoms, asthmatic symptoms, and decrements in lung func-
tion. Exposure to inhaled cat allergen in an experimental cat room
led to significant decreases in forced expiratory volume in one
second (FIVE range, 6-57%; mean, 25%) in a study of 13 adults
with cat allergy. The percentage decrease in FEVER did not corre-
late significantly with either the intradermal titration end point
with cat allergen or the magnitude of the RAST response with cat
allergen. Those cat-allergic subjects classified as asthmatic by
methacholine challenge testing experienced almost identical re-
sponses to environmental allergen challenge in an experimental
cat room and inhalation challenge with cat allergen (Sicherer et
al., 1997~. Norman and colleagues documented progressive in-
creases in both nasal and lung symptom scores during a 60-
minute period in a cat room (Norman et al., 1996~.
While initial cat room studies involved very high airborne cat
allergen levels, a later experimental cat room exposure study by
Bollinger and colleagues (1996) evaluated symptom and lung
function responses of cat-sensitive subjects to low-level airborne
cat allergens. They demonstrated that cat-sensitive individuals
can have increases in upper- (congestion, rhinorrhea, pruritus)
and lower- (chest tightness, wheezing) respiratory symptoms and
decrements in Jung function at levels of cat allergen occurring in
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INDOOR BIOLOGIC EXPOSURES
109
homes without cats. The median FEVER change was 15% in the
seven challenges with a Fe! ~ I level less than 100 ng/m3.
In a Delaware case-control study, Gelber and colleagues (1993)
studied allergen predictors of emergency room visits for asthma.
This study compared 93 patients, 15 to 55 years of age, who pre-
sented with breathlessness and airway obstruction, to 93 patients
presenting without breathlessness. For cat and cockroach, the
combination of sensitization and the presence of allergen in the
house was associated with asthma presenting to hospitals (14/93
asthmatics versus 1/93 controls). Whether other exposures po-
tentiate the response of cat-allergic asthmatics to cat exposure is
unknown. In a cross-sectional study of children in New Mexico
with asthma or bronchial hyperresponsiveness, cat sensitization
and exposure to cat allergen were common (Sporik et al., 1995~.
Among children with asthma (defined as symptomatic bronchial
reactivity), 13/19 were sensitized to cat. Numbers were too small
to compare symptoms in cat-sensitized asthmatics with and with-
out significant home exposure to cat allergen (Ingram et al., 1995~.
Evidence Regarding Asthma Development
Insufficient data are available to assess whether exposure to
cats influences the development of asthma. Cross-sectional stud-
ies of children suggest an association between sensitization to cats
and home exposure in the first six months of life (Suoniemi et al.,
1981; Warner et al., 1991~. These studies may be subject to recall
bias. A longitudinal birth cohort study from the Isle of Wight
found that the presence of a cat in the home predicted a greater
risk of skin test reactivity to cat and a greater risk of any skin test
reactivity by 2 years of age (Hide et al., 1994~. Sensitization to cat
predicts asthma development, but this may simply be a confir-
mation of the well-documented fact that atopic individuals are
more likely to develop asthma than nonatopic individuals. In a
New Zealand birth cohort study, the development of asthma by
13 years of age was associated with sensitization to cats and dogs
at age 13 (Sears et al., 1989~. Sensitization to cats predicted the
development of bronchial hyperresponsiveness in a longitudinal
study of adults in Boston, Massachusetts (Litonjua et al., 1997~.
However, neither of these studies provides evidence of whether
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110
CLEARING THE AIR
exposure to cats predicts either asthma or bronchial hyperrespon-
siveness. Since cat allergen exposure can potentially take place
either at home or in schools and public places, the relative impor-
tance of home versus community-wide exposure to cat allergen
in the risk of specific sensitization to cats is unknown.
