Reducing patients' exposures to asthma and allergy triggers in their homes: an evaluation of effectiveness of grades of forced air ventilation filters

The impact of heating, ventilation, and air conditioning design features on the transmission of viruses, including the 2019 novel coronavirus: A systematic review of filtration

Historically, viruses have demonstrated airborne transmission. Emerging evidence suggests the novel coronavirus (SARS-CoV-2) that causes COVID-19 also spreads by airborne transmission. This is more likely in indoor environments, particularly with poor ventilation. In the context of airborne transmission, a vital mitigation strategy for the built environment is heating, ventilation, and air conditioning (HVAC) systems. HVAC features could modify virus transmission potential. A systematic review was conducted to identify and synthesize research examining the effectiveness of filters within HVAC systems in reducing virus transmission. A comprehensive search of OVID MEDLINE, Compendex, and Web of Science Core was conducted to January 2021. Two authors were involved in study selection, data extraction, and risk of bias assessments. Study characteristics and results were displayed in evidence tables and findings were synthesized narratively. Twenty-three relevant studies showed that: filtration was associated with decreased transmission; filters removed viruses from the air; increasing filter efficiency (efficiency of particle removal) was associated with decreased transmission, decreased infection risk, and increased viral filtration efficiency (efficiency of virus removal); increasing filter efficiency above MERV 13 was associated with limited benefit in further reduction of virus concentration and infection risk; and filters with the same efficiency rating from different companies showed variable performance. Adapting HVAC systems to mitigate virus transmission requires a multi-factorial approach and filtration is one factor offering demonstrated potential for decreased transmission. For filtration to be effective, proper installation is required. Of note, similarly rated filters from different companies may offer different virus reduction results. While increasing filtration efficiency (i.e., increasing MERV rating or moving from MERV to HEPA) is associated with virus mitigation, there are diminishing returns for filters rated MERV 13 or higher. Although costs increase with filtration efficiency, they are lower than the cost of ventilation options with the equivalent reduction in transmission. Systematic review registration: PROSPERO 2020 CRD42020193968.

Filter evaluation and selection for heating, ventilation, and air conditioning systems during and beyond the COVID-19 pandemic

Particle size removal efficiencies for 0.1-1.0 μm ( PSE 0.1 - 1.0 $$ {PSE}_{0.1-1.0} $$ ) and 0.3-1.0 μm ( PSE 0.3 - 1.0 $$ {PSE}_{0.3-1.0} $$ ) diameter of Minimum Efficiency Reporting Value (MERV) filters, an electrostatic enhanced air filter (EEAF), and their two-stage filtration systems were evaluated. Considering the most penetrating particle size was 0.1-0.4 μm particulate matter (PM), the PSE 0.1 - 1.0 $$ {PSE}_{0.1-1.0} $$ as an evaluation parameter deserves more attention during the COVID-19 pandemic, compared to the PSE 0.3 - 1.0 $$ {PSE}_{0.3-1.0} $$ . The MERV 13 filters were recommended for a single-stage filtration system because of their superior quality factor (QF) compared to MERV 6, MERV 8, MERV 11 filters, and the EEAF. Combined MERV 8 + MERV 11 filters have the highest QF compared to MERV 6 + MERV 11 filters and EEAF + MERV 11 filters; regarding 50% of PSE 0.1 - 1.0 $$ {PSE}_{0.1-1.0} $$ as the filtration requirements of two-stage filtration systems, the MERV 8 + MERV 11 filtration system can achieve this value at 1.0 m/s air velocity, while PSE 0.1 - 1.0 $$ {PSE}_{0.1-1.0} $$ values were lower than 50% at 1.5 m/s and 2.0 m/s. EEAF obtained a better PSE 0.3 - 1.0 $$ {PSE}_{0.3-1.0} $$ in the full-recirculated test rig than in the single-pass mode owing to active ionization effects when EEAF was charged by alternating current.

