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The MEDEA childhood asthma study design for mitigation of desert dust health effects: implementation of novel methods for assessment of air pollution exposure and lessons learned

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The MEDEA childhood asthma study design for mitigation of desert dust health effects: implementation of novel methods for assessment of air pollution exposure and lessons learned

Abstract

Background Desert dust events in Mediterranean countries, originating mostly from the Sahara and Arabian deserts, have been linked to climate change and are associated with significant increase in mortality and hospital admissions from respiratory causes. The MEDEA clinical intervention study in children with asthma is funded by EU LIFE+ program to evaluate the efficacy of recommendations aiming to reduce exposure to desert dust and related health effects. Methods This paper describes the design, methods, and challenges of the MEDEA childhood asthma study, which is performed in two highly exposed regions of the Eastern Mediterranean: Cyprus and Greece-Crete. Eligible children are recruited using screening surveys performed at primary schools and are randomized to three parallel intervention groups: a) no intervention for desert dust events, b) interventions for outdoor exposure reduction, and c) interventions for both outdoor and indoor exposure reduction. At baseline visits, participants are enrolled on MEDena® Health-Hub, which communicates, alerts and provides exposure reduction recommendations in anticipation of desert dust events. MEDEA employs novel environmental epidemiology and telemedicine methods including wearable GPS, actigraphy, health parameters sensors as well as indoor and outdoor air pollution samplers to assess study participants’ compliance to recommendations, air pollutant exposures in homes and schools, and disease related clinical outcomes. Discussion The MEDEA study evaluates, for the first time, interventions aiming to reduce desert dust exposure and implement novel telemedicine methods in assessing clinical outcomes and personal compliance to recommendations. In Cyprus and Crete, during the first study period (February–May 2019), a total of 91 children participated in the trial while for the second study period (February–May 2020), another 120 children completed data collection. Recruitment for the third study period (February–May 2021) is underway. In this paper, we also present the unique challenges faced during the implementation of novel methodologies to reduce air pollution exposure in children. Engagement of families of asthmatic children, schools and local communities, is critical. Successful study completion will provide the knowledge for informed decision-making both at national and international level for mitigating the health effects of desert dust events in South-Eastern Europe. Trial registration ClinicalTrials.gov: NCT03503812 , April 20, 2018.
S T U D Y P R O T O C O L Open Access
The MEDEA childhood asthma study design
for mitigation of desert dust health effects:
implementation of novel methods for
assessment of air pollution exposure and
lessons learned
Panayiotis Kouis
1,2*
, Stefania I. Papatheodorou
3,4
, Maria G. Kakkoura
1,5
, Nicos Middleton
6
, Emmanuel Galanakis
7
,
Eleni Michaelidi
7
, Souzana Achilleos
3
, Nikolaos Mihalopoulos
8
, Marina Neophytou
9
, Gerasimos Stamatelatos
10
,
Christos Kaniklides
11
, Efstathios Revvas
12
, Filippos Tymvios
12
, Chrysanthos Savvides
13
, Petros Koutrakis
14
and
Panayiotis K. Yiallouros
1
Abstract
Background: Desert dust events in Mediterranean countries, originating mostly from the Sahara and Arabian
deserts, have been linked to climate change and are associated with significant increase in mortality and hospital
admissions from respiratory causes. The MEDEA clinical intervention study in children with asthma is funded by EU
LIFE+ program to evaluate the efficacy of recommendations aiming to reduce exposure to desert dust and related
health effects.
Methods: This paper describes the design, methods, and challenges of the MEDEA childhood asthma study, which
is performed in two highly exposed regions of the Eastern Mediterranean: Cyprus and Greece-Crete. Eligible
children are recruited using screening surveys performed at primary schools and are randomized to three parallel
intervention groups: a) no intervention for desert dust events, b) interventions for outdoor exposure reduction, and
c) interventions for both outdoor and indoor exposure reduction. At baseline visits, participants are enrolled on
MEDena® Health-Hub, which communicates, alerts and provides exposure reduction recommendations in
anticipation of desert dust events. MEDEA employs novel environmental epidemiology and telemedicine methods
including wearable GPS, actigraphy, health parameters sensors as well as indoor and outdoor air pollution samplers
to assess study participantscompliance to recommendations, air pollutant exposures in homes and schools, and
disease related clinical outcomes.
