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Wise et al.

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• Benefit: Reduction in cockroach count, but allergen levels (Bla g 1 and Bla g 2) often above acceptable levels for clinical benefits. No studies included clinical endpoints related to AR. • Harm: None reported. • Cost: Moderate. Multiple treatments applications required as well as a multi interventional approach. • Benefits-Harm Assessment: Balance of benefit and harm, given lack of clear clinical benefit. • Value Judgments: Control of cockroach populations especially in densely populated, multifamily dwellings is important to controlling allergen levels. • Policy Level: Option. • Intervention: Combination of physical measures (such as insecticide bait traps, house cleaning) and educational-based methods are options in the management of AR related to cockroach exposure. IX.A.3. Pets— Pet avoidance and EC represent options for the treatment of AR. Pet removal is a commonly cited strategy without high-quality outcomes evaluation. 1118,1144,1145 Sánchez et al. 1146 evaluated compliance rates among sensitized patients (n = 288), finding 4% of patients with direct exposure to home animals complied with removal recommendations (Table IX.A.3). EC has therefore been evaluated to decrease antigen exposure, with mixed results. Björnsdottir et al. 1147 evaluated outcomes of multimodality EC among 40 patients with diagnosed cat (Fel d 1) sensitization, finding significant improvements in nasal airflow and clinical symptoms. However, despite reductions in environmental antigens, single-modality EC has not been associated with improved symptoms. Wood et al. 1148 evaluated HEPA filtration in a high-quality randomized controlled study of 35 patients with Fel d 1 sensitization, finding unchanged nasal symptom scores, sleep disturbance, rescue medication usage, and spirometry following a 3-month trial. Several lower-quality studies have evaluated the duration of antigen reduction following pet washing, finding that cat and dog washing must be completed at least twice weekly to maintain significant reductions in environmental antigens. 1149,1150 Furthermore, pet removal may only result in decreased allergen levels after several months 1151 and Can f 1 levels in homes with “hypoallergenic” animals are generally similar to homes with non hypoallergenic species. 1152 An additional study has identified benefits of pet avoidance in the secondary prevention of asthma among previously sensitized individuals. 1153 Similarly, current asthma treatment guidelines recommend pet removal from a sensitized individual’s home. 1154 • Aggregate Grade of Evidence: B (Level 1b: 1 study; Level 2b: 2 studies; Table IX.A.3.) • Benefit: Decreased environmental antigen exposure with possible reduction in nasal symptoms and secondary prevention of asthma.

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.