Safe Control of Pest and Pet Asthma Triggers

www.npjournal.org The Journal for Nurse Practitioners - JNP 571

The authors, reviewers, and editors allreport no financial relationships thatpose a conflict of interest. The authorsdo not present any off-label or non-FDA-approved recommendations fortreatment. There is no impliedendorsement by NPI, MNA, orANCC of any commercial productsmentioned in this article.

Continuing Education

Asthma continues to be one of the leading publichealth problems in the United States. Although hospi-

talizations and deaths due to asthma have decreased, asthmasymptoms continue to seriously affect national school andwork productivity. U.S. data reported by the AmericanLung Association show that asthma was responsible foralmost 14 million lost school days and 14.5 million lostwork days for adult employees in 2004.1 Over 30% of thecaregivers of children with asthma lose workdays whentheir children experience asthma symptoms.2 While the

origins of asthma remain obscure, there is wide evidence-based consensus on exposures that cause asthma symp-toms, including infectious illnesses, airborne allergens, air-borne particulates, and emotional stress.3-9 Nurse practi-tioners (NPs) can impact the costs of asthma by counsel-ing patients about ways to minimize exposures, especiallyin the environments in which they spend the most time,such as homes.

The role of indoor pollutants and allergens as asthmatriggers is well known. The substantial amount of time that

Patricia Newcomb

Safe Control of Pest and Pet Asthma Triggers

ABSTRACTAsthma remains a substantial public health problem. Collecting environmental history and

educating patients about asthma triggers are crucial for influencing asthma morbidity. Failure

to educate patients and families about avoiding asthma triggers is a predictor of preventable

hospitalization for asthma. This review of control measures focuses on common pests, such

as cockroaches, dust mites, and rodents, and warm-blooded pets. Emphasis is placed on con-

trol through integrated pest management, an environmentally sensitive approach that uses

knowledge about the life cycles and habits of pests to eliminate them.

Keywords: allergens, asthma, cockroach, disease management, dust mites, patient education,

pests, pets, rodents, self management

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Volume 5, Issue 8, September 2009572 The Journal for Nurse Practitioners - JNP

children in the United States and other developed countriesspend indoors is also recognized. U.S. guidelines for thediagnosis and management of asthma recommend assessingfor exposure to indoor and outdoor asthma triggers, andprovide information about how to control such triggers.10

Failure to educate patients and their families aboutthe importance of avoiding known disease triggers hasbeen identified as one predictor of preventable hospital-ization for childhood asthma.11 Primary care nurses andphysicians do not routinely take environmental historiesor counsel on indoor pollution control,12 nor is this skilltypically included in medical and nursing education.13

The purposes of this paper are to encourage clini-cians to obtain environmental histories for patients withasthma and to provide information about the manage-ment of asthma triggers that are commonly encounteredin indoor environments.

OBTAINING AN ENVIRONMENTAL HISTORYMany individuals are aware that environmental factorsinfluence health, but understanding which factors arerelevant and how to control them is rare. The collectionof environmental history from an asthma patient may bethe first time patients and families make the connectionbetween specific environmental conditions and asthmasymptoms. This process provides an opportunity to edu-cate families and answer their questions, while helpingclinicians gain insight into the specific triggers that mayplay a role in an individual’s symptom patterns.

One barrier to collecting the environmental history isthe clinical time permitted for each patient. While a sim-ple environmental screening for well individuals mighttake 2 or 3 minutes, the environmental history collectionfor asthma patients is more detailed, and time for itshould be included in the encounter. Because the processinvolves counseling and education, as well as collection ofdata, clinicians caring for children or adults covered byMedicaid may consider billing based on time/counselingfor this encounter. Delegating the task to an educatormay be an option in some settings, although it is impera-tive that a system for clinician review of the informationand counseling occur, because treatment decisions shouldincorporate this important information. Conducting theassessment in a face-to-face encounter, rather than havingpatients or parents fill out histories prior to the visit, hasthe advantage of helping to build a partner relationshipbetween the medical care providers and the patients andtheir families. It is expected that children with asthma

will receive the routine environmental screenings thatwell children receive, such as screening for exposures tolead and household poisons, in addition to the morefocused asthma-related environmental history.