Although the field of the genetics of asthma is in its infancy,
preliminary studies suggest that certain genetic phenotypes are
associated with allergy to specific insects or animals (Fukuda et
al., 1995; Hizawa et al., 1998; Young et al., 1992, 1993~. Under-
standing the genetics of allergy and asthma, including under-
standing the phenotypes associated with allergy specificity, may
eventually prove useful in understanding gene-by-environment
interaction in the development of asthma.
Conclusions: Asthma Exacerbation and Development
In cat-sensitive asthmatics, cat allergen exposure leads to
worsening of respiratory symptoms and to a decline in Jung func-
tion. Although sensitization to cats is a prerequisite to reactivity
to cat exposure, the level of airborne cat allergen that exacerbates
asthma varies by individual and is not necessarily predictable by
the size of the skin test reaction to cat or the titer of IgE antibody.
However, specific sensitive subgroups have not been defined. The
relationship between cat allergen in the home and asthma devel-
opment is uncertain. Because cat allergen is frequently found out-
side the home and in households without cats, the assessment of
individual exposures to cats is difficult, making evaluation of the
association between cat allergen exposure and asthma develop-
ment difficult as well. In summary:
· There is sufficient evidence of a causal relationship between
cat allergen exposure and exacerbation of asthma in individuals
specifically sensitized to cats.
· There is inadequate or insufficient evidence to determine
whether or not an association exists between cat allergen expo-
sure and the development of asthma.
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INDOOR BIOLOGIC EXPOSURES
Evidence Regarding Exposure Mitigation and Prevention:
Homes
111
Removal of the cat from the home will decrease exposure to
cat allergen and is widely recommended for symptomatic cat-sen-
sitive asthmatics. However even when the owner removes the
cat, cat allergen levels may remain elevated for 20 weeks or more
(Wood et al., 1989~. Removal of carpets and upholstery, with en-
casement of mattresses and pillows, may be required for dimin-
ishing cat allergen to levels commonly measured in homes with-
out cats (Wood et al., 1989~.
No studies are available that evaluate symptoms or Jung func-
tion in cat-sensitive asthmatics before and after removal of the cat
from the home. Nor are there studies of change in symptoms or
lung function after moving from a home with a cat to a home
without a cat. However, exposure studies suggest that in cat-sen-
sitive subjects the decline in lung function associated with low-
leve] airborne exposure to cat allergen, which can be present in a
home with no cats, tends to be less extreme than the decline in
Jung function associated with higher-level airborne exposure
(Bollinger et al., 1996~. The experiments demonstrating entry into
a room with a cat as a source of exacerbation of asthma in cat-
sensitive individuals also suggest that removal of the cat from the
household may decrease symptoms in cat-allergic asthmatic.
Because of the reluctance of cat-allergic symptomatic asthmat-
ics to get rid of their cats, a number of studies have focused on the
potential for lowering cat allergen levels by washing the cat. In
eight households with cats, de Blay and colleagues (1991a) found
that the combination of washing the cat weekly, reducing furnish-
ings, vacuum cleaning, and air filtration reduced airborne cat al-
lergen levels. In a second study, however, Avner and colleagues
(1997) from the Platts-MilIs group found that while washing cats
by immersion will transiently remove significant allergen from
the cat and reduce the quantity of airborne Fe! ~ I, this reduction
in allergen is not maintained by one week. Klucka and colleagues
(1995) found no significant reduction of Fe! ~ I by washing, use of
Allerpet-C (a widely advertised topical spray), or acepromazine,
a tranquilizer advocated as efficacious in subsedating doses.
