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

05/01/2000

1. Research

Strengthen and accelerate focused research into the environmental factors that cause or worsen childhood asthma.

Expand Research Into the Environmental Factors That Contribute to the Onset of Asthma in Children.

Though progress has been made in understanding what causes asthma, there is currently insufficient scientific information to establish specific guidelines and recommendations for public health practices to prevent the onset of asthma in children (i.e. primary prevention).

In order to establish primary prevention guidelines, the top priority for research is to determine the causes of asthma in children and particularly the role of the environment. To understand what causes asthma, research must identify the basic cellular and molecular mechanisms that cause airway inflammation and sensitization and, in particular, the interaction of environmental exposures and genetic susceptibility. In addition, clinical and epidemiologic studies are needed to examine the relationship between environmental exposures and the onset of asthma.

Because of promising preliminary work on the relationship of indoor allergens and asthma onset, as well as the much greater proportion of time that children spend indoors, greater emphasis on examining the relationship of indoor exposures to the development of asthma is warranted. Exposures to high levels of allergens in the indoor environment have been shown in some studies to be associated with the subsequent development of asthma. However, few studies have examined the importance, by geography, of particular allergens. In studies evaluating the role of indoor allergens on exacerbations of asthma, different allergens, such as those associated with cockroaches, dust mites, and mold, have been implicated in different cities. This suggests that different allergens can exacerbate asthma, and that different allergens may be capable of inducing the new onset of asthma.

1. Research

Strengthen and accelerate focused research into the environmental factors that cause or worsen childhood asthma.

Expand Research Into the Environmental Factors That Contribute to the Onset of Asthma in Children.

Though progress has been made in understanding what causes asthma, there is currently insufficient scientific information to establish specific guidelines and recommendations for public health practices to prevent the onset of asthma in children (i.e. primary prevention).

In order to establish primary prevention guidelines, the top priority for research is to determine the causes of asthma in children and particularly the role of the environment. To understand what causes asthma, research must identify the basic cellular and molecular mechanisms that cause airway inflammation and sensitization and, in particular, the interaction of environmental exposures and genetic susceptibility. In addition, clinical and epidemiologic studies are needed to examine the relationship between environmental exposures and the onset of asthma.

Because of promising preliminary work on the relationship of indoor allergens and asthma onset, as well as the much greater proportion of time that children spend indoors, greater emphasis on examining the relationship of indoor exposures to the development of asthma is warranted. Exposures to high levels of allergens in the indoor environment have been shown in some studies to be associated with the subsequent development of asthma. However, few studies have examined the importance, by geography, of particular allergens. In studies evaluating the role of indoor allergens on exacerbations of asthma, different allergens, such as those associated with cockroaches, dust mites, and mold, have been implicated in different cities. This suggests that different allergens can exacerbate asthma, and that different allergens may be capable of inducing the new onset of asthma.

In one study (Hyde, et al, 1997) avoiding exposure to dust mite and food allergens early in life was found to reduce the risk of developing asthma in the first year of life. However, this effect was not statistically significant at 2 to 4 years of age. Whether such allergen avoidance strategies are feasible and effective in reducing the development of asthma is not known. The complex interactions between outdoor air pollutants and allergens and the development of asthma have not been adequately evaluated. Some epidemiologic studies have suggested a relationship between exposure to volatile organic compounds and prevalence rates of childhood asthma. Because adult-onset asthma is known to be associated with occupational exposures to volatile organic compounds including formaldehyde, ethylene oxide, and isocyanates, further work to assess the possible etiologic role of specific pollutants in childhood asthma is appropriate.

Expand and Accelerate Research To Develop and Evaluate Environmental Strategies That Will Improve the Quality of Life for Children with Asthma.

It is well established that inhaled allergens and irritants and outdoor pollutants provoke asthma symptoms. Research is needed to identify if other environmental exposures are significant. Further, the relative importance of various exposures is not well understood. Cost effective strategies for reducing exposures are not well developed.

Patient education strategies in certain populations have profound impacts on reducing the frequency and severity of exacerbations and improving the quality of life for children. But many of these programs are not responsive to the cultural, ethnic, and economic diversity of the American population. Innovative strategies are urgently needed for reaching a wide range of children and their families, for tailoring recommendations for reducing environmental exposures to their needs, and for providing support to follow the recommendations.

2. Programs to Improve Public Health

Implement public health programs that improve use of scientific knowledge to prevent and reduce the severity of asthma symptoms by reducing environmental exposures.

Promote Clinician and Patient Implementation of National Guidelines for Reducing Environmental Risks That Worsen Asthma.

Despite uncertainty about the causes of the increase in asthma prevalence rates, much can and should be done to prevent severe illness and death from asthma and improve the quality of life of persons with asthma. Experts convened by the National Asthma Education and Prevention Program (NAEPP) coordinated by the National Institutes of Health (NIH) have reviewed the scientific literature and produced guidelines for managing asthma. These include specific recommendations for controlling environmental factors that contribute to asthma severity.