Learning about exposures to asthma triggers involvesattention to all environments in which an individual mayspend time. Number and diversity of environments increaseas patients age, but even infants rarely remain in a singleenvironment. Day care, school, after-school programs, rela-tives’ and friends’ homes, and shopping venues contributeto children’s exposures to triggers, as well as the home inwhich the children live. For adults, occupational and recre-ational exposures are additional important factors. Forms forrecording the asthma-related environmental history havebeen created by multiple groups and are easily accessible onthe Internet. For example, the National EnvironmentalEducation and Training Foundation created a popular envi-ronmental history form specifically for patients with asth-ma, which can be downloaded and used without charge.14

Standard components should be included in the asthmaenvironmental history, but regional and demographic varia-tions may affect the significance of some routine items. Forinstance, regions with warm, humid climates promote thegrowth of dust mites and mold, while regional preferencesin heating systems influence indoor combustion products.Socioeconomic factors, including housing type and familyincome, are associated with exposure to indoor asthma trig-gers. Minority, inner-city residence, and low-income statusare risk factors for asthma morbidity.15-17

Developmental factors play an important role. Forinstance, during the pre-school through middle-schoolperiods, allergy increases in importance. By age 12, about80% to 90% of children with asthma will have allergic trig-gers, and a history of atopic dermatitis or parental asthma isstrongly associated with allergic airway disease.18 Thus, theenvironmental history must be interpreted in conjunctionwith the patient’s development, family and personal medicalhistories, geography, and socioeconomic factors. The routineenvironmental history for asthma patients should includethe minimum components outlined in Table 1. The pres-ence of pests and pets are common indoor exposuresrevealed in the environmental history. Strategies for reduc-ing these exposures are explored in the following sections.

MANAGING PESTSCockroaches

Cockroach infestations are common in inner-city areasglobally, particularly where warmth and humidity provide



favorable conditions. The National Survey for Lead andAllergens in Housing (NSLAH) conducted in 1998-1999found that cockroach allergens exceeded levels associatedwith sensitization on 13% of kitchen floors in the UnitedStates. Concentrations associated with sensitization werefound in 32% of low-income homes sampled in the south-ern region.19 Most patients become aware of the existenceof cockroaches in the home when they see them. Roachesare most active at night, so they will usually be sightedwhen turning on a light in the kitchen at night. If they arenot sighted, their presence may be inferred from feces thatresemble grains of pepper. Established infestations oftencreate a peculiar musty smell.

The first step in preventing asthma symptoms due tocockroaches is to monitor the indoor environment fortheir presence. Monitoring is easily done with a flashlightand mirror with an extension arm, such as a dental mirror.Illuminating dark areas, especially those near water andfood, will reveal the typical black flecks of roach feces,roach parts, cast skins, dead roaches, and live roaches.Obvious areas to explore include under sinks and otherkitchen and bathroom counters, behind refrigerators andstoves, under water heaters, corners of rooms at floor or

ceiling level, in stacks of papers, such as grocery bags ornewspapers, and around lighting fixtures. Placing “sticky”roach traps in areas that might be attractive to roaches canalso provide information about infestations. Such traps willonly catch roaches if they are placed within 5 to 6 feet ofan infested area. Finding roaches in a trap indicates a prob-lem nearby. Sticky traps can be purchased baited or unbait-ed. Baited traps are impregnated with pheromones toattract roaches, but if the objective is to locate infestations,unbaited traps should work well.20

If cockroaches are not thought to be present, the bestmanagement is prevention. Eliminating the cockroachcomfort zone by depriving roaches of food, water, andcluttered hiding places is the most effective preventive.This is also the first step in removing existing cockroach-es from the environment. It is difficult to permanentlyeradicate cockroaches from home environments, particu-larly for apartment dwellers vulnerable to transmissionfrom adjacent housing units. Nevertheless, families shouldbe queried regarding the methods of roach control theyare currently using, and basic principles of asthma-saferoach control should be shared with them. Generalroach-prevention sanitation guidelines are included inTable 2.

Integrated pest management (IPM) is recommended forroach eradication.21 The IPM approach is based on usingthe least toxic measures first. After instituting routine meas-ures to deny roaches food and housing, families may stillneed to apply chemical measures to destroy pests.Pyrethrum, a chrysanthemum derivative, and boric acid arecommonly recommended. Both have low toxicity tohumans.

