Conference Electronic Draft

30 July 2001

Vision Statement and Action Agenda

Catching Your Breath:  Strategies to Reduce Environmental Factors that Affect Asthma in Children

Notes on this draft:

This is a draft of a vision statement and action agenda for consideration at a meeting of policy leaders from state health agencies and state environment agencies on August 7-8, 2001, in San Diego.  This draft was developed in consultation with the steering committee for the conference and with the suggestions and comments of staff from many states.  This project is sponsored by the Environmental Council of the States in cooperation with the Association of State and Territorial Health Officials.

I.  Preamble

Asthma continues to increase in frequency in children in the US.  Nearly one in thirteen school-aged children has asthma, and asthma is rising most rapidly in children younger than school age.  More than four million children in the US now have asthma, and some estimates are higher.  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 are 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 for the US (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 trigger asthma attacks.  These include dust mites, cockroaches, molds and dampness, animal dander, and environmental tobacco smoke (9).

Outdoor air pollutants and allergens also contribute to triggering attacks.  Pollutants include ozone, particulate matter, sulfur dioxide, and nitrogen dioxide (10-13).   Allergens include pollens, molds, and fungi (14).  They are associated with increased symptoms and emergency room visits (10).  The World Health Organization identified traffic pollution as a possible cause of asthma (15), and diesel exhaust has also been identified as a possible concern (16)

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 genetic factors. 

It is critical to ensure that every child has the medical care and active support to manage their asthma.  While this document is intended to identify ways that state environment and health agencies can work together to contribute to reduction in asthma triggers, it is being developed with a commitment to supporting this appropriate medical management and support. 

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

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

III.  Goals

The fundamental goal of this document is to identify steps that would lead to a more coordinated and effective response to the epidemic of asthma in children with regard  to indoor and outdoor environmental triggers.  To carry out these steps will require the involvement of people from many organizations, with many types of expertise, in many types of actions and the allocation of sufficient resources.  This document is developed in a spirit of support and cooperation with  those involved in primary health care and patient support, to achieve a more effective overall response.

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

A.  Competent and Pro-active Management of Asthma for Every Child with Symptoms of Asthma 

The states believe that, in every neighborhood of every town in every county in every state, every child with asthma should have appropriate support for management of their asthma to reduce symptoms and loss of activity as much as possible. This includes medical care that incorporates current guidelines, tangible support for families, and assistance at schools.  Moreover, support and medical resources to identify all children who have asthma must also be provided.  While this is not an area of focus for this strategy, state health and environment agencies support this work.

B.   Data and Tracking

To establish systems to track the prevalence of asthma  in the population and to track measures of morbidity such as hospitalizations or visits to emergency rooms in all states; to establish systems or studies that help agencies better understand and respond to links between asthma and triggers,  particularly air pollution, allergens, frequency of smoking by parents, and quality of housing conditions that contribute to asthma;  to link information in ways that promote identification of target areas of concern, coordinated response, and greater knowledge. 

C.  Coordination, Coalitions, and Capacity Building

To establish capacity for coordination of resources throughout each state, including health and environment authorities and other organizations. 

D.  Education

To provide for education of the many persons and groups who need to be involved in an effective response to asthma, including those who provide medical care, those who work with children in schools and child care settings, and those who are most directly affected -- families of children with asthma; to address the needs of each audience; to competently address cultural and language differences.

E.  Improved Control of Triggers of Asthma Attacks

For triggers that originate indoors, to empower, motivate, and equip 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

F.  Improving Knowledge of the Causes of the onset of asthma

To see that research needed to determine the causes of the onset of asthma is conducted so that these causes can be addressed in the future.  Suspected causes may be appropriate for action before causes are finally established.

IV.  Action Agenda for States

A.  Developing Data and Tracking Systems for Asthma

Currently, data about the prevalence of asthma in populations is limited.  Twelve states are currently being funded by CDC to develop tracking systems.

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 core asthma questions on the Behavioral Risk Factor Surveillance Survey; and a few collect data in schools.  Each data source has strengths and limitations.  There appears to be no convergence in approach. 

1.  The states recommend that priorities for data collection be identified.  The Centers for Disease Control (CDC) should convene a working group to identify priorities for data collection.  With limited dollars, what should a state collect first? 

2.  The states recommend that methods to achieve comparability of data be developed by CDC in consultation with states.  It may be appropriate to incorporate a definition of asthma developed by the Council of State and Territorial Epidemiologists for use in tracking systems.

3.  A national data system into which state data could be readily transferred is needed and should be coordinated by CDC.  States will strive to work toward contributing to such a system.  Federal support will likely be needed.

