Fourth draft for discussion by the Conference Steering Committee

12 July Draft, approved by Conference Steering Committee

For review by conference participants.

Vision Statement and Action Agenda: Prevention and Reduction of Childhood Asthma

I. Preamble

Asthma continues to increase in frequency in children in the US.  Nearly one in thirteen school-aged children has asthma, and the percentage of children with asthma is rising most rapidly in children younger than school age.  Best available estimates are that more than six million children in the US now have asthma.  Asthma causes many children to miss school, resulting in more than ten million missed school days each year.  Asthma also has other effects on children and their families, interrupting sleep, limiting activity, and disrupting routines (1)

 In general, asthma rates seem to be highest in cities (2).  Children of color are especially impacted (3), and African American children have a significantly higher likelihood of dying from asthma than white children (4).  Poorer children are at greater risk (5).  Some of the differences may be due to differences in access to health care (6) including primary preventive care (7).  The cost of asthma is enormous and was estimated in 1998 to be $11.3 billion (1).  Most of the cost was for direct medical expenses.  Asthma is responsible for about 1% of expenditures for health care in the US (8).

Certain indoor environmental factors are thought to contribute to triggering asthma attacks.  These include dust mites, cockroaches, mold, animal dander, and environmental tobacco smoke [add refs].

Outdoor air pollutants and allergens can also contribute to triggering attacks.  Pollutants include ozone, particulate matter, sulfur dioxide, and nitrogen dioxide (9-12).   Allergens include pollens, molds, and fungi) (13).  They are associated with increased symptoms and emergency room visits (9).  The World Health Organization identified traffic pollution as a causative influence for asthma (14), and diesel exhaust has also been identified as a possible concern (15).  There is some evidence of greater susceptibility among children of color (9)

It is less certain what causes the onset of asthma in the first place.  Different researchers have come to different conclusions.  Environmental factors may contribute to the onset of asthma, probably in conjunction with other factors including genetic factors. 

The problems posed by asthma transcend the area of responsibility of any one agency or organization and demand new partnerships and new commitments to taking all actions needed to achieve results.  Health, environment, education, housing, transportation authorities are all needed to contribute toward solutions.  Action is needed at many levels – individual, family, neighborhood or school district, community, county, state, national.

II.  Vision Statement: Improving the Quality of Life for Children and Moving Toward Prevention

III.  Goals: 

Data and tracking:  To establish systems to track the prevalence of asthma symptoms in the population and the prevalence of severe cases in all states; to establish systems to track the prevalence of triggers, particularly air pollution, allergens, frequency of smoking by parents, and quality of housing conditions that contribute to asthma; and to link these systems to allow for coordinated response, identification of target areas of concern, and research. 

Coordination, Coalitions, and Capacity Building:  To establish capacity for coordination of resources throughout each state, including health and environment authorities and other organizations. 

Competent and pro-active management of asthma for every affected child:  In every neighborhood of every town in every county in every state, every single child with asthma should have appropriate support for management of their asthma to reduce symptoms and loss of activity as much as possible, including medical care conducted according to current guidelines, tangible support for families, and assistance at schools.  While this is not an area of focus for this strategy, state health and environment agencies seek to support this work.

Triggers of asthma attacks:  For triggers that originate indoors, to empower and motivate persons responsible for all buildings in which children spend time to reduce triggers to prevent asthma attacks.   For triggers that originate outdoors, to reduce triggers to levels that do not contribute to asthma attacks

Causes of the onset of asthma:  Research is needed to finally determine the causes of the onset of asthma so that these causes can be addressed in the future.  Suspected causes may be appropriate for action before causes are finally established.

 State policy leaders agree to work together to build support for this vision and to reduce the burden of death and suffering that children bear as a result of asthma.

IV.  Action Agenda for Today

Developing Data and Tracking Systems for Asthma

Currently, data about the incidence of asthma in populations is very limited.  Few states have surveillance programs capable of accurately determining the prevalence of symptoms at varying levels of severity or identifying areas of particular concern.  A 1996 study by the Council of State and Territorial Epidemiologists reported that only 8 state health departments had surveillance and intervention programs (6).

From the data collected as part of this project, it appears that more states are now actively working on asthma.  Many states look at deaths from asthma using vital statistics data.  Many states also look at hospital discharge data to identify the number of cases where patients were sick enough to be admitted to the hospital.   Some states collect data about emergency room visits; some look at health care utilization, largely through Medicaid data; a few use surveys including state questions added to the Behavior Risk Factor Surveillance Survey; and a few collect data in schools.  There appears to be no convergence in approach.  Note to reviewers:  What do you think would be the priority for data collection?