Boric acid powder (borate) is applied lightly in areaswhere roaches are active. As roaches walk through thepowder it sticks to their bodies. It works as a desiccant, butalso as an internal poison when the insects lick the pow-der off their bodies. It is important that the powder isapplied lightly. Roaches will avoid heavy accumulations.Boric acid will begin working within a few days of appli-cation and will continue to work for years. Although it isnot highly toxic, it must be applied in areas out of reach ofchildren and pets. Boric acid powder is inexpensive andeasy to find in most hardware stores.

An alternative or supplement to boric acid is roachbait. Roach bait can be purchased in the form of gels,pastes, grains, or powders. The bait contains poison orgrowth regulators that will be spread by the roaches thateat the bait, either through their feces or dead bodies,

Table 1. Minimum Components of the EnvironmentalHistory for Asthma Patients

Explore Patient Exposures to the FollowingPets and Pests• Furry pets • Rodents• Cockroaches• Dust mites

Particulates• Tobacco smoke • Wood smoke• Traffic emissions• Dust• Unvented heating appliances

Plants and pollens• Indoor molds (eg, mildew)• Indoor plants• Outdoor seasonal molds• Outdoor tree and grass pollens

Perfumes• Household cleaning chemicals (eg, bleach)• Cosmetics with strong odors• Paint• Chemicals used in hobbies• Chemicals used at work



both of which will be consumed by other roaches. Gelsand pastes are sold in syringes that are used to deposittiny (BB sized) amounts in strategic locations. Theamounts of bait that are deposited should be tiny, notbecause of toxicity to humans, but because roaches willavoid large deposits of bait, just as they avoid large accu-mulations of boric acid powder.

Other forms of bait are sold in small bait “stations”that can be placed where roaches will find them. Becauseroaches will eat whatever food is closest, including card-board glue, book bindings, and so forth, it is important toplace bait closer to the roaches than other sources offood. Understanding where roaches might hide is impor-tant. Families can be taught to place baits within 10 to 12inches of hiding places, such as under sinks, under appli-ances, near plumbing fixtures, and anywhere they seedroppings. Bait, like boric acid, should be placed in areasout of the reach of children. Baits do not work if thereare strong smells nearby; therefore, using roach spraysdestroys the effectiveness of the baits. Odors from ciga-rettes and strong-smelling cleansers will also keep roachesaway from the bait. Roach bait is available in most hard-ware and grocery stores.

Families should be taught to avoid bug sprays, foggers,and “bombs.” These methods are likely to cause roachesto scatter and may not be as effective as alternatives. They

release toxic chemicals into the air, which are inhaled, andare therefore more likely to cause asthma symptomsthemselves. The chemicals are also deposited on surfaceswhere they are in contact with hands. If a live roach isseen, it should be destroyed by smashing it, not by spray-ing with roach spray.

Because dead roaches and their body parts and drop-pings become part of household dust, removing dust is alsoimportant in controlling asthma symptoms associated withroach allergens. If possible, individuals with asthma shouldnot clean dusty areas because they may inhale dust that isstirred up into the air. If people with asthma must dust,wearing a dust mask is recommended. Where possible, dustshould be removed with a damp rag or paper that can bediscarded. Cleaners should not dip a cleaning rag back intodirty water because this practice merely spreads the roachdust. A 10% bleach solution can be used on surfaces, such astile floors or counters. The bleach will denature roach aller-gens. It should be left on surfaces for about 10 minutesbefore rinsing. If bleach is used, good ventilation should beprovided to prevent inhalation of bleach fumes.

Families living in apartments will seldom be able tocontrol roaches on their own. Although the rights of rentersdiffer from state to state in the United States, generally, oneof the basic rights of renters is access to a habitable (pest-free) environment. This means the apartment should be freeof roaches prior to the family’s occupancy. Renters andbuilding owners must work cooperatively to solve pestproblems. Medical providers may be able to assist familiesby helping them find ways to articulate their needs to land-lords. Clinicians who work with low-income familiesshould become thoroughly familiar with renters’ rights intheir states before recommending specific strategies.