4.  States will seek to investigate how to better coordinate data systems used for health data with data systems used for relevant environmental data when this can contribute to better understanding of causes of asthma or ways to respond to it.

5.  The states note that, ultimately, national surveillance of sentinel chronic disease is needed.

B.  Data and Tracking for 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 collection of better information might lead to targeting of resources, for example, to address dampness in housing or areas where insect infestations are common.  School conditions are a significant concern, as many schools are old, and maintenance has been deferred in many jurisdictions. 

1.  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 or, where possible, to conduct sufficient monitoring to provide meaningful data for all populations.

2.  The states recommend that US EPA develop and implement sound methods for monitoring and risk characterization for diesel.

3.  States will seek to investigate whether additional monitoring for biological allergens is needed and identify methods to better report on the allergens that contribute to asthma.

4.  States will seek to investigate approaches to systematically monitor housing and building conditions to identify priority areas for intervention.

5.  States will seek to investigate whether information about school conditions could be usefully collected and used to identify schools for priority attention. 

C.  Integration of Environmental and Health Information

Both research and intervention require integration of information about both environment and health. 

1.  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. 

2.  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.

D.  Capacity Building: Coalitions between Partners; Planning

Planning groups or coalitions that include representation of the many parties that are needed to address asthma can identify needs and resources; identify and recruit partners in the health care, education, housing, and other communities; and develop strategies to obtain resources needed for effective and comprehensive programs. 

1.  States will seek to develop or support coordinated planning groups for childhood asthma prevention and reduction that include representatives for the several agencies that can contribute, including health, environment, housing, education, transportation, health care, child care, and welfare.  States will seek to involve community-based organizations as well as tobacco control groups, parent groups, faith-based organizations and business communities.  In some cases, state-level planning groups may be most appropriate.  In other some cases, locally based initiatives may be better able to change systems and reach target audiences.  States may wish to support such groups in addition to or as an alternative to a statewide group.

2.  States will seek appropriate resources to fund and staff such groups as a continuing process. 

E.  Education

Education is a crucial aspect of the response to asthma, as many parties and participants need to know what to do for an intervention program to be effective.  Families of children with asthma in particular need information about how to reduce children's exposure to indoor and outdoor triggers.

1.  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 help them reduce triggers, recognize attacks and take appropriate action, know how to interact with health care providers, and recognize any side effects of medication (17).  The states will seek to develop programs that are competent in the diverse languages and cultures of America's children.

2.  In cooperation with education authorities, state health and environment agencies will seek to develop and implement education programs for personnel at child care centers and schools to improve the indoor environment to reduce triggers and to support effective action in case of attacks. 

3.  States will seek to ensure that local environmental staff have adequate training in inspecting homes, schools, child care centers, workplaces, and other buildings for indoor air quality, including asthma triggers.

4.  State will seek to ensure that state and local environmental health staff are aware of asthma-related resources available in the county or state.

5.  States will seek to ensure that health professionals who make home visits (such as social workers or home health nurses) are adequately trained to recognize asthma triggers in homes, provide educational materials for parents, and recommend resources to resolve more serious problems.

F.  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 other fungi may occur in buildings with water penetration or inadequate ventilation, in any climate.  Cockroaches are more common in poorly maintained buildings.  For detached buildings, individual families or building managers may be able to take remedial actions.  Low-income families are particularly in need of assistance to remedy such problems.   For larger buildings, families may need to seek action from landlords or housing or health authorities.

1.  Environmental tobacco smoke: 

a.  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 elimination of smoking. 

b.  States will seek to make smoking cessation programs readily available and affordable for any parent of a child with asthma.

c.  States will seek to make persons such as social workers or home health aides who work with parents and families aware of resources available to support smoking cessation.

d.  States will seek to ensure that smoking prohibitions in schools and child  care facilities are enforced and that smoking is prohibited at school-sponsored events held away from school facilities such as sporting events or field trips. 

e.  States will seek to improve protection of the public from environmental tobacco smoke by reducing or eliminating smoking in public buildings and facilities, particularly those such as restaurants, retail stores, shopping malls, and fast-food facilities that children are likely to frequent.

f.  States will seek to partner with statewide and local tobacco control groups and coalitions to ensure that effective and consistent public health messages regarding smoking are delivered to reduce smoking.

2.  Building factors:  Dampness, mold, cockroaches

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

b.  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. 

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

d.  States will seek to incorporate provisions for good indoor air quality into their rules and programs for sanitation and public health. 

3.  Household factors:  Dust mites, animals, products used in the home, cooking practices

Dust mites can be found in bedding, particularly in bedding that is not sealed and frequently washed at high temperature.  Animal dander is found in homes of children with animals.  A variety of chemical products used in the home, particularly those with volatile components, may trigger asthma attacks in some cases.   Use of poorly vented stoves or heating devices can result in accumulation of air pollutants that may trigger asthma.