Reductions in particulate matter concentrations resulting from air filtration: A randomized sham-controlled crossover study

One-hundred seventy-two households were recruited from regions with high outdoor air pollution (Fresno and Riverside, CA) to participate in a randomized, sham-controlled, cross-over study to determine the effectiveness of high-efficiency air filtration to reduce indoor particle exposures. In 129 households, stand-alone HEPA air cleaners were placed in a bedroom and in the main living area. In 43 households, high-efficiency MERV 16 filters were installed in central forced-air heating and cooling systems and the participating households were asked to run the system on a clean-air cycle for 15 min per hour. Participating households that completed the study received true air filtration for a year and sham air filtration for a year. Air pollution samples were collected at approximately 6-month intervals, with two measurements in each of the sham and true filtration periods. One week indoor and outdoor time-integrated samples were collected for measurement of PM2.5 , PM10 , and ultrafine particulate matter (UFP) measured as PM0.2 . Reflectance measurements were also made on the PM2.5 filters to estimate black carbon. True filtration significantly improved indoor air quality, with a 48% reduction in the geometric mean indoor PM0.2 and PM2.5 concentrations, and a 31% reduction in PM10 . Geometric mean concentrations of indoor/outdoor reflectance values, indicating fraction of particles of outdoor origin remaining indoors, decreased by 77%. Improvements in particle concentrations were greater with continuously operating stand-alone air cleaners than with intermittent central system filtration. Keeping windows closed and increased utilization of the filtration systems further improved indoor air quality.

A framework for estimating the United States depression burden attributable to indoor fine particulate matter exposure

Recently published exploratory studies based on exposure to outdoor fine particulates, defined as particles with a nominal mean diameter less than or equal to 2.5 μm (PM_2.5) indicate that the pollutant may play a role in mental health conditions, such as major depressive disorder. This paper details a model that can estimate the United States (US) major depressive disorder burden attributable to indoor PM_2.5 exposure, locally modifiable through input parameter calibrations. By utilizing concentration values in an exposure-response function, along with relative risk values derived from epidemiological studies, the model estimated the prevalence of expected cases of major depressive disorder in multiple scenarios. Model results show that exposure to indoor PM_2.5 might contribute to 476,000 cases of major depressive disorder in the US (95% confidence interval 11,000-1,100,000), approximately 2.7% of the total number of cases reported annually. Increasing heating, ventilation, and air conditioning (HVAC) filter efficiency in a residential dwelling results in minor reductions in depressive disorders in rural or urban locations in the US. Nevertheless, a minimum efficiency reporting value (MERV) 13 filter does have a benefit/cost ratio at or near one when smoking occurs indoors; during wildfires; or in locations with elevated outdoor PM_2.5 concentrations. The approach undertaken herein could provide a transparent strategy for investment into the built environment to improve the mental health of the occupants.

Does Air Filtration Work for Cat Allergen Exposure?

PURPOSE OF REVIEW

The goal of this review is to compress all important information and results of the research in reducing cat allergen exposure using air filtration. Fel d 1 is the major allergen responsible for IgE responses in 90 to 95% of patients with cat allergy.

RECENT FINDINGS

Reduction of cat allergen in indoor air with different air filtration systems and portable devices has been demonstrated in the majority of the studies. Recently, early and late asthmatic responses were significantly reduced using portable HEPA air cleaners in an environmental exposure chamber. This review provides a comprehensive overview of the current state of airborne Fel d 1 air filtration targeting the most efficient devices in cat allergen reduction. Novel emerging HEPA filters are targeting reduction of cat indoor asthma trigger so patient can might benefit from efficient solution.