(Continued on next page)
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* Correspondence: kouis.panayiotis@ucy.ac.cy
1
Respiratory Physiology Laboratory, Medical School, University of Cyprus,
Nicosia, Cyprus
2
Shiakolas Educational Center of Clinical Medicine, Palaios Dromos
Lefkosias-Lemesou 215/6, 2029 Aglantzia, Nicosia, Cyprus
Full list of author information is available at the end of the article
Kouis et al. BMC Pediatrics (2021) 21:13
https://doi.org/10.1186/s12887-020-02472-4
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
(Continued from previous page)
Discussion: The MEDEA study evaluates, for the first time, interventions aiming to reduce desert dust exposure and
implement novel telemedicine methods in assessing clinical outcomes and personal compliance to
recommendations. In Cyprus and Crete, during the first study period (FebruaryMay 2019), a total of 91 children
participated in the trial while for the second study period (FebruaryMay 2020), another 120 children completed
data collection. Recruitment for the third study period (FebruaryMay 2021) is underway. In this paper, we also
present the unique challenges faced during the implementation of novel methodologies to reduce air pollution
exposure in children. Engagement of families of asthmatic children, schools and local communities, is critical.
Successful study completion will provide the knowledge for informed decision-making both at national and
international level for mitigating the health effects of desert dust events in South-Eastern Europe.
Trial registration: ClinicalTrials.gov: NCT03503812, April 20, 2018.
Keywords: Desert dust, Asian dust, Asthma, Children, Public health intervention
Background
Desert dust storm events across southern Europe and
human health
Mediterranean countries belong to the global dust belt,
extending from West Africa to the Arabian Peninsula
and populations residing in the region are frequently ex-
posed to desert dust storms (DDS) [1]. During DDS
events, particulate matter up to 10 μm (PM
10
) levels rise
considerably higher above the EU daily limit value of
50 μg/m
3
[2]. In the Eastern Mediterranean region, 10
15% of the days of the year are DDS days, while most
of each years DDS events appear between February to
May [2,3]. Evidence from Eastern Mediterranean coun-
tries suggests that in the past 20 years there might have
been an increase in the frequency and duration of DDS
[2,4,5]. Climate change may be the driving factor for
increased DDS frequency and duration, through: (1) an
increase in desertification and desert surface
temperature; (2) reduction in rainfall, which increases
desertification and soil erosion and reduces PM washout
from the atmosphere, and; (3) changes in the synoptic
atmospheric patterns [6].
Desert dust particles are mostly composed of rock-
forming and clay minerals but also carry microbial
agents, such as bacteria, fungi and viruses [7], and ab-
sorb a mix of anthropogenic atmospheric pollutants
during transport. Historically, DDS were not consid-
ered harmful to humans due to their natural origin
and crustal composition. In line with this approach,
EU legislation considers DDS impossible to prevent,
implicitly harmless and discounts their contribution
to daily and annual air quality standards of PM
10
.
However, during the last two decades, several studies
from around the world, as well as from Mediterra-
nean countries such as Cyprus [8,9] and Greece [10]
have demonstrated associations of PM
10
during DDS
outbreaks with increased total and case-specific mor-
tality and hospital admissions for asthma and chronic
obstructive pulmonary disease.
The pathogenic effects of PM inhalation have been at-
tributed to direct physical and toxic action of particles
on human airway epithelium [11]. Exposure to DDS par-
ticles has also been associated to symptomatic exacerba-
tions of pre-existing conditions reported as unscheduled
hospital visits, use of excessive medication, loss of sense
of well-being and days off work or school [1214]. These
relatively less severe consequences are more common,
but largely unquantified and un-investigated. Children
with asthma are considered one of the most vulnerable
group to DDS exposure [10,15,16].
Framework for designing, implementing and testing an
adaptability strategy
Currently, during DDS events, EU national competent
authorities and mass media in DDS-exposed regions
issue non-standardised warnings to the public/vulner-
able groups, most commonly advising them to stay in-
doors, and reduce outdoor activities. To date, no
scientific evidence exists on the efficacy of any of these
recommendations in either reducing exposure to DDS
PM or mitigating related health effects.