Dust Mites

House dust mites are microscopic arachnids that aretypically harmless to people. They consume dead skincells that are shed regularly by humans and their pets.Unlike roaches, they do not carry disease, but substan-tial numbers of children with asthma living in warm,humid climates are sensitive to the proteins present indust mite fecal material. Sensitization among children isestimated to be as high as 65% in humid areas of theUnited States12 and has been demonstrated to be ashigh as 94% to 98% in tropical environments.22,23 Highlevels of dust mite allergens are commonly found inmattresses, pillows, quilts and comforters, carpets, andupholstered furniture.

Table 2. Roach-Prevention Sanitation Measures

Deny roaches access to food and water• Store food and trash in closed containers• Clean up food crumbs and spills as soon as possible• Take garbage outside daily• Check for and repair water leaks under sinks and wrap

pipes to prevent condensation• Do not let water stand in plant dishes• Clean kitchen countertops daily• Do not allow dirty dishes to stand overnight• Mop kitchen floors at least weekly• Limit food consumption to kitchen and dining areas –

do not permit food in bedrooms• Caulk gaps around sinks and tubs

Deny roaches entry and remove hiding places• Check for and repair interior and exterior crevices and

holes through which roaches can enter• Unpack cardboard boxes and paper bags outside if

possible to prevent bringing in hidden roaches• Remove collections of empty bottles, boxes,

newspapers, and other clutter from around the home • Empty vacuum cleaner bags regularly to prevent

surviving roaches or eggs from re-emerging



The high incidence of dust mite sensitization andubiquitousness of dust mites seem adequate rationale forcontrol efforts; however, evidence for the effectiveness ofdust mite control measures is lacking. Most control meas-ures are devoted to removing dust mites from favoredmite habitats by physical means, such as mattress and pil-low encasings, or chemical means, such as acaricides. Acontroversial 2008 systematic review by Gøtzsche andJohansen for the Cochrane Collaboration examined 54clinical trials of dust mite control measures and found noclinical effect subsequent to the physical or chemicalmeasures for reducing dust mite exposure.24 The lack ofclinical effectiveness of existing dust mite control meas-ures resulted in the conclusion that methods aimed atreducing exposure to house dust mites cannot be recom-mended. In spite of the lack of evidence, many allergistsand professional organizations, such as the Asthma andAllergy Foundation of America, recommend dust mitecontrol measures, especially encasing mattresses and pil-lows in allergen-impermeable covers. Table 3 lists com-mon recommendations for reducing exposure to dustmite allergens.

Rodents

Rats and mice have adapted well to living withhumankind, but they produce allergens that triggerasthma symptoms and carry numerous pathogens thatcan infect humans.25 In the United States, the mostcommon species of rats are Norway rats and roof rats.The 2 groups have somewhat different habits, soknowing which type is present can help with choosingcontrol strategies. Norway rats tend to build nests nearor in the ground, such as around foundations or inyards under brush or wood piles. Roof rats usually nestabove ground in trees, attics, walls in upper floors, andcabinets. Roof rats are distributed mostly in the south-ern United States, from Texas to Virginia, and along thewest coast.26 Consistent with the principles of roachcontrol, the least toxic measures should be employedfirst to manage rodents.

Rats and mice are most active at night, and thereforemay not be easily spotted, but signs of their presence areeasy to detect. If a pet dog or cat brings home rat car-casses or if rodent droppings are visible around pet dish-es, recycling bins, or garbage cans, there are certain tobe rodents nearby. Other signs include scratching orskittering noises from the attic after dark, remnants ofrat nests under firewood stacks or piles of lumber,

drowned rats in swimming pools or hot tubs, andsmudge marks on beams, rafters, pipes, or walls as aresult of rats rubbing their fur as they travel.