Data and Tracking of Triggers or Suspected Causes

Environmental data, particularly about air pollution, tends to be collected more systematically than data about prevalence of asthma.   Air monitors are deployed across the nation to measure concentrations of the six criteria pollutants -- ozone, particulate matter (PM10 or PM 2.5), sulfur dioxide, nitrogen dioxide, carbon monoxide, and lead.  Diesel exhaust, considered to be a potential trigger for asthma, is a more difficult problem as methods are still under development to monitor concentrations of diesel.   For indoor factors, it is obviously not practical to measure every indoor environment.  However, in some cases better information might lead to targeting of resources, for example, to address damp housing or areas where insect infestations might trigger asthma.  Such conditions might appropriately be addressed by housing authorities.  School conditions are also a significant concern, as many schools are old, and maintenance has been deferred in many jurisdictions. 

·         States will seek to evaluate monitor locations to see whether they are collecting information about air pollutant concentrations in areas where asthma rates are high or populations are at particular risk. 

·          Development and implementation of methods for monitoring and risk characterization for diesel should be a key priority for US EPA.

·         Note to reviewers:  What about monitoring for molds, fungi, pollens?

·         States will investigate approaches to systematically monitoring indoor housing and other factors that exacerbate asthma.

·         States will investigate whether information about school conditions could be usefully collected and used to identify schools for priority attention.  Note to reviewers:  Could this be systematically reviewed in a way that would lead to useful results?

Integration of Environmental and Health Information

·         States will seek to design and implement data systems so that data from disease tracking systems can be compared with data from environmental tracking systems. 

·         States will seek to address areas of at-risk populations when locations for environmental monitoring are selected and to address areas of environmental risk when areas for interventions and research are selected.

Capacity Building: Coalitions between Partners; Planning


·         State health and environment agencies will seek to develop and implement education programs to provide families of children with asthma with sufficient information to be able to take steps to reduce triggers, to recognize attacks and take appropriate action, to know how to interact with health care providers, and to recognize any side effects of medication (16)

·         State health and environment agencies will seek to develop and implement education programs for day care and school personnel improving the environment to reduce triggers and to support effective action in case of an attack. 

Action and Practices to Reduce Indoor Environmental Triggers

For reducing triggers that contribute to asthma attacks in children, the principal indoor environments of concern are homes, schools, and day care facilities.  Mold and cockroaches may occur in buildings that are not sufficiently well maintained or in buildings in warm and humid climates.  For detached buildings, individual families or building managers may be able to take remedial actions.  For larger buildings, families may need to seek action from landlords or housing or health authorities

Environmental tobacco smoke: 

·          States will seek to implement programs to promote elimination of smoking in homes where children are present.  Health care providers may also be able to work with parents to encourage eliminate of smoking.  Assistance through smoking cessation support programs may be appropriate. 

·          States will seek to prohibit smoking in all schools and day care facilities. 

Building factors:  Dampness, mold, cockroaches

·          States will seek to inform and empower families to reduce dampness and molds in homes.  States will seek to inform and empower landlords to reduce dampness and molds in rental housing. 

·          States will seek to work with housing authorities to identify and implement effective strategies to improve building conditions for low-income housing, which is often most impacted. 

·          States will seek to make remedial actions reimbursable through programs that provide health insurance to children and low-income families.

Household factors:  dust mites, animals, products used in the home, cooking practices

Dust mites can be found in bedding and are more common in bedding that is not sealed and frequently washed at high temperature or aired.  Animal dander is found in homes of children with animals and their friends.  Products used in the home may trigger asthma attacks in some cases.  Cooking practices that result in accumulation of higher concentrations of NOx may also trigger asthma.  These conditions generally need to be addressed through the home management and housekeeping practices of individual families.

·          States will seek to inform and empower families to address household factors that can trigger asthma, with emphasis on families of children with asthma.

Home Visits and Assistance

Several states have programs in which environmental health staff visit homes of children with asthma to identify possible sources of triggers and to identify remedies.  This may be a useful approach to addressing the multiple possible triggers that may apply in each case.  Coordination between health agencies, which may be the ones identifying homes of concern, and environment agencies, which may be the ones providing the in-home assistance, would be especially important for this task.

·          States will consider whether home visits and assistance would be useful and effective components of programs to address asthma.

School based programs

The "Tools for Schools" program developed by US EPA provides a good model for how existing school personnel can identify possible sources of triggers and take actions to reduce them.  The "Open Airways" program from the American Lung Association provides a good model for how schools can plan to work with children and their families to control asthma and to reduce mortality.  There are also additional models from curricula developed by states for use in schools.

 ·          State health and environment authorities will consider working with education authorities to bring asthma management and trigger reduction programs to schools.  Schools with high rates of asthma may be appropriate to target first. 

Day care based programs

Day care centers have some attributes that are similar to schools and some that are more similar to homes. Appropriate strategies would address these attributes.