Study objectives
A demonstration project called MEDEA(Mitigating
the Health Effects of Desert Dust Storms Using
Exposure-Reduction Approaches) has been co-funded by
the LIFE 2016 Programme (LIFE16 CCA/CY/000041) of
the European Commission with the main goal to provide
the field-based evidence for the feasibility and effective-
ness of an adaptation strategy to DDS in South-Eastern
Europe, focusing on exposure reduction approaches and
inform EU policy making. The MEDEA Childhood
Asthma panel study is implemented by seven partner in-
stitutions (see details in Supplementary Material)in
highly DDS-exposed Mediterranean regions with the fol-
lowing specific objectives:
1. Design easy to implement and sustainable exposure-
reduction recommendations to follow during DDS;
Kouis et al. BMC Pediatrics (2021) 21:13 Page 2 of 9
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2. Demonstrate the feasibility of applying models for
early forecasting of DDS events and timely notification
of the public, targeting susceptible individuals, and;
3. Demonstrate which of the recommendations are
effective in reducing exposure to DDS and disease-
relevant adverse health effects in panels of vulnerable
patients.
Methods/design
Overview of the project setting and design
To evaluate the comparative effectiveness of the recom-
mendations, we have undertaken a clinical study in
school-aged children with asthma in Cyprus and Crete.
Patients (and schools) are randomized to three parallel
intervention groups to receive: a) no additional interven-
tion for DDS, b) project interventions for outdoor expos-
ure reduction, and c) project interventions for both
outdoor and indoor exposure reduction.
The MEDEA Asthma panel study has been registered
with and approved by the clinicaltrials.gov online reposi-
tory (ClinicalTrials.gov Identifier: NCT03503812) and
national authorities at both sites (see details in Supple-
mentary Material).
Exposure reduction recommendations and the MEDena®
health-hub
We have developed the recommendations for reduction
of outdoor and indoor exposures to DDS and produced
audiovisual spots for their implementation according to
intervention group and audience (parents and teachers).
As an example, animated guidelines in English addressed
to parents participating in the outdoor exposure reduc-
tion intervention (Video S1) or the outdoor and indoor
exposure reduction intervention (Video S2) are available
as supplementary material. In brief, in outdoor interven-
tion, participants are asked to stay indoors, as well as
avoid intense physical activity outdoors, competitive
sports and unnecessary walks. In indoor intervention,
participants are asked to close windows and doors, seal
possible cracks around windows and doors in order to
minimize home ventilation, and use continuously an air
cleaner in order to filter indoor air.
Concurrently, we have validated existing models for
forecasting DDS events in Cyprus and Crete, and we
have developed the MEDena® Health-Hub, a bidirec-
tional, patient-centered web-based platform (Figure S1),
and the MEDEApp® smart mobile application (Figure
S2) for:
a. collection of early forecasting data from
meteorology modelers;
b. early dissemination of warnings and audiovisual
recommendations for exposure reduction to alert
patients about upcoming DDS events;
c. acquisition of accurate spatiotemporal activity and
health data from patients via wearable sensors and
online questionnaires, and;
d. storage and management of personal exposure and
health data with cloud technologies.
Monitoring the intervention
On recruitment, participants are assigned an ID number
and their personal, demographic, house and classroom
location (coordinates) information are entered through
the web to the MEDena® Health-Hub. Each patient
wears a wristwatch and through the MEDEApp® mobile
app installed in the Android smartphone of the parent
the MEDena® Health-Hub tracks which patient ID is
equipped with each device. The children, their parents
and schoolteachers are trained in the tools and proce-
dures to be followed and are given a leaflet with instruc-
tions on the use of the wristband and smartphone.
Participants are asked to wear the smart wristbands 7
days a week, but not during sleep, bathing or swimming.
Following the eligibility assessment at the baseline
visit, patients are assigned to the three parallel interven-
tion groups at a 1:1:1 ratio. Assignment to the three par-
allel intervention groups is based on the randomization
of their school to the three legs and interventions are
implemented in the asthmatic childs classroom and
household settings. Details of monitoring the interven-
tion can be found in Supplementary Material.
