Action Against Asthma: A Strategic Plan for the Department of Health and Human Services . Introduction


The Growing Problem of Asthma in Children

Asthma is a chronic inflammatory lung disease characterized by recurrent episodes of breathlessness, wheezing, coughing, and chest tightness; these episodes are also known as exacerbations or attacks. The severity of exacerbations can range from mild to life threatening. Both the frequency and severity of asthma symptoms can be reduced by the use of medications and by reducing exposure to the environmental triggers of asthma attacks.

For the past 15 years, an epidemic of asthma has occurred in the United States. By all indications, this epidemic is continuing. Although asthma has become a major public health problem affecting Americans of all ages, races and ethnic groups, children have been particularly severely affected.

National survey data indicate that the number of children with asthma in the United States has more than doubled in the past 15 years. In 1980, 2.3 million American children had asthma. In 1995, the most recent year for which data are available, the number of affected children had risen to 5.5 million. Based on these trends, it is estimated that in 1998 more than 6 million children in the United States have asthma. Prevalence rates of asthma are highest in boys and are increasing in both boys and girls, and in all race and ethnic groups. The prevalence of asthma in children under age 18 is 7.3%. The most rapid increase has occurred in children under 5 years old, with rates increasing over 160% over the past 15 years.

The number of deaths attributed to asthma in children has also increased. In 1977, 84 deaths in children 18 and younger were recorded; the number of deaths has risen to 280 in 1995, a more than 3-fold increase. Although the death rate due to asthma has increased in all racial and ethnic groups, minority populations experience a disproportionately higher death rate from asthma. In 1995, the death rate from asthma in African-American children, 11.5 per million, was over four times the rate in white American children, 2.6 per million. The higher death rates among African-American children are especially troubling.

The number of hospitalizations and emergency room visits for asthma have increased in all population groups. Asthma accounts for one-third of all pediatric emergency room visits and is the fourth most common cause for physician office visits. The variation in the impact of asthma across racial and ethnic groups is significant. African-American children have an annual rate of hospitalization of 74 per 10,000, over 3 times that for white children, 21 per 10,000. In addition, African-American children are approximately 4 times more likely than white children to seek care at an emergency room. In short, African-American children have a slightly higher risk of getting asthma, but have a much higher risk of hospitalization or death due to the disease.

At the present time, surveillance for asthma in children is limited to analyses of ongoing surveys and data systems on health events such as mortality, hospitalization, and outpatient visits. Other than for African Americans, such information is extremely limited for most ethnic groups. There is no national system to collect data from states specifically on asthma, although several states are developing systems to collect such data. Although national data do not provide the resolution necessary to identify particular geographic areas hardest hit by the asthma epidemic, surveys undertaken in a number of large cities in the United States indicate that the prevalence and severity of asthma are greatest in the large, urban inner cities.

These measures, particularly for death, hospitalization, and emergency room visits, give an incomplete picture of the true burden of asthma in the United States. For example, one follow-up study of children with asthma in inner city areas found a nearly 10 times higher likelihood of a child suffering symptoms of asthma on a given day than visiting an emergency room. Asthma is one of the leading causes of school absenteeism, accounting for over 10 million missed school days per year. Asthma also accounts for many nights of interrupted sleep, limitation of activity, and disruptions of family and care-giver routines. Asthma symptoms that are not severe enough to require a visit to an emergency room or to a physician can still be severe enough to prevent a child with asthma from living a fully active life.

Estimating the costs of asthma is an indirect way to measure its health burden. In 1990, the cost of asthma to the U.S. economy was estimated to be $6.2 billion (Weiss, 1992), with the majority of the expense attributed to direct medical expenses. A 1996 analysis (Farquhar, et al, 1998) found the cost of asthma to be $14 billion, indicating a rapidly increasing financial burden. These estimates indicate that the direct medical costs of asthma for all ages account for between 1% and 3% of all health care expenditures in the United States.

What We Know About Childhood Asthma

Over the past 15 years, there have been major advances in the scientific understanding of asthma. Asthma is now known to be a disease of airway inflammation resulting from a complex interplay between environmental exposures and genetic and other factors. This has implications for the medical treatment and for the environmental management of asthma.

In contrast to the limited understanding of the relationship of environmental exposures to the onset of asthma, the environmental triggers of asthma attacks for children with asthma have become increasingly well characterized. House dust mites, cockroaches, mold and animal dander have been identified as the principal allergens that trigger asthma symptoms. Reducing exposure to these allergens has been shown not only to reduce asthma symptoms and the need for medication, but also to improve lung function. Environmental tobacco smoke is an important irritant that can trigger an asthma episode and possibly worsen the effects of allergens. Upper respiratory viral infections are also recognized as important triggers for asthma episodes.

