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Survey Research Protocol: Mold Exposure and Respiratory Effects in Post-Katrina
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Survey Research Protocol: Mold Exposure and Respiratory Effects in Post-Katrina New Orleans
Introduction
Although levee and floodwall failure during Hurricane Katrina caused flooding of over 75% of the city of New Orleans in August 2005, the majority of residential and commercial structures in the city were left standing, and the extended presence of floodwater and late-summer weather caused unchecked mold growth in those structures. Upon their return, many residents of flooded structures were exposed to these molds to varying degrees, depending on the amount of mold present; the amount of time spent surveying the damage, removing debris, and gutting the structures; and whether they used personal protective equipment such as a mask. Further, many people continue to reside in Federal Emergency Management Agency (FEMA)-provided trailers--often located directly on the grounds of damaged structures--while they repair their residences, possibly prolonging their exposure to mold and other irritants.
The unchecked proliferation of molds in flooded buildings was such that what became known locally as 'the Katrina Cough' was largely blamed on exposure to those molds. Based on air sampling, these molds primarily consisted of Cladosporium, Aspergillus, Penicillium, and Stachybotrys species (NRDC 2006), and airborne particles were present at much higher concentrations than those seen normally. Adverse respiratory-related effects in humans such as asthma, nasal and throat irritation, and coughing and wheezing have increasingly been attributed to exposure to toxins produced by environmental fungi (Shelton et al. 2002), which can trigger an allergic response in atopic individuals. Koskinen et al. (1999) found a significant association between observed moisture in homes--a proxy for mold infestation--and occurrence of sinusitis, bronchitis, nocturnal cough, and nocturnal dyspnea. Earlier, Hodgson et al. (1998) reported on an outbreak of building-associated pulmonary disease that was likely attributable to inhaled Aspergillus and Stachybotrys toxins, both of which have been linked to respiratory symptoms in humans, and Dales et al. (1991) found that prevalences of all respiratory symptoms were higher among children in homes with reported mold or dampness present. Further, inspiration of organic dusts that included particles of various Aspergillus and other mold species has been associated with upper airway inflammation and respiratory symptoms in domestic waste collectors (Wouters et al. 2002). Depending on their degree and duration, respiratory symptoms such as those that can be triggered by exposure to environmental molds could have a measurable negative impact on quality of life.
Study Goals and Population
In its report of a case-control study (Golden & Ratard 2006) based partly on hospital emergency department data collected in September and October 2006, the Louisiana Office of Public Health (OPH) found no statistically significant evidence that 'Katrina Cough' even existed in the first place, from which it logically follows that no particular etiology, environmental or otherwise, could be singled out as a cause. The OPH study, however, had acknowledged flaws, in that it addressed only respiratory conditions serious enough to prompt people to seek medical care through an emergency facility; confounders such as the presence of normally occurring respiratory conditions were not controlled for; and no data regarding the dwelling type or degree of mold infestation and exposure were collected. The goal of this proposed survey-based study is to determine whether there is a dose-response relationship between exposure to visible mold growing inside structures after Hurricane Katrina and biologically plausible respiratory symptoms experienced by those who have spent significant time in and around those structures, and whether any respiratory effects possibly attributable to post-Katrina mold exposure differ from those experienced by the population of the New Orleans area at large. Further, the study will attempt to gauge the impact that mold-attributable respiratory symptoms have had on perceived quality of life of those who have experienced such symptoms following Hurricane Katrina.
Sample Design
Names of potential survey respondents will be drawn from 2 sources: *A listing of New Orleans residents who have received a trailer from FEMA, so a random sample of trailer residents in mold-heavy flooded areas may be obtained; and *A pre-Katrina residential telephone listings for the city of New Orleans and the surrounding area, so a random sample of the overall metropolitan-area population may be obtained.
The FEMA-trailer list was chosen as a sampling frame because from that list a targeted pool of potential subjects based on their ZIP codes within the city and location of the trailers may be generated. A non-probability sampling methodology of this segment of the study population will be used, as only those persons whose trailers are located on the grounds of the damaged property would be eligible to participate. (Persons whose trailers are located in any of the several FEMA trailer park locations in the city would not be eligible, based on the assumption that their mold exposure levels would be sufficiently lower overall than those whose trailers are located on the grounds of their flooded residences [in other words, that their exposure level is more comparable to residents of non-flooded areas than those occupying trailers on the grounds of their mold-infested homes] that the difference in outcome between the two groups would be washed out to some extent.) The pre-Katrina a telephone listing was chosen as a sampling frame because from those listings would yield persons who lived in the city before the disruption of Hurricane Katrina, as well as persons who continue to live in the area after the storm, thus allowing selection of a sample that most accurately represents the experience of the entire metropolitan area both pre-and post-Katrina. Names of persons on the FEMA-trailer list will be removed from the phone listing before sampling so redundancies between the two sampling frames may be avoided.