Assessing compliance to intervention
The participantsbehavioural patterns and compliance
to the exposure-reduction guidelines are monitored in
the three legs using wearable sensors, air pollution sam-
plers and activity diaries. Compliance to outdoor recom-
mendation to reduce time spent outdoors and avoid
physical activity during DDS, is assessed continuously
using a smart wristband (J-Style GPS watch tracker,
model JC-1755, Joint Ltd., China), which is equipped
with global positioning system (GPS) and activity track-
ing (pedometer) hardware and software. The wristband,
continuously, collects the participants GPS and activity
data and transmits them wirelessly to the MEDena®
Health-Hub, a secure e-platform via Bluetooth connec-
tion to the MEDEApp® mobile app installed in the par-
ticipants parentssmartphone. Compliance to indoor
recommendation to minimize home and classroom ven-
tilation and use an air cleaner is assessed by using
particle samplers (Harvard High Volume Cascade Im-
pactors, Harvard University, USA) placed outside and in-
side representative participantshouses and school
classrooms and with indoor, commercial low volume air
quality sensors (OPC-N3 Optical Particle Counters,
Alphasense, United Kingdom). The Harvard samplers
measure concentrations of PM
10
,PM
2.5
, black carbon
Kouis et al. BMC Pediatrics (2021) 21:13 Page 3 of 9
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(BC) and elements collected on Teflon filters at repre-
sentative premises during DDS and DDS-free days.
Alphasense sensors provide qualitative estimates of
PM
10
for a larger number of microenvironments in the
three legs of the panel study. In addition, compliance to
recommendations is assessed in all participants in the
three legs through activity questionnaires following each
DDS event. A schematic diagram of the Asthma panel
study is presented in Fig. 1.
The GPS sensors continuously assess the time partici-
pants spend indoors and outdoors. For the time spent
indoors, we assign PM
10
,PM
2.5
, BC and elements expo-
sures measured by the indoor air pollutant samplers. For
the time spent outdoors, we assign exposures to outdoor
PM
10
and PM
2.5
levels as obtained from measurements
of local air pollution monitoring stations and BC and el-
ements measured by the outdoor samplers positioned
outside representative premises.
Project course and progress
The MEDEA project commenced in September 2017
and will continue through December 2022. During pro-
ject year 1, we conducted pilot studies at both sites to
test the feasibility of the set-up and protocols to assess
exposures, activity and health outcomes in a small num-
ber of patients with and without implementation of ex-
posure reduction recommendations.
During project years 2, 3 and 4, we perform the panel
study in school-aged children with asthma and continue
the assessment of the effectiveness of MEDEA recom-
mendations to reduce indoor and outdoor exposure in
the respective intervention legs of the studies. Simultan-
eously, we collect disease relevant health outcomes, as
described below, to assess the effect of interventions.
In project year 5, we will demonstrate which of the
recommendations are more effective to reduce exposure
and associated adverse health effects in participating
subjects. We will also address transferability of recom-
mendations that are proven effective by targeting: a) citi-
zens with social media and smartphone applications,
and; b) institutions and competent EU authorities with
the aim to assist the development of adaptation strategy
in DDS-exposed South Europe areas.
Panel study in schoolchildren with asthma in Cyprus and
Crete (Greece)
Recruitment protocol - recruiting schools
In order to perform a challenging clinical trial like the
MEDEA childhood asthma panel study that involves
changes in behavior of children at the school and home
environment, we pursue the highest collaboration and
support from the schoolsauthorities, as well as from the
local teachers and parentscommunities. Details of re-
cruitment of schools can be found in Supplementary
Material. The International Study of Asthma and Aller-
gies in Children, (ISAAC) questionnaire, available in
both Greek and English, enriched with additional ques-
tions on medical care and medication utilization, is used
to identify asthmatic children. Parents of the asthmatic
children, who met our eligibility criteria, are contacted
via telephone to inform them about the study and ask
them to participate.