In-situ effectiveness of residential HVAC filters

In this study, we explore different filter and contextual characteristics that influence effectiveness of high-efficiency filters in 21 residences in Toronto, Canada. The in situ effectiveness was assessed with decay tests at the beginning and the end of filter life with four different filters (MERV 8-14 from ASHRAE Standard 52.2) installed in operational HVAC systems, compared with either the system off or with no filter installed. There was considerable difference between median PM_2.5 effectiveness of the non-electret filters when compared to electret filters (16% vs. 36%) of the same nominal efficiency (MERV 8). However, median PM_2.5 effectiveness of electret filters only slightly improved (between 5% and 9% absolute increase) as MERV increased from 8 to 14. There was more variation in filter effectiveness between the same filter in different homes than there was between different filters in the same home. Variations in filter performance arose because home-specific particle loss rates (eg, ventilation rate) vary greatly in different buildings. The higher the loss rates due to non-filter factors, the lower the effectiveness of a filter. Given the relatively large variation in effectiveness for a given filter over time and in different homes, increasing system runtime may be a productive way to improve filter performance in many homes.

Different cardiorespiratory effects of indoor air pollution intervention with ionization air purifier: Findings from a randomized, double-blind crossover study among school children in Beijing

Indoor air pollution is associated with numerous adverse health outcomes. Air purifiers are widely used to reduce indoor air pollutants. Ionization air purifiers are becoming increasingly popular for their low power consumption and noise, yet its health effects remain unclear. This randomized, double-blind crossover study is conducted to explore the cardiorespiratory effects of ionization air purification among 44 children in Beijing. Real or sham purification was performed in classrooms for 5 weekdays. Size-fractionated particulate matter (PM), black carbon (BC), ozone (O₃), and negative air ions (NAI) were monitored, and cardiorespiratory functions were measured. Mixed-effect models were used to establish associations between exposures and health parameters. Real purification significantly decreased PM and BC, e.g. PM_0.5, PM_2.5, PM₁₀ and BC were decreased by 48%, 44%, 34% and 50%, respectively. O₃ levels were unchanged, while NAI was increased from 12 cm^-3 to 12,997 cm^-3. Real purification was associated with a 4.4% increase in forced exhaled volume in 1 s (FEV₁) and a 14.7% decrease in fractional exhaled nitrogen oxide (FeNO). However, heart rate variability (HRV) was altered negatively. Interaction effects of NAI and PM were observed only on HRV, and alterations in HRV were greater with high NAI. Ionization air purifier could bring substantial respiratory benefits, however, the potential negative effects on HRV need further investigation.

Fine and ultrafine particle removal efficiency of new residential HVAC filters

Particle air filters used in central residential forced-air systems are most commonly evaluated for their size-resolved removal efficiency for particles 0.3-10 µm using laboratory tests. Little information exists on the removal efficiency of commercially available residential filters for particles smaller than 0.3 µm or for integral measures of mass-based aerosol concentrations (eg, PM_2.5 ) or total number concentrations (eg, ultrafine particles, or UFPs) that are commonly used in regulatory monitoring and building measurements. Here, we measure the size-resolved removal efficiency of 50 new commercially available residential HVAC filters installed in a recirculating central air-handling unit in an unoccupied apartment unit using alternating upstream/downstream measurements with incense and NaCl as particle sources. Size-resolved removal efficiencies are then used to estimate integral measures of PM_2.5 and total UFP removal efficiency for the filters assuming they are challenged by 201 residential indoor particle size distributions (PSDs) gathered from the literature. Total UFP and PM_2.5 removal efficiencies generally increased with manufacturer-reported filter ratings and with filter thickness, albeit with numerous exceptions. PM_2.5 removal efficiencies were more influenced by the assumption for indoor PSD than total UFP removal efficiencies. Filters with the same ratings but from different manufacturers often had different removal efficiencies for PM_2.5 and total UFPs.