Good sanitation, indoors and out, is the most impor-tant rodent prevention measure. In the absence of goodsanitation, other control measures will usually fail.Outside, Norway rats should be denied convenient nest-ing spots. Gardening equipment, lumber, and otherobjects should be stored off the ground, and trash andother yard debris should be removed frequently. If dogsare fed outdoors, they should only be fed as much as theywill eat at one time so pet food will not attract rodents,and the pet food should be stored in rodent-proof con-tainers with tightly fitting lids. Roof rats use climbingvines, such as ivy, and tree limbs that closely overhangroofs, as avenues for entry into houses. As much as possi-

Table 3. Common Dust Mite Control Measures

Method Comments

1. Reduce humidity(increase ventilation,use a dehumidifier)

2. Use allergen-impermeable coversfor pillows andmattress

3. Use acaricide, such asbenzyl benzoate,DEET, or geranium oil

4. Vacuum regularlywith a cleanerequipped with aHEPA filter

5. Remove carpetingover wood or tilefloors.

6. Freeze stuffed toysfor 24 hours to killmites

7. Wash bed linens inhot water (140°F)weekly

High humidity favors dustmite reproduction. Keepinghumidity below 50%-60%can help reduce dust miteallergen

Vinyl is inexpensive andblocks dust mites, but canbe uncomfortable. Otherfabrics should have a poresize of no more than10 microns in diameter

Benzyl benzoate is themost common acaricideand may be applieddirectly to mattresses andcarpets. Effects may last upto 3 months

HEPA filters can trap smallparticles that wouldotherwise be recirculatedinto the air whilevacuuming

Carpet traps dust mites,dust, pollens, pet dander,and other allergens

Freezing causes mites torupture as water in tissuesexpand

Heat (130°-140°F) willdestroy mites and theireggs



ble, limbs, hedges, and climbing vines should be removedfrom close proximity to exterior walls and roofs.

Denying rodents access to food, water, and shelter inthe house is accomplished by sealing every opening larg-er than 1⁄4 inch in diameter, including gaps under doors.Openings around pipes, cables, and wires should besealed. Windows should be screened and screens shouldbe kept in good condition. Rooftop plumbing vent pipesshould be screened, as well as outside clothes dryer vents.Chimneys should be screened and attic ventilationscreens under the eaves should be checked and keptrepaired. Exterior doors should fit tightly and be weath-erproofed at the bottom.

If rats or mice are already present, traps are recom-mended. Rodenticides, including anticoagulants andother poisons, are all toxic to humans and pets. If used,

they should be purchased and placed with professionalassistance. Trapping is safer and less expensive than poi-son; however, mice and rats tend to avoid new objects intheir environments, thus traps may not attract them forseveral days following placement. Traditional snap traps,like those shown in Figure 1, are effective and cheap.These traps consist of a heavy spring-loaded bar with atrip release. Bait such as cheese, bread, or a small piece ofmeat, is placed on the trip. When the mouse touches thetrip, the spring-loaded bar swings down with great force,breaking the animal’s spinal cord or crushing its skull orribs. Larger versions are available for catching rats.

Sticky traps are non-toxic to humans. They consist ofadhesive applied to cardboard or plastic trays. When miceor rats cross the surface they are caught in the adhesive.Rodents can be released from sticky traps by applyingvegetable oil and then humanely killed or freed; howev-er, many times the traps are not checked for long peri-ods and the animals suffer needless trauma and pain,dying of starvation or dehydration, or sometimes chew-ing off their own limbs in an effort to escape.27

Although snap traps and sticky traps are the most com-monly used rodent traps, other trapping methods are avail-able, including electric traps, inert gas traps, and buckettraps, in which mice are lured to a bucket of water, wherethey drown. Traps that catch rodents alive are also market-ed, but users should be aware that mice have a stronghoming instinct and should be released at a great distancefrom the building in which they are caught. Obviously, thismay not be popular with city neighbors.

MANAGING PETSWhile decreasing exposure to pests helps everyone, regard-less of asthma status, avoiding a beloved pet can be anemotional issue and should be undertaken only if the indi-

Table 4. Supplemental Resources

National Center for Chronic Disease Prevention and HealthPromotion: Healthy Youth Asthma• This resource includes a focus on strategies to reduce

asthma triggers in the school environment• http://www.cdc.gov/healthyyouth/asthma/

National Institute for Occupational Safety and Health:Prevention of Occupational Asthma• This resource provides a review of literature that is

easily queried and focuses on strategies to preventasthma induced by occupational exposures