A total sample size of 2000 is the goal for this study, with the proportions of FEMA-trailer residents in flooded parts of the city making up 50% of the sample, and residents of non-flooded areas making up the remainder.
Data Collection Methods
Data for this study will be collected via a pen-and-paper survey instrument, completed by study personnel during scheduled interviews with New Orleans residents who have returned to flooded structures, as well as with greater New Orleans area residents whose homes did not flood and who continue to reside in the area. This method will help ensure proper completion of the survey, which has skip patterns that could lead to erroneous responses, and minimize non-response. Data collected during the interview will be entered into an electronic database for subsequent analysis. Additionally, those who complete the survey will be asked to sign a release for giving study personnel permission to review their medical record for verification of diagnoses and healthcare services sought and received post-Katrina, including psychiatric care. Information obtained from the medical record will be included in the database for analysis.
Potential study subjects will initially be sent a letter explaining the study and providing a telephone number to call so questions may be answered and an interview appointment may be made; the subject may also opt out of the study by calling the provided telephone number. Sending of the letter and details of any follow-up communication, including full or partial completion of the survey and the date, will be recorded in a separate tracking database. After an allowance of 2 weeks from the date of mailing for the letter to arrive, attempts to contact eligible persons participants will be contacted by telephone will begin. A maximum of 15 attempts to contact eligible persons by phone will be made. Once the subject is contacted and he or she agrees to participate, an appointment to conduct the interview by telephone at a time convenient for the subject will be made.
Once a potential participant agrees to take part in the research, he or she will be assigned a unique study identification number. No names, addresses, phone numbers, Social Security numbers, or other data that could be used to identify study participants will be entered onto paper interview records or into the database that will be analyzed. All study-related documentation will be kept in a secure location accessible only to individuals directly involved in the research.
All subjects will complete identical survey instruments, with identical methods of follow-up of medical information if permission is granted. Permission will be requested at the time of the interview, with permission secured in writing via a separate form.
Pilot Testing
The survey will be pilot tested among the first 100 respondents for identification of survey-administration problems and refining of interviewer techniques. Based on those results modifications to the survey instrument and interview and data-collection procedures will be instituted for the remainder of the study.
Survey Reliability and Validity
Reliability of the survey instrument will be assessed via the test-retest method. At the beginning of survey administration, all interviewees will be asked if they would be willing to be interviewed again as a means of quality assurance. Re-interviews will be conducted by a member of the research team other than the one who conducted the original interviews. When 100 re-interviews have been performed, responses from the first and second interviews will be analyzed to generate an r value. If that r value is below 0.70, the survey instrument will be reviewed and modified to make it a more reliable data-collection tool.
Concurrent validity of the exposure and outcome data collected will be assessed by 2 primary means. Reported length of mold exposure for FEMA trailer residents will be confirmed against the dates that trailers were delivered and dates of connection to water/sewer and electric utilities. Further, self-reported health-related behaviors, symptoms, and visits to healthcare providers will be confirmed via review of relevant information contained in the subjects' medical records. Correlation coefficients will be calculated for both exposure and outcome data. Additionally, wherever possible, questions developed for the survey were based on constructs and questions used in previously published studies (Burge 2004, Dales, 1991, Hodgson 1998, Koskinen 1999).
Instructions for Interviewers
*During interviews, interviewers should adhere to the script exactly as it is written for all subjects so bias is minimized. *Interviewers should use the same professional, friendly, conversational tone of voice with all subjects, regardless of the person's gender, age, ethnic background, or any other characteristic. *Interviewers should keep the focus on the survey if it appears that the person is more interested in discussing other matters, such as his or her personal situation outside the scope of the study. *Interviewers may repeat a question as many times as is reasonably necessary and re-phrase it slightly without changing its meaning if that is necessary to help the person answer it. *If the person has a hard time answering a question satisfactorily, the 'Don't Know' option is available (use of this option should be minimized, however). *Interviewers must satisfactorily conduct 5 practice surveys with people they do not know and who have no prior knowledge of the survey topic or contents before they may begin calls to potential subjects.
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