Fig. 1 Asthma panel study schematic diagram. The bidirectional MEDena® Health-Hubis updated with meteorological forecasting and air-quality
information regarding DDS events and sends alerts and exposure reduction guidelines to parents and teachers of asthmatic children participating
in the study. At the same time, the MEDena® Health-Hub is automatically collecting the physical activity and GPS data from the wristbands worn
by the children. Researchers also manually upload children clinical data and air quality measurements. DDS: Desert Dust Storm, FeNO: Fractional
exhaled Nitric Oxide, GPS: Global Positioning System, SMS: Short Messaging Service text message
Kouis et al. BMC Pediatrics (2021) 21:13 Page 4 of 9
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Population
The target population consists of children aged from 6
to 11 years from Greek- or English-speaking families
who attend the participating schools in Cyprus and
Crete during the academic years 20182019, 20192020
and 20202021. Children with mild to moderate persist-
ent asthma are eligible for the study. Each child is
assessed during only one high DDS period (February
May). The Standard Protocol Item: Recommendations
for Interventional Trials (SPIRIT) flow diagram for the
Asthma Panel study is presented in Fig. 2.
Definition of asthma
Children who report a physicians diagnosis of asthma
AND at least one of the following: wheezed in the past
year, and/or, currently, take daily preventative asthma
medication, and/or had an unscheduled medical visit for
asthma in the past year, are considered eligible for the
study. Exclusion criteria include lung disease other than
asthma, cardiovascular disease or not living for at least
5 days per week in the same household.
Baseline and follow-up clinical assessments
Eligible asthmatic patients at screening are invited for a
baseline clinical assessment in January 2019, 2020 and
2021 prior to the onset of the respective high DDS pe-
riods. During the baseline visit, questionnaires are
administered to obtain data on socio-demographic char-
acteristics, asthma and allergy symptoms, utilization of
medical care and classroom and home environmental
characteristics, including tobacco smoke exposure.
The follow-up period spans from February to late
May/early June and includes continuous monitoring of
the daily location and physical activity of patients using
Fig. 2 Childhood Asthma panel study SPIRIT flow diagram: The schedule of enrolment, interventions and assessments in the Childhood Asthma
panel study according to SPIRIT template
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the wristbands and smartphones. Phone interviews at
baseline and then at every 1 month throughout the high
DDS period are performed collecting information on
asthma symptoms control, medication use and unsched-
uled visits to health professional for asthma. Asthma
control in the past 4 weeks is assessed using English and
Greek versions of the pediatric Asthma Control Test (c-
ACT, license number: QM044906) as used previously
[17,18]. Lastly, participants have assessments of lung
function (Spirometry - In2itive Spirometer, Vitalograph
Ltd., United Kingdom), Fractional exhaled nitric oxide
(FeNO - NIOX VERO portable nitric oxide analyzer,
Circassia, United Kingdom), at baseline, mid-period
(April) and at the end of the follow up period (late
MayJune). At the end of the follow up period, skin
prick testing to 14 common aero-allergens (Allergy
Therapeutics PLC, United Kingdom) is performed as
described previously [19]. The timeline and details of
baseline and follow-up assessments for the asthma panel
study are presented in Fig. 3and in Supplementary
Material.
Asthma morbidity outcomes and data analysis
The ACT questionnaire score is the primary health out-
come and a change of 3 points in the total score is con-
sidered clinically meaningful [17]. For the primary
analysis, we will compare the combined effect in the two
intervention groups versus the control group. Next, we
will compare between each of the intervention groups
and control group and between the intervention groups.
Secondary health outcomes will be the presence or ab-
sence of asthma symptoms in the prior 4-week period,
asthma medication use, unscheduled visits for asthma,
and values of forced expiratory volume in 1 s, peak ex-
piratory flow and FeNO.
Sample size
Our primary health outcome, childhood ACT, has seven
items and provides a score ranging from 0 (poorest
asthma control) to 27 (optimal asthma control). A cut-
off point of 19 indicates uncontrolled asthma [20] while
previous studies have shown that the minimally mean-
ingful change in the ACT score is 3 points [17]. To de-
tect a statistically significant difference of 3 points, and
assuming a 30% dropout rate, the minimum sample size
needed in each of the 3 groups is 100 participants. This
sample size calculation is assuming a level of 0.05 and a
power of at least 80% to detect this difference between
the comparison groups. In the first study period of Feb-
ruaryMay 2019, 91 children from six primary schools
in Cyprus and eight primary schools in Crete partici-
pated in the clinical trial. For the second study period of
FebruaryMay 2020, another 10 primary schools in
Cyprus and 10 primary schools in Crete have been iden-
tified and additional 120 asthmatic children completed
data collection. Recruitment for the third study period
(FebruaryMay 2021) is underway.