• http://www.cdc.gov/niosh/topics/asthma/occasthmaprevention.html

National Academies Press: Clearing the Air, Asthma andIndoor Air Exposures• This IOM report is a seminal publication on the

relationship between asthma and indoor air exposures. • http://www.nap.edu/openbook.php?isbn50309064961

U.S. Environmental Protection Agency: Managing Asthma inthe School Environment• This resource features Tools for Schools and other helpful

materials for use in controlling asthma triggers at school • http://www.epa.gov/iaq/schools/managingasthma.html

Asthma-Friendly Child Care: A Checklist for Parents andProviders• This resource was developed by the Asthma and Allergy

Foundation of America/New England Chapter. It featuresa simple to use checklist for evaluating allergen controlin day care centers

• http://www.asthmaandallergies.org/Articles/Asthma%20FriendlyChild%20Care.htm

Figure 1. Traditional snap trap for rodents.



vidual with asthma is allergic to the pet. Therefore, allergytesting should be recommended prior to making decisionsabout acquiring or removing pets. The types of pets thatproduce asthma triggers are warm-blooded animals,including all mammals and birds. Allergens are present inthe saliva of dogs and cats and in the flakes (dander) ofskin, fur, and feathers of any furred or feathered creature.

Cat and dog allergens are found in virtually everyhome and public building regardless of whether or not apet lives in the building; however, allergen levels aremuch higher in homes where pets live. Cat and dogallergens easily become airborne and can be transferredfrom one environment to another on articles of clothingand other surfaces, so eliminating pets from the homewill not completely eliminate exposure.28 The onlymethod of significantly reducing the level of animalallergen in the home is to remove pets. Even when petsare completely removed allergen levels will not declineappreciably for up to 6 months, though vigorous clean-ing can speed the process.28 If removing pets is not anoption, the recommendation to keep the pet outsideshould be considered.

If removing pets from the indoor environment is notacceptable to the family, then keeping pets out of thebedroom, and certainly out of the bed of allergic indi-viduals, is mandatory. Laboratory investigations byMatsui et al suggest that cleaning appropriate surfaceswith low concentrations of household bleach disruptsthe biological activity of the allergenic proteins.29

Cleaning as described for dust mite avoidance also pro-vides some decrease in exposure to pet allergens.

Additional measures shown to be effective and feasi-ble include the use of air filtration systems30,31 and the useof common furniture polish when dusting.32 Frequentwashing of pets has been recommended, but allergensreturn to previous levels so rapidly after washing thatbathing is required at least twice a week. Such frequentwashing may damage the pet if it dangerously alters lipidfilms in fur, resulting in skin irritation.33 Finally, removalof pet allergens from the cotton clothes of owners canbe accomplished by simple washing in water, and drycleaning has been shown to partially remove pet aller-gens from wool fabrics.34,35

CONCLUSIONManagement of respiratory allergies is complex and avoid-ance of allergens is only one of multiple strategies thatcomprise a treatment plan. Completely eliminating indoor

allergens and other triggers may not be feasible. The aller-gens generated by pests and pets are vulnerable to reduc-tion, but keeping them controlled requires consistent effort.Table 4 includes online resources with strategies that sup-plement those discussed here. Recommendations for indoorallergen avoidance should be made available to all asthmapatients, but complete success should not be expected. It isdesirable that allergen avoidance measures are safe andhumane so that damage to patients, animals, and the envi-ronment does not occur. Patients and clinicians should rec-ognize the importance of all relevant asthma control meas-ures, including allergen and irritant avoidance, medicationadherence, early symptom recognition, and, when appropri-ate, immunotherapy.

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35. Liccardi G, Russo M, Barber D, et al. Efficacy of dry cleaning in removingFel d 1 allergen from wool fabric exposed to cats. Ann Asthma AllergyImmunol. 2002;88:301-305.

Patricia Newcomb, PhD, RN, CPNP, is an assistant professor at the

University of Texas at Arlington and a pediatric nurse practitioner at

Cook Children’s Health System in Fort Worth, TX. She can be

reached at [email protected]. In compliance with national ethical

guidelines, the author reports no relationships with business or industry

that would pose a conflict of interest.

1555-4155/09/$ see front matter

© 2009 American College of Nurse Practitioners

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Safe Control of Pest and Pet Asthma Triggers