title: The effects of indoor environmental exposures on pediatric asthma: a discrete event simulation model.
abstract: BACKGROUND
  In the United States, asthma is the most common chronic disease of childhood across all socioeconomic classes and is the most frequent cause of hospitalization among children. Asthma exacerbations have been associated with exposure to residential indoor environmental stressors such as allergens and air pollutants as well as numerous additional factors. Simulation modeling is a valuable tool that can be used to evaluate interventions for complex multifactorial diseases such as asthma but in spite of its flexibility and applicability, modeling applications in either environmental exposures or asthma have been limited to date.
  
  
  METHODS
  We designed a discrete event simulation model to study the effect of environmental factors on asthma exacerbations in school-age children living in low-income multi-family housing. Model outcomes include asthma symptoms, medication use, hospitalizations, and emergency room visits. Environmental factors were linked to percent predicted forced expiratory volume in 1 second (FEV1%), which in turn was linked to risk equations for each outcome. Exposures affecting FEV1% included indoor and outdoor sources of NO2 and PM2.5, cockroach allergen, and dampness as a proxy for mold.
  
  
  RESULTS
  Model design parameters and equations are described in detail. We evaluated the model by simulating 50,000 children over 10 years and showed that pollutant concentrations and health outcome rates are comparable to values reported in the literature. In an application example, we simulated what would happen if the kitchen and bathroom exhaust fans were improved for the entire cohort, and showed reductions in pollutant concentrations and healthcare utilization rates.
  
  
  CONCLUSIONS
  We describe the design and evaluation of a discrete event simulation model of pediatric asthma for children living in low-income multi-family housing. Our model simulates the effect of environmental factors (combustion pollutants and allergens), medication compliance, seasonality, and medical history on asthma outcomes (symptom-days, medication use, hospitalizations, and emergency room visits). The model can be used to evaluate building interventions and green building construction practices on pollutant concentrations, energy savings, and asthma healthcare utilization costs, and demonstrates the value of a simulation approach for studying complex diseases such as asthma.
authors.affiliation: Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA. pfabian@bu.edu
authors.forename: M Patricia
authors.initials: MP
authors.lastname: Fabian
authors.forename: Natasha K
authors.initials: NK
authors.lastname: Stout
authors.forename: Gary
authors.initials: G
authors.lastname: Adamkiewicz
authors.forename: Amelia
authors.initials: A
authors.lastname: Geggel
authors.forename: Cizao
authors.initials: C
authors.lastname: Ren
authors.forename: Megan
authors.initials: M
authors.lastname: Sandel
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Levy
mesh_terms: D000293:Adolescent; D000393:Air Pollutants / Q000633:toxicity; D016902:Air Pollution, Indoor / Q000009:adverse effects*; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D002648:Child; D003198:Computer Simulation; D004781:Environmental Exposure / Q000009:adverse effects*; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008962:Models, Theoretical; D009585:Nitrogen Dioxide / Q000633:toxicity; D052638:Particulate Matter / Q000633:toxicity; D011203:Poverty; D011638:Public Housing
chemical_list: D000393:Air Pollutants; D018927:Anti-Asthmatic Agents; D052638:Particulate Matter; D009585:Nitrogen Dioxide