These conditions generally need to be addressed through the home management and housekeeping practices of individual families.

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

b.  States will seek to see that reimbursement from public and private insurers is provided for scientifically proven, low-cost interventions that reduce or eliminate asthma triggers.  Such measures would include pillow and mattress covers, reduction in dampness, or cockroach abatement.

4.  Home Visits and Assistance

Several states have environmental health staff that visit homes of children with asthma to identify possible sources of triggers and to identify remedies. 

a.  States will seek to improve coordination between health providers (such as physicians, school nurses, etc) who identify children with asthma, and environment and health agencies, which provide the in-home assistance.

b.  States will consider whether home visits and assistance would be useful and effective components of programs to address asthma.  In jurisdictions where local health, environment, or sanitation officers are suited to perform these functions, states may wish to consider whether funding to support additional visits or inspections would be an effective way to achieve improved capacity.

G.  School Programs

School nurses play an important role in both recognizing children with asthma, in helping children with their care, and in educating parents and others.  Programs that provide resources for nurses can be valuable components for schools.

The "Tools for Schools" program developed by US EPA provides a model for how school personnel can identify sources of triggers and take actions to reduce them. 

The "Open Airways" program from the American Lung Association provides a model for how schools can plan to work with children and their families to control asthma and to reduce mortality and hospital visits.  There are also additional models from curricula developed by states and other organizations for use in schools.

1.  State health and environment authorities will consider working with state and local education authorities to bring asthma management and trigger reduction programs, including those that assist school nurses, to schools.  Schools in areas with high rates of asthma may be appropriate to target first. 

2.  In cooperation with education authorities, state health and environment agencies will seek to ensure adequate resources for school facility maintenance and health improvement projects.

H.  Child Care Programs

1.  State health and environment authorities will consider working with child-care centers, including both commercial and licensed residential facilities, to incorporate asthma management and trigger reduction programs.  Areas with high rates of asthma may be appropriate to target first.  States may consider funding to assist child-care facilities with repair or correction of building deficiencies that contribute to asthma triggers.

I.  Action and Practices to Reduce Outdoor Environmental Triggers

Common outdoor air pollutants have been shown to be associated with exacerbation of asthma.  Adverse effects may occur at concentrations below currently adopted National Air Quality Standards.  Coordination between health and environment authorities could contribute to the identification of where areas with high concentrations of air pollution are located.  Several states 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. 

1.  State environmental agencies will strive to 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.

2.  States may wish to consider alternative transportation strategies to reduce vehicular pollution, particularly from diesel, where this appears to be a significant concern.  These could include increased sharing of rides, use of carpool lanes, and measures to increase walking and bicycling.  Some federal funding is available to support such programs (through TEA-21).

3.  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.

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

5.  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. 

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

7.  States will seek to educate and mobilize the public.

8.  States will seek to improve control of sources of air pollutants that trigger asthma.  In some states, interstate sources may be important.

J.  Defining, Measuring, Achieving Results

Evaluation and testing of intervention and education programs is a critical need to ensure that resources are devoted to efforts that will achieve results.

1.  The states recommend that review and evaluation of the effectiveness of intervention and education programs be conducted and results shared among the states.

K.  Research

1.  The states recommend that additional studies be conducted to determine the efficacy of programs that reduce exposures to asthma triggers.

2.  The states recommend that additional studies be conducted to determine the causes of onset of asthma.

L.  Future Needs and Directions

1.  The States request that federal agencies with jurisdiction and resources related to health and the environment develop, in consultation with the states, ways to support state efforts to better coordinate health and environment activities to address asthma, through funding and technical assistance.

2.  The States will seek to obtain sufficient funding to carry out programs that effectively address asthma, both through their own funding and through enhanced federal funding.

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 1992; 101:362S-367S.

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

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 (JAMA) 1992; 268:2673-7.

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

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

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

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

9.     Institute of Medicine. Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National Academy Press, 2000.

10.   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 2001; 12:200-8.

11.   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 1996; 154:300-7.

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

13.   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 1999; 54:320-9.

14.   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 1997; 105:622-35.

15.   WHO. WHO Prevention of Allergy and Asthma Interim Report. Geneva: World Health Organization, Management of Noncommunicable Diseases Department, Chronic Respiratory Diseases and Arthritis, 2000.

16.   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 2001; 7:20-6.

17.   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 Noncommunicable Diseases Department, Chronic Respiratory Diseases and Arthritis, 2000.

Updated July 30, 2001

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