While removal of the cat from the living room and bedroom areas
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112
CLEARING THE AIR
of the home and use of a High-Efficiency Particulate Air (HEPA)
filter reduced airborne levels of cat allergen in homes with cats,
the reduction was not evenly spread across the particle size range
(Custovic et al., 1998b). It is unclear that the level of reduction of
allergen obtained in this study is sufficient to influence symp-
toms in cat-sensitized asthmatics. No studies are available to as-
sess the efficacy of recommendations to wash cats in reducing
symptoms in cat allergic-asthmatics. Although the combination
of HEPA filter use, mattress and pillow covers, and exclusion of
cats from the bedroom reduced airborne cat allergen levels, a
Maryland study detected no improvement in daily symptom
scores, peak flow rates, medication use, monthly spirometry, pre-
and post-study cat-specific IgE levels, and methacholine chal-
lenge studies in cat-allergic subjects (Wood et al., 1998~. On the
other hand, in a double-blind, placebo-controlled, cross-over
study of twenty asthmatic children sensitized to cat or dog aller-
gens, and living in homes with these animals, airway
hyperresponsiveness was improved and peak flow variation was
decreased during the use of air cleaners in the living room and
bedroom of the child (van der Heide et al., 1999~. The authors
report that substantial amounts of cat and dog allergen were cap-
tured by the air cleaners; floor cat and dog allergen levels were
unchanged by air cleaner use.
Evidence Regarding Exposure Mitigation and Prevention:
Schools and Hospitals
Even if the cat is removed from the home, continued low-
grade exposures may occur in public places or via clothes from
cat owners. Since cat allergen is everywhere, there is little poten-
tial for absolute avoidance (Dybendal and Elsayed, 1994; Warner,
1992~. Norwegian investigators have demonstrated the presence
of Fe! ~ 1 in schools on both smooth and carpeted floors, with
approximately 11 times more allergen on the carpeted floors
(Dybendal et al., 1991, 1989a, 1989b). The frequency of cleaning
floors and furniture was believed to influence the level of cat and
dog allergen, which were higher on chairs than in floor dust
(Warner, 1992~. Upholstered chairs and mattresses in hospitals are
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INDOOR BIOLOGIC EXPOSURES
113
also demonstrated reservoirs for cat and dog allergen (Custovic
et al., 1998a).
To lessen the risk of exacerbation of asthma in cat- or dog-
sensitized asthmatics in public buildings, Warner and others
(1992) have recommended the use of smooth floors and frequently
cleaned wooden or plastic chairs. In their study demonstrating
the presence of significant cat and dog allergen levels in a hospi-
tal in Manchester, England, Custovic and colleagues (1998a) ques-
tioned the introduction of soft furnishings and carpets into hospi-
tals where highly cat- or dog-allergic asthmatics may come for
care. Where upholstered chairs were present, they demonstrated
that vacuuming three times a week significantly reduced allergen
levels.
Conclusions: Exposure Mitigation and Prevention
Cat allergen levels can be reduced to levels found in homes
without cats by removal of the cat from the home, but the reduc-
tion in allergen levels may require a prolonged period of time.
The combination of HEPA filter use, mattress and pillow covers,
and exclusion of cats from the bedroom may not reduce airborne
cat allergen levels sufficiently to improve symptoms in cat-sensi-
tive asthmatics. The absence of carpet, the use of plastic or
wooden rather than upholstered chairs, and of frequent vacuum-
ing in schools and hospitals may decrease the levels of cat aller-
gen in public places. No studies are available to evaluate whether
these measures improve symptoms or lung function in cat-sensi-
tized asthmatics or whether they decrease the potential for sensi-
tization in nonsensitized individuals. In summary:
· There is sufficient evidence of an association between re-
moval of a cat from the home and a decrease in levels of cat aller-
gen in the home; this decrease in levels of allergen may be slow if
reservoirs of cat allergen are not simultaneously removed from
the home.
· There is limited or suggestive evidence of an association
between removal of a cat from the home and improvement of
symptoms or lung function in cat-allergic asthmatics.
· There is limited or suggestive evidence of an association
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114
CLEARING THE AIR
between measures short of removal of a cat from the home (e.g.,
washing the cat, HEPA filter use) and some transient reduction in
cat allergen levels in the home.
· There is inadequate or insufficient evidence to determine
whether or not an association exists between measures short of
removal of a cat from the home (e.g., washing the cat, HEPA filter
use) and improvement in symptoms in cat-allergic asthmatics.
