Action Against Asthma: A Strategic Plan for the Department of Health and Human Services . Epidemic of a Chronic Disease

05/01/2000

The Growing Problem of Asthma

Asthma is a chronic inflammatory lung disease characterized by recurrent episodes of breathlessness, wheezing, coughing, and chest tightness, termed exacerbations. The severity of exacerbations can range from mild to life threatening. Exacerbations can be triggered by exposures and conditions such as: respiratory infections, house dust mites, cockroaches, animal dander, mold, pollen, cold air, exercise, stress, tobacco smoke and indoor and outdoor air pollutants . Both the frequency and severity of asthma symptoms can be reduced by using medications and reducing exposure to environmental triggers.

Ongoing preventive management is needed for patients with persistent asthma, even when mild. Learning how to manage asthma as a chronic disease is a major challenge for patients, as well as for health care providers and others involved in asthma care.

An epidemic of asthma is underway in the United States. The number of people with asthma has more than doubled in the past 15 years. Even if rates were to stabilize, asthma would continue to be a profound public health problem.

For the past 15 years, an epidemic of asthma has been underway in the United States. The steady rise in the prevalence of asthma constitutes an epidemic, which by all indications is continuing. Even if rates were to stabilize, asthma would continue to be a profound public health problem. It is a potentially fatal, chronic disease responsible for over 1.8 million emergency room visits per year, over 460 thousand hospitalizations per year and over five thousand deaths per year (4). Although the burden asthma affects Americans of all ages, races and ethnic groups, recent data indicate that children, low-income and minority (4) populations have been most severely affected. (5)

Figure 1. Estimated average annual number of persons with self-reported asthma during the preceding 12 months by age group, United States, National Health Interview Survey, 1980-1994.

Figure 1. Estimated average annual number of persons with self-reported asthma during the preceding 12 months by age group, United States, National Health Interview Survey, 1980-1994.

Source: Morbidity and Mortality Weekly Report, Vol. 47, No. SS-1, April 24, 1998.

National survey data - the responses of randomly selected US residents when asked whether they had symptoms of physician-diagnosed asthma in the previous 12 months -- indicate that the number of people with asthma in the United States has more than doubled in the past 15 years (see figure 1). In 1980, 6.8 million Americans had asthma. By 1996, the number had risen to 14.6 million (5). Rates of asthma are increasing in all age groups, among both men and women, and across all racial and ethnic groups (4) (see figure 2). Total deaths from asthma have also risen, from a low of 1,674 in 1977, to 5,637 in 1995 (4) (see figure 3).

Asthma is a common chronic disease of childhood, affecting an estimated 4.4 million children (6). In the United States, the prevalence of asthma is slightly higher in boys than in girls under age 18. Asthma is more common in school-aged children than in preschool-aged children or adults. However, the most rapid increase in cases of asthma are occurring in children under five years old, with rates increasing over 160 percent between 1980 and 1994 (4).

Figure 2. Estimated average annual rate of self-reported asthma during the preceding 12 months by age group, United States, National Health Interview Survey, 1980-1994.

Figure 2. Estimated average annual rate of self-reported asthma during the preceding 12 months by age group, United States, National Health Interview Survey, 1980-1994.

Source: Morbidity and Mortality Weekly Report, Vol. 47, No. SS-1, April 24, 1998.

Asthma remains a common problem in adults, reflecting the persistence of childhood asthma and the new cases that develop in adulthood . Among adults, women of all races suffer greater asthma mortality and morbidity than men. Occupational asthma, or the new onset of asthma due to conditions at the workplace , has become the most common occupational lung disease (7, 8, 9, 10, 11). Recent studies in the U.S. have found that in working adults, 6 to 21 percent of new onset asthma is attributable to occupational asthma (12, 13, 14). Depending on the type and intensity of work exposures, the frequency of occupational asthma may be very high in some industrial settings (e.g., about 25 percent in one group of platinum-refinery workers); in other industries, only sporadic cases may be reported (15).

Figure 3. Average number of deaths with asthma as the underlying cause of death diagnosis, by age group, United States, Underlying Cause of Death dataset, 1960-1995.

Figure 3. Average number of deaths with asthma as the underlying cause of death diagnosis, by age group, United States, Underlying Cause of Death dataset, 1960-1995.

Source: Morbidity and Mortality Weekly Report, Vol. 47, No. SS-1, April 24, 1998.