Effectiveness of Using Enhanced Filters in Schools and Homes to Reduce Indoor Exposures to PM2.5 from Outdoor Sources and Subsequent Health Benefits for Children with Asthma

Filters can reduce indoor concentrations of particulate matter (PM_2.5), but their benefits have not been well-characterized. This study investigates exposure, health, and cost impacts of high efficiency filters in homes and schools, focusing on the asthma-related outcomes. Reductions in indoor exposures to PM_2.5 from outdoor sources with enhanced filters (e.g., MERV 12) are estimated using probabilistic indoor air quality models, and avoided health impacts are quantified using health impact assessment. These methods are applied using data from Detroit, Michigan, an urban region with elevated asthma rates. Replacing inefficient filters with enhanced filters in schools would reduce the PM_2.5-attributable asthma burden by 13% annually, with higher benefits for more efficient filters. Marginal costs average $63 per classroom or $32 per child with asthma per year. In homes, using efficient furnace filters or air cleaners yields 11 to 16% reductions in the asthma burden with an annualized marginal costs of $151-494 per household. Additional benefits include reductions in health risk for adults and lower exposures to other contaminants such as PM from indoor sources. On the basis of the included health outcomes, efficient filters in schools in particular is a potentially cost-efficient way to reduce the asthma-related health burden for children.

Allergic Rhinitis

Among the atopic disorders, allergic rhinitis is the most prevalent. Patients who suffer from allergic rhinitis sustain significant morbidity and loss of productivity. Cardinal symptoms include nasal congestion, rhinorrhea, sneezing, and nasal itching, although multiple related symptoms may occur. Causes should be ruled out with a thorough history and physical examination, with particular attention to red flag or atypical symptoms. Skin testing or serum sampling can confirm diagnosis and also guide therapy. Therapy is multimodal, tailored to a particular patient's symptom burden and quality of life.

Approaches to prevent the patients with chronic airway diseases from exacerbation in the haze weather

Haze weather is becoming one of the biggest problems in many big cities in China. It triggers both public anxiety and official concerns. Particulate matter (PM) plays the most important role in causing the adverse health effects. Chemical composition of PM2.5 includes primary particles and secondary particles. The toxicological mechanisms of PM2.5 to the human body include the oxidative stress, inflammation and carcinogenesis. Short or long-term exposure to PM (especially PM2.5) can cause a series of symptoms including respiratory symptoms such as cough, wheezing and dyspnea as well as other symptoms. There are positive associations between PM2.5 and mortality due to a number of causes. PM2.5 is considered to contribute to the onset of asthma, the exacerbation of chronic obstructive pulmonary disease (COPD) in haze weather. Some approaches including outdoor health care, indoor health care and preventive medications can prevent the patients with chronic airway diseases from exacerbations.

Evaluating the Long-Term Health and Economic Impacts of Central Residential Air Filtration for Reducing Premature Mortality Associated with Indoor Fine Particulate Matter (PM2.5) of Outdoor Origin

Much of human exposure to fine particulate matter (PM2.5) of outdoor origin occurs in residences. High-efficiency particle air filtration in central heating, ventilating, and air-conditioning (HVAC) systems is increasingly being used to reduce concentrations of particulate matter inside homes. However, questions remain about the effectiveness of filtration for reducing exposures to PM2.5 of outdoor origin and adverse health outcomes. Here we integrate epidemiology functions and mass balance modeling to estimate the long-term health and economic impacts of HVAC filtration for reducing premature mortality associated with indoor PM2.5 of outdoor origin in residences. We evaluate 11 classifications of filters (MERV 5 through HEPA) using six case studies of single-family home vintages and ventilation system combinations located in 22 U.S. cities. We estimate that widespread use of higher efficiency filters would reduce premature mortality by 0.002-2.5% and increase life expectancy by 0.02-1.6 months, yielding annual monetary benefits ranging from $1 to $1348 per person in the homes and locations modeled herein. Large differences in the magnitude of health and economic impacts are driven largely by differences in rated filter efficiency and building and ventilation system characteristics that govern particle infiltration and persistence, with smaller influences attributable to geographic location.

Meteorological conditions, climate change, new emerging factors, and asthma and related allergic disorders. A statement of the World Allergy Organization

The prevalence of allergic airway diseases such as asthma and rhinitis has increased dramatically to epidemic proportions worldwide. Besides air pollution from industry derived emissions and motor vehicles, the rising trend can only be explained by gross changes in the environments where we live. The world economy has been transformed over the last 25 years with developing countries being at the core of these changes. Around the planet, in both developed and developing countries, environments are undergoing profound changes. Many of these changes are considered to have negative effects on respiratory health and to enhance the frequency and severity of respiratory diseases such as asthma in the general population.