Dogs
Definition of the Agent and Means of Exposure
Dogs are present in 31% of U.S. households and are also
sources of allergens (Schou, 1993~. Allergy to cats is reported to be
about twice as common as allergy to dogs, despite the fact that
dogs are as common in U.S. households as cats (Bollinger et al.,
1996~. CanfI and CanfII are purified dog allergens that have been
identified (Schou, 1993~. CanfIis a polypeptide whose molecular
weight and structure have been partially but not fully defined
(Schou, 1993~. It is present in dander, pelt, hair, and saliva, but not
in the urine or feces of dogs (Schou, 1993~. Though there are likely
to be other dog allergens, no others have been found to have clini-
cal importance. CanfIis considered a major allergen, because it
accounts for at least half of the allergenic activity in dog hair and
dander. In addition, 92% of dog-allergic patients had a positive
skin prick test to CanfI (Schou, 1993; Yman et al., 1973~. It is still a
controversial matter whether true breed-specific dog allergens
exist or whether the differences observed between breeds are
quantitative rather than qualitative (Schou, 1993~. Hair is not the
only source of dog allergen, and it is not known whether short-
haired dogs are less allergenic. Cross-reactivity can be found be-
tween dog and cat allergen (Vanto and Koivikko, 1983~.
Dog allergen, like cat allergen and unlike cockroach, is easily
aerosolized and widely disseminated throughout the community
(Custovic et al., 1997~. In a Baltimore study of 42 homes, dog anti-
gen was demonstrated in more than half of households (Lied et
al., 1987; Schou, 1993~. In Sweden, dog allergen has been mea-
sured in homes that have never had dogs (Munir et al., 1992~.
Like cat allergen, dog allergen has been found in significant
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INDOOR BIOLOGIC EXPOSURES
115
amounts in public buildings such as schools (Berge et al., 1998;
Dybendal et al., 1989a; Schou, 1993; Warner, 1992) and hospitals
(Custovic et al., 1998a). In dust from upholstered English hospital
chairs, CanfI levels (geometric mean = 22,ug/g, range, 4-63) were
as high as levels in settled dust from households with dogs
(Custovic et al., 1998a; Munir et al., 1994~. Hospital airborne Canf
I levels were detectable in 7 of 10 testing days but were lower
(range 0.09-0.22 ng/m3) than those often found in homes with
dogs (range 0-100 ng/m3 Canf I) (Custovic et al., 1998a; Hodson
et al., 1999~.
Evidence Regarding Asthma Exacerbation
The asthmatic response to bronchial provocation test (PT)
with dog allergen was evaluated in a cross-sectional Finnish study
of 203 asthmatic children selected from the Children's Asthma
Registry (Vanto and Koivikko, 1983~. Of those with a positive PT,
64% had kept dogs, whereas only 36% with a negative PT had
kept dogs. A positive PT was correlated with a positive skin prick
test to dog (correlation coefficient = 0.8), but not with the fre-
quency of reported asthma symptoms. In immunotherapy trials,
positive response to bronchial provocation with dog allergen has
also been associated with elevated levels of IgE to dog allergen in
asthmatic subjects (Hedlin et al., 1995; Valovirta et al., 1984; Vanto
et al., 1980~. Some investigators consider symptomatic and bron-
chial response to animal allergen in an experimental animal room
to be more definitive proof that animal allergen triggers asthma
than allergen bronchial PT. They question whether the airway re-
sponse to bronchial provocation with an allergen is always an
allergic rather than an irritant response. The committee could find
no published studies of the response of dog-sensitized asthmatics
to exposure to dogs in an experimental dog room analogous to
the cat room set up by the Hopkins group (Sicherer et al., 1997~.
Evidence Regarding Asthma Development
There is insufficient evidence regarding the role of dog aller-
gen in the development of asthma. In keeping with the ecology of
Los Alamos, New Mexico, which is high and dry, with less dust
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212
CLEARING THE AIR
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Representative terms from entire chapter:
cat allergen