Disproportionate Burden of Asthma Among Minority Groups and Those Living in Poverty

In the most recent years for which data are available, African Americans were slightly more likely to have asthma than were whites, with prevalence rates of 58.8 per 1,000 population and 50.8 per 1,000 respectively (4). However, it is disturbing to note that African Americans are much more likely to die from asthma than whites (4) . From 1993 through 1995, the death rate from asthma in African Americans of 38.5 per million was over twice the rate of 15.1 per million in white Americans (4) (see figure 4). Among children, the disparity was even greater: African American children were over four times as likely to die from asthma as were white American children (16). In the Northeast, Hispanics had a death rate of 34 per million (17).

Although asthma affects Americans of all ages, races, and ethnic groups, low-income and minority populations experience substantially higher rates of fatalities, hospital admissions, and emergency room visits due to asthma.

Figure 4. Rates of death with asthma as the underlying cause of death diagnosis, by race, United States, Underlying Cause of Death dataset, 1979-1995.

Figure 4. Rates of death with asthma as the underlying cause of death diagnosis, by race, United States, Underlying Cause of Death dataset, 1979-1995.

Source: Morbidity and Mortality Weekly Report, Vol. 47, No. SS-1, April 24, 1998.

Hospitalizations and emergency room visits for asthma demonstrate the disparity in the impact of asthma among different racial and ethnic groups. African Americans have an annual rate of hospitalization of 35.5 per 10,000, nearly four times that for whites (10.9 per 10,000) (see figure 5). African Americans are approximately five times more likely than white Americans to seek care for asthma at an emergency room (4) .

Studies examining the link between socioeconomic status and asthma confirm that the impacts of asthma are greatest on low income populations (18, 19, 20, 21). For example, in the U.S. in 1996, pediatric hospitalizations for asthma were estimated to be five times higher for children in lower income families (22). The National Cooperative Inner-City Asthma study demonstrated that over 50% of study participants, who were poor children living in inner cities, found it difficult to get follow-up asthma care. Among those with severe asthma, less than half were using anti-inflammatory medication (23, 24).

Figure 5. Estimated average rates of hospitalization for asthma as the first-listed diagnosis, by race, United States, National Hospital Discharge Survey, 1979-1994.

Figure 5. Estimated average rates of hospitalization for asthma as the first-listed diagnosis, by race, United States, National Hospital Discharge Survey, 1979-1994.

Source: Morbidity and Mortality Weekly Report, Vol. 47, No. SS-1, April 24, 1998.

Health Impairment from Asthma Not Fully Captured by Hospital or Emergency Room Visits

These measures -- rates of death, hospitalization, and emergency room visits -- give an incomplete picture of the true burden of asthma in the United States. Asthma symptoms that are not severe enough to require a visit to an emergency room can still be severe enough to restrict activities and affect quality of life . Asthma is responsible for 10 million physician office visits and 134 million days of restricted activities per year (4, 25). Children with asthma miss over 10 million school days annually, making asthma one of the leading causes of school absenteeism (26). Asthma in children also accounts for many lost nights of sleep, disrupts family and caregiver routines, including lost work days. Asthma in adults, including occupational asthma, has consequences of lost work time, job loss, disability and premature death (23, 27).

Data Tracking Asthma are Insufficient

Public health officials need to understand changes in rates of disease in different locations or populations in order to target health services and public health programs where they are most needed, to help evaluate the success of intervention efforts, and to provide clues about risk factors. At the present time, surveillance of asthma -- the systematic collection, evaluation and dissemination of data to track the occurrence and severity of the disease -- is limited to analyses of ongoing surveys and data systems on health events such as mortality, hospitalization, and outpatient visits. These data are typically several years out of date when they become available, and only provide national estimates. With the exception of recent work in several states to examine hospitalization and emergency room visits for asthma, data that would allow comparisons among states or cities are available only for deaths due to asthma.

Cost of Asthma to the U.S. Economy: Eleven Billion Dollars Annually

Estimating the costs of asthma is one way to measure its health burden. In 1990, the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority attributed to direct medical expenses, such as hospitalization, physician and nursing care, and medication (27). In 1998, the National Heart, Lung and Blood Institute (NHLBI) estimated that the annual costs of asthma were $11.3 billion per year. This estimate includes $7.5 billion in direct medical expenses and $3.8 billion in indirect expenses, such as lost workdays for adults with asthma and lifetime earnings lost due to mortality from asthma (28).

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