Fig. 3 Childhood Asthma panel study assessments timeline. Timeline of baseline and follow-up assessments in Childhood Asthma panel study for
the two study years. DDS: Desert Dust Storm, FeNO: Fractional exhaled Nitric Oxide, ACT: Asthma Control Test questionnaire
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Statistical analysis
Differences in the distribution of primary and secondary
outcomes between the three intervention groups will be
investigated using chi-square test for categorical parame-
ters while the Wilcoxon Sum Rank test will be used for
continuous parameters. In an adjusted analysis, the
mean change in ACT score and other outcomes will be
examined using a regression mixed effects model which
will include fixed effects for intervention group and
physical activity and subject-specific random intercepts
and slopes for the control and intervention groups. The
main spatio-temporal covariates that we will consider
for the regression mixed-effects model are house charac-
teristics, meteorological parameters (temperature, rela-
tive humidity) and local air pollution levels (PM
2.5
,
PM
10
, and NOx). Additional details on the statistical
analysis plan are available at: https://clinicaltrials.gov/
ct2/show/NCT03503812.
Discussion
The MEDEA Childhood Asthma panel study represents
one of the largest, most comprehensive evaluation of the
efficacy of recommendations aiming to reduce exposure
to desert dust and related health effects in two highly ex-
posed regions of the Eastern Mediterranean, Cyprus and
Crete-Greece. In addition, the MEDEA Childhood
Asthma panel study is unique because it benefits from
the implementation of novel environmental epidemi-
ology and telemedicine methods for assessing personal
compliance to the recommendations, measuring expos-
ure to air pollutants in home and school environments,
and monitoring clinical outcomes among the study
population.
The methods usually employed in air pollution health
effects studies have several inherent inaccuracies in
assessing exposure and health outcomes. Exposure esti-
mates are commonly based on measurements conducted
at monitoring stations that are sparsely distributed.
These approaches use outdoor air pollution concentra-
tions as a proxy for total exposure; therefore, they lack
information on indoor air pollution levels, which intro-
duces significant exposure error [2123]. Furthermore,
exposure estimates are usually assessed for a given resi-
dential address without taking into consideration partici-
pantsactivity and mobility throughout the day [2426].
In MEDEA, we use wearable GPS and activity sensors
and measure continuously activity and time asthmatic
children spend indoors and outdoors. Thus, we are able
to assign exposure to the respective air pollutants levels
measured by indoor and outdoor samplers in representa-
tive premises, differentiated by the activity levels
throughout the day providing a much higher spatiotem-
poral resolution. As a result, the uncertainties related to
the variability of asthmatic childrens mobility during
exposure assessment, are minimized and personal com-
pliance and change in behaviour in response to the
MEDEA recommendations can be assessed.
Health effects of desert dust exposure are usually
assessed by using ecological retrospective data on major
outcomes like deaths or hospital admissions and out-
patient clinicsvisits [810,27]. However, data on hos-
pital admissions and outpatient clinicsvisits are
influenced by subjective health care seeking behavior
and are therefore, problematic in evaluation of the onset,
duration and severity of an outcome [28]. In MEDEA
Childhood Asthma panel study, we assess prospectively
a range of clinical outcomes in both the control and in-
terventions groups with standard clinical assessment
tools like validated clinical symptoms questionnaires,
lung function tests and other clinically relevant
parameters.
During the first 2 years of the MEDEA project, we
faced many unique challenges that we continue to ad-
dress. The greatest challenge was overcome during the
first year of the project. This is related to the develop-
ment of the electronic sentinel platform (MEDena®
Health-Hub), the selection and interface with the plat-
form of adequate wearable devices and establishment of
credible pathways of data acquisition from participants.