Children with asthma have long been recognized as particularly sensitive to outdoor air pollution. Many common air pollutants, such as ozone, sulfur dioxide, and particulate matter are respiratory irritants and can exacerbate asthma. Air pollution also might act synergistically with other environmental factors to worsen asthma. For  example, some evidence suggests that exposure to ozone can enhance a person’s  responsiveness to inhaled allergens. Whether long term exposure to these  pollutants can actually contribute to the development of asthma is not known.  To date, little research has examined the role of other hazardous air pollutants  (e.g., metals and volatile chemicals) in the development or exacerbation of asthma, although this is an issue of increasing public concern. In addition to improved understanding of appropriate environmental management of asthma, the medical management of asthma has changed significantly. Inhaled anti-inflammatory medications have become the mainstay of medical management to prevent asthma episodes and lessen chronic symptoms of asthma. In addition, improvements in monitoring techniques now permit objective measures of lung function that are easy for patients and physicians to use in assessing asthma severity and monitoring changes in the disease. In a disease like asthma that varies considerably over time and where changes in lung function can occur before symptoms develop, these objective measures are essential tools for making management decisions.

As a result of these advances, the medical and environmental management of asthma is better defined and the knowledge exists to manage asthma better than ever before. One especially important finding is that patient education has been documented to be cost effective. Teaching patients and their families specific management skills improves asthma management, reduces the use of emergency services, and improves quality of life. This is particularly important for asthma management, since the environmental management of asthma requires knowledge of asthma triggers and specific actions that can be undertaken to reduce exposure to these triggers. The treatment goal for almost all individuals with asthma should be for that person to lead a life unrestricted because of asthma.

Reducing exposure to environmental allergens and pollutants will reduce the frequency and severity of attacks for children with asthma, reduce their need for medicine, and improve their lung function. Children are exposed to many environmental agents that could trigger asthma attacks. For example, 25% of children in America live in areas that regularly exceed EPA limits for ozone. Approximately 29% of households still permit exposure of children to secondhand smoke in the home on a regular basis and exposure to environmental tobacco smoke is so widespread that approximately 88% of all children have some level of documented exposure (Pirkle, 1996). A high proportion of children living in the inner city are exposed to high levels of cockroach antigen.

Why Has Asthma Reached Epidemic Proportions in Children?

The causes of the increasing rate of asthma over the past 15 years and the particular role that environmental exposures play are not known, but there are some clues. Atopy, the genetically inherited susceptibility to become allergic, is the most important predictor of a child developing asthma. A substantial research effort is underway to identify the genes that are responsible for susceptibility to asthma. Because the genetic make-up of the population changes slowly, genetic susceptibility alone cannot be responsible for the epidemic of asthma that has occurred in the United States over the past 15 years. Further work is essential to clarify how genetic susceptibility and environmental exposures interact to cause asthma. Factors such as the intensity of environmental exposure and the age of the person being exposed are likely to be important.

Exposure to allergens found indoors is a strong risk factor for developing asthma. Children are spending increasing amounts of time indoors, thus increasing their exposure to indoor allergens.

The environmental exposures most strongly suspected of causing asthma to develop include environmental tobacco smoke and allergens such as house dust mites, cockroaches, mold, and animal dander. Exposures that stimulate the immune system may also be significant, such as diet during the prenatal period and early infancy, the pattern of respiratory infections early in life, and even decreasing rates of exercise have all been suggested as risk factors for the development of asthma.

Scope of the Strategy

This strategy is about protecting children from the environmental risk factors that make their asthma worse. Environmental action may also help prevent asthma. To accomplish this goal, the environmental aspects of asthma must be considered in the context of other aspects of asthma prevention and management, such as access to quality medical care and efforts to understand the disproportionate health impact of asthma among minority populations. Childhood asthma is a multi-factorial disease, and efforts to improve its management and to prevent it will require multi-dimensional, multi-disciplinary efforts that must occur simultaneously. This Asthma and the Environment strategy focuses on improving the environment in which children with asthma live, learn, play and work. Environmental action, along with medical care, will help children with asthma live productive, active lives and may spare future generations of children from the disease altogether. The Task Force has prepared the following four goals to be accomplished in the next ten years, guided by the vision that in the 21st century, every child in America will live, learn, work, and play in environments that do not cause or worsen asthma.

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