Increased concentrations of greenhouse gases, and especially carbon dioxide (CO₂), in the atmosphere have already warmed the planet substantially, causing more severe and prolonged heat waves, variability in temperature, increased air pollution, forest fires, droughts, and floods – all of which can put the respiratory health of the public at risk. These changes in climate and air quality have a measurable impact not only on the morbidity but also the mortality of patients with asthma and other respiratory diseases. The massive increase in emissions of air pollutants due to economic and industrial growth in the last century has made air quality an environmental problem of the first order in a large number of regions of the world. A body of evidence suggests that major changes to our world are occurring and involve the atmosphere and its associated climate. These changes, including global warming induced by human activity, have an impact on the biosphere, biodiversity, and the human environment. Mitigating this huge health impact and reversing the effects of these changes are major challenges.

This statement of the World Allergy Organization (WAO) raises the importance of this health hazard and highlights the facts on climate-related health impacts, including: deaths and acute morbidity due to heat waves and extreme meteorological events; increased frequency of acute cardio-respiratory events due to higher concentrations of ground level ozone; changes in the frequency of respiratory diseases due to trans-boundary particle pollution; altered spatial and temporal distribution of allergens (pollens, molds, and mites); and some infectious disease vectors. According to this report, these impacts will not only affect those with current asthma but also increase the incidence and prevalence of allergic respiratory conditions and of asthma. The effects of climate change on respiratory allergy are still not well defined, and more studies addressing this topic are needed. Global warming is expected to affect the start, duration, and intensity of the pollen season on the one hand, and the rate of asthma exacerbations due to air pollution, respiratory infections, and/or cold air inhalation, and other conditions on the other hand.

Eastern Carolina Asthma Prevention Program (ECAPP): An Environmental Intervention Study Among Rural and Underserved Children with Asthma in Eastern North Carolina

OBJECTIVE

Asthma is the most common chronic childhood condition affecting 6.3 million (US) children aged less than 18 years. Home-based, multi-component, environmental intervention studies among children with asthma have demonstrated to be effective in reducing asthma symptoms. In this study, a local hospital and university developed an environmental intervention research pilot project, Eastern Carolina Asthma Prevention Program (ECAPP), to evaluate self-reported asthma symptoms, breathing measurements, and number of asthma-related emergency department (ED) visits among low-income, minority children with asthma living in rural, eastern North Carolina. Our goal was to develop a conceptual model and demonstrate any asthma respiratory improvements in children associated with our home-based, environmental intervention.

METHODS

This project used a single cohort, intervention design approach to compare self-reported asthma-related symptoms, breathing tests, and ED visits over a 6 month period between children with asthma in an intervention study group (n = 12) and children with asthma in a control study group (n = 7). The intervention study group received intense asthma education, three home visits, 2 week follow-up telephone calls, and environmental intervention products for reducing asthma triggers in the home. The control group received education at baseline and 2 week calls, but no intervention products.

RESULTS

At the end of the study period, significant improvements were observed in the intervention group compared with the control group. Overall, the intervention group experienced a 58% (46 ± SD 26.9) reduction in self-reported asthma symptoms; 76% (34 ± SD 29.7) decrease in rescue medicine; 12% (145 ± SD 11.3) increase in controller medicine; 37% decrease in mean exhaled nitric oxide levels and 33% fewer ED asthma-related visits.

CONCLUSION

As demonstrated, a combination of efforts appeared effective for improving asthma respiratory symptoms among children in the intervention group. ECAPP is a low cost pilot project that could readily be adapted and expanded into other communities throughout eastern North Carolina. Future efforts could include enhanced partnerships between environmental health professionals at local health departments and pediatric asthma programs at hospitals to carry out ECAPP.