Using smart devices requires a certain degree of techno-
logical literacy, which is challenging. In order to over-
come this, we tested several commercially available
smart watch devices. Subsequently, we chose the
LEMFO-LM25 smartwatch equipped with embrace
software (Embrace Tech LTD, Cyprus), which does not
require manual synchronization with the created smart-
phone application to upload collected data but it does so
automatically when it gets in contact with a WI-FI net-
work. We also dealt with other limitations of smart de-
vices such as missing data due to device malfunction,
quick drain of wearable devices battery and need for fre-
quent recharging, and reduced data storage issues. We
were able to address these limitations by maintaining a
very good and frequent communication with asthmatic
children and their families in order to maintain their
commitment and motivation to continue participation in
the studies and not to forget wearing and frequently
charging the smartwatch.
Performing environmental monitoring at homes and
schools is challenging [29,30]. Implementation of envir-
onmental interventions in schools and homes requires
commitment by participating children, their families and
schools. In order to maintain excellent engagement of
the participants, our research staff monitored closely
and follow-up our participating families not only by
regular phone calls but also by paying regular visits, es-
pecially to the homes and classrooms of the participants
in the combined outdoor-indoor intervention leg.
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During these visits, field workers reinforced implementa-
tion of recommendations for minimizing ventilation dur-
ing DDS events, changing HEPA filters of the air
cleaning devices, and ensuring that the air cleaners func-
tion effectively and are not inadvertently turned off.
A significant challenge is the analysis of GPS geo-spatial
data and construction of individual participants trajector-
ies for assessing personal exposures in outdoor and indoor
microenvironments, which requires sophisticated algo-
rithms [31,32]. This is further complicated by an import-
ant limitation of GPS tracking, which is the loss of signal,
especially in indoor environments, introducing the chal-
lenge of how to treat missing values questions. Automated
microenvironment classification algorithms that include
spatial and temporal buffering have been developed and
validated, especially for air pollution exposure studies [33].
In an effort to have additional independent data on com-
pliance besides the wearable sensors data, we also collect
activity data after each DDS event with the use of a short-
term recall questionnaire. Although replies to the ques-
tionnaire are still subjective, the short time frame between
activity and questionnaire administration (few days to a
maximum of 1 week), limits the potential recall bias and
allows the assessment of compliance to the provided rec-
ommendations [34,35].
Conclusion
In MEDEA Childhood Asthma panel study, we evaluate
for the first time interventions aiming to reduce expos-
ure to DDS and implement novel environmental epi-
demiology and telemedicine methods in assessing
personal compliance to the recommendations and re-
lated clinical outcomes. This requires the engagement of
the entire local communities at each study site, asth-
matic children, their families and schools. The commit-
ment of large numbers of dedicated and talented
researchers are also critical to the ongoing and contin-
ued success of this project. The successful completion of
this study will provide the scientific knowledge for in-
formed decision-making and strategic planning both at
national (individual country stakeholders) and cross-
national levels for mitigating the health effects of DDS
events in South-Eastern Europe.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12887-020-02472-4.
Additional file 1.
Additional file 2: Video S1.
Additional file 3: Video S2.
Abbreviations
DDS: Desert Dust Storms; PM
10
: Particulate Matter < 10 μm; PM
2.5
: Particulate
Matter < 2.5 μm; GPS: Global Positioning system; BC: Black Carbon; ISAA
C: International Study of Asthma and Allergy; ACT: Asthma Control Test;
FeNO: Fractional Exhaled nitric oxide
Acknowledgments
The authors are grateful to the members of the MEDEA Advisory Committee
for the continuous feedback provided to the LIFE MEDEA project, the
schools for their support to carry out the project and the participants and
their family members for their contribution to the project.