Action and Practices to Reduce Outdoor Environmental Triggers

Common outdoor air pollutants have been shown to be associated with exacerbation of asthma, measured in several ways.  The effects may occur at concentrations below currently adopted National Air Quality Standards for criteria pollutants.  Coordination between health and environment authorities could contribute to the identification of where these areas are.  Several estates are increasing their capacity to issue warnings of high pollution days particularly for ozone, to help persons at risk, including those with asthma, to avoid spending time outdoors when pollution levels are high.    Moreover, if multiple pollutants contribute to exacerbation of asthma, consideration of net pollution burdens may be relevant. 

·         State environmental agencies will continue efforts to reduce air pollution, particularly in areas where asthma rates are high.  Linking the health consequences of air pollution to the pollution control mission may help to increase public and political support for reductions in emissions.  Statewide asthma coalitions could contribute to this effort.

·         States may wish to consider transportation strategies to reduce vehicular pollution, particularly from diesel, where this appears to be a significant concern.

·         Several states have targeted reduction of open burning as an important activity.  Other states may wish to consider whether efforts to address this issue may be appropriate.

·         States may wish to consider whether additional effort toward warning sensitive populations of adverse levels of air pollution is warranted. 

·          States may wish to consider whether information about air pollution warnings would be appropriate in training and education programs offered to children with asthma and their families. 

·         It may be appropriate to expand the warnings to include other pollutants or to the biological triggers as well.

Defining, Measuring, Achieving results

· Review of the effectiveness of intervention and education programs should be conducted when feasible and results shared among the states.


Future Needs and Directions

References Cited

1.        President's Task Force on Environmental Health Risks and Safety Risks to Children. Asthma and the Environment: A Strategy to Protect Children, 2000.

2.        Weiss KB, Gergen PJ, Crain EF. Inner-city asthma. The epidemiology of an emerging US public health concern. Chest 101:362S-367S(1992).

3.        Cunningham J, Dockery DW, Speizer FE. Race, asthma, and persistent wheeze in Philadelphia schoolchildren. American Journal of Public Health 86:1406-9(1996).

4.        Weitzman M, Gortmaker SL, Sobol AM, Perrin JM. Recent trends in the prevalence and severity of childhood asthma. Journal of the American Medical Association. 268:2673-7(1992).

5.        Malveaux FJ, Houlihan D, Diamond EL. Characteristics of asthma mortality and morbidity in African-Americans. Journal of Asthma 30:431-7(1993).

6.        Brown CM, Anderson HA, Etzel RA. Asthma. The states' challenge. Public Health Reports 112:198-205(1997).

7.        Murray MD, Stang P, Tierney WM. Health care use by inner-city patients with asthma. Journal of Clinical Epidemiology 50:167-74(1997).

8.        Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the United States. New England Journal of Medicine 326:862-6(1992).

9.        Ostro B, Lipsett M, Mann J, Braxton-Owens H, White M. Air pollution and exacerbation of asthma in African-American children in Los Angeles. Epidemiology 12:200-8(2001).

10.        Romieu I, Meneses F, Ruiz S, Sienra JJ, Huerta J, White MC, Etzel RA. Effects of air pollution on the respiratory health of asthmatic children living in Mexico City. American Journal of Respiratory and Critical Care Medicine 154:300-7(1996).

11.        Pope 3rd CA, Dockery DW. Acute health effects of PM10 pollution on symptomatic and asymptomatic children. American Review of Respiratory Disease 145:1123-8(1992).

12.        Chew FT, Goh DY, Ooi BC, Saharom R, Hui JK, Lee BW. Association of ambient air-pollution levels with acute asthma exacerbation among children in Singapore. Allergy 54:320-9(1999).

13.        Delfino RJ, Zeiger RS, Seltzer JM, Street DH, Matteucci RM, Anderson PR, Koutrakis P. The effect of outdoor fungal spore concentrations on daily asthma severity. Environmental Health Perspectives 105:622-35(1997).

14.        WHO. WHO Prevention of Allergy and Asthma Interim Report. Geneva: World Health Organization, Management of Non-communicable Diseases Department, Chronic Respiratory Diseases and Arthritis, 2000.

15.   Nel AE, Diaz-Sanchez D, Li N. The role of particulate pollutants in pulmonary inflammation and asthma: evidence for the involvement of organic chemicals and oxidative stress. Current Opinion in Pulmonary Medicine 7:20-6(2001).

16.        Volovitz B, Vichyanond P, Zhong N-S, Hemo-Lotem M. WHO Prevention of Allergy and Asthma Interim Report, Chapter Six: Education. Geneva: World Health Organization, Management of Non-communicable Diseases Department, Chronic Respiratory Diseases and Arthritis, 2000.

Updated July 12, 2001

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