Authorscontributions
PK: Methodology, Investigation, Software, Data curation, Project
Administration Writing-Original draft preparation; SIP: Conceptualization,
Methodology, Data curation, Writing-Original draft preparation; MGK: Data
Curation, Investigation, Visualisation, Writing - Review & Editing; NM: Method-
ology, Writing - Review & Editing; EG: Conceptualization, Methodology, Writ-
ing - Review & Editing, Project Administration, EM: Data curation,
Investigation, Writing Review & Editing; SA: Data curation, Investigation,
Writing Review & Editing; NM: Methodology, Resources, Writing - Review &
Editing; MN: Conceptualization, Methodology, Resources, Writing - Review &
Editing; GS: Conceptualization, Data Curation, Software, Visualisation, Writing
- Review & Editing; CK: Visualisation, Resources, Writing - Review & Editing;
ER: Conceptualization, Data Curation, Software, Visualisation, Writing - Review
& Editing; FT: Conceptualization, Methodology, Resources, Software, Writing -
Review & Editing; CS: Conceptualization, Methodology, Resources, Writing -
Review & Editing; KP: Conceptualization, Methodology; Software, Validation,
Resources, Writing - Review & Editing; PKY: Conceptualization, Methodology;
Software, Validation, Writing - Review & Editing, Supervision, Funding acquisi-
tion. All authors have read and approved the manuscript.
Funding
This study was supported by the European Union LIFE project MEDEA
(LIFE16 CCA/CY/000041). The funders had and will not have a role or
authority in study design, data collection, data analysis, data interpretation,
preparation of the manuscript or decision to publish the manuscript. Funder
contact info: easme-life@ec.europa.eu
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
The MEDEA Childhood Asthma panel study has been approved by the
relevant authorities at both sites, according to national legislation. In Cyprus,
approvals have been obtained from the Cyprus National Bioethics
Committee (EEBK EΠ2017.01.141), by the Data Protection Commissioner (No.
3.28.223) and Ministry of Education (No 7.15.01.23.5). In Greece, approvals
have been obtained from the Scientific Committee (25/04/2018, No: 1748)
and the Governing Board of the University General Hospital of Heraklion (25/
22/08/2018). As participants are under 18 years of age, written informed
consent for their participation, is obtained from their parents/guardians by
completing and signing the relevant consent form. Prior completion and
signing of the consent form, the study outline and requirements are
explained to the parents/guardians during a face to face discussion with
study personnel at the school premises. The information about the study is
provided to the parents/guardians in both verbal and written form.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Respiratory Physiology Laboratory, Medical School, University of Cyprus,
Nicosia, Cyprus.
2
Shiakolas Educational Center of Clinical Medicine, Palaios
Dromos Lefkosias-Lemesou 215/6, 2029 Aglantzia, Nicosia, Cyprus.
3
Cyprus
International Institute for Environmental & Public Health, Cyprus University of
Technology, Limassol, Cyprus.
4
Department of Epidemiology, Harvard T.H.
Chan School of Public Health, Harvard University, Boston, MA, USA.
5
Clinical
Trial Service Unit and Epidemiological Studies Unit CTSU, Nuffield
Department of Population Health, University of Oxford, Oxford, UK.
6
Department of Nursing, Cyprus University of Technology, Limassol, Cyprus.
Kouis et al. BMC Pediatrics (2021) 21:13 Page 8 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
7
Medical School, University of Crete, Heraklion, Crete, Greece.
8
Department of
Chemistry, University of Crete, Heraklion, Greece.
9
Department of Civil &
Environmental Engineering, University of Cyprus, Nicosia, Cyprus.
10
E.n.A
Consulting LP, Arachova Boeotia, Greece.
11
Cyprus Broadcasting Corporation,
Nicosia, Cyprus.
12
Department of Meteorology, Ministry of Agriculture, Rural
Development and Environment, Nicosia, Cyprus.
13
Department of Labor
Inspection, Ministry of Labor, Welfare and Social Insurance, Nicosia, Cyprus.
14
Department of Environmental Health, Harvard TH Chan School of Public
Health, Boston, USA.
Received: 6 November 2020 Accepted: 15 December 2020
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... 73,120-124 Six protocols and prototypes were identified but there were no empirical studies. Three papers reported sensing of environmental hazards such as desert dust 120,121 or personal variables such as body temperature using wearable devices. 122 The SMARTICE system measured sea ice thickness via stationary sensors and then notifies community users. ...
... This study used a visual representation of the symptoms and developed color-code-based alerts. 67 In addition to data from EHRs, environmental and health data collected from individuals, either via sensors [120][121][122] or user-entered data 130 can be used for monitoring. Monitoring symptoms using web data such as search engine queries and social media posts 8,28,76,[131][132][133][134][135] or data collected by applications specifically designed for community participation 28 have been proposed. ...
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