While there is consensus that NAEPP guidelines define the best diagnosis and management practices for asthma, dissemination of the guidelines must be expanded and adoption improved. Many clinicians do not include advice about environmental control in their patient education. Among families who do receive recommendations, adherence is generally low. Asthma is highly variable, and families need help establishing priorities for environmental control measures that will be suitable for their individual child’s asthma and their family circumstances. Effective public health programs can provide this education and support.

For children without access to quality health care, appropriate instruction on the environmental triggers of asthma is impossible or severely limited. Emergency rooms or urgent care facilities may serve as the only source of primary care for such children. These settings should be recruited to provide the kind of education and links to chronic disease management services that are essential to reducing the severity and frequency of asthma attacks.

Expand Support for State and Local Public Health Action.

Recent advances in the treatment of asthma and in identifying the environmental triggers of asthma attacks make it possible to control and prevent symptoms at a level unheard of just ten years ago. But these gains have not been realized by many of our children. Public health agencies have a critical role in helping to reduce environmental factors affecting asthma and the human and financial toll of the disease. These programs should include the following components:

(1) Education and training
(2) Asthma surveillance
(3) Coalitions for prevention

Reduce Children’s Exposure to Environmental Tobacco Smoke and Other Indoor Triggers in Their Homes.

Secondhand tobacco smoke and indoor allergens are major contributors to the incidence of wheezing in young children and play a significant role in the number and severity of asthma attacks. Reducing smoking in homes with young children will improve the health status of the estimated 2 million children with asthma who are exposed to secondhand smoke. In addition, exposure to allergens such as cockroach, house dust mite, mold, and animal dander causes many attacks of asthma that are preventable.

Establish School Based Asthma Programs in Every Community.

The educational system is a critical component of effective efforts to reduce illness due to asthma in children. Programs will be implemented in schools to assure a healthy physical environment at the school and to promote improved self-management of asthma through education.

Continue to Reduce Outdoor air Pollution

The U.S. EPA set national ambient air quality standards (NAAQS) for six air pollutants in 1971, in part based on evidence of associations between air pollutants such as ozone, particulate matter, and sulfur dioxide and asthma. Since that time substantial new epidemiological evidence has been published supporting the association between levels of ozone and particulate matter and increased hospitalization for respiratory causes, such as childhood asthma. In 1997, NAAQS for both ozone and particulate matter were strengthened to improve the protection afforded by these standards and to help reduce the risk of ambient exposures that aggravate asthma in children.

Federal, State, local, and private sector efforts to implement the original NAAQS resulted in substantial improvements in air quality, yet notable problems remain. Following the 1990 Clean Air Act Amendments, efforts were expanded to improve nationwide air quality and reduce related health effects. In conjunction with the strengthening of the ozone and particulate matter NAAQS, EPA has taken steps to integrate implementation measures for these pollutants and to improve the effectiveness of control programs. EPA has also taken steps to inform the public about air pollution that may affect children.

3. Surveillance

Establish a coordinated nationwide asthma surveillance system for collecting and analyzing health outcome and risk factor data at the state, regional and local levels.

Current national surveillance permits tracking of asthma prevalence, asthma physician office visits, asthma emergency room visits, asthma hospitalizations and asthma mortality at a national level and in four geographic regions (i.e., Northeast, Midwest, South, and West) through surveys conducted by the National Center for Health Statistics. Surveillance information on asthma, with the exception of mortality data, are not available at the state or local level. This information is needed to identify high risk populations and environmental risk factors of relevance to particular communities and to design and implement interventions that will be most suitable for, and therefore most likely to succeed, in that community. State and local health agencies also need this information to evaluate the impact of local sources of air pollution on childhood asthma in specific communities. A significantly enhanced and expanded surveillance program will be essential to study issues related to race and gender differences in asthma morbidity and mortality among children, identify gaps in providing comprehensive care, and monitor trends in asthma morbidity and mortality at the community level.

4. Disproportionate Impacts on the Poor and Minorities

Identify the reasons for and eliminate the disproportionate burden of asthma among different racial and ethnic groups and those living in poverty.

Poor and minority children are disproportionately affected by asthma, which has reached epidemic proportions in many American inner cities. Prevalence rates vary only by a few percentage points among different race and ethnic groups, yet emergency room use, hospitalization, and mortality rates vary 3- to 4-fold. Understanding the factors that contribute to the disproportionate impact of asthma on minority and lower income populations is the critical first step to reducing and eventually eliminating the disparities between rich and poor, minority and non-minority children. Such factors may include differing intensities of environmental exposures, such as exposure to cockroach antigen and access to and quality of care, among others.

Improve Asthma Management for Children Within the Medicaid Program.

Disease management combines prevention, intensive attention to treatment and patient compliance, and guidance for self-care. This concept has considerable promise for reducing the frequency and severity of asthma attacks. Integrating an asthma disease management initiative within the fee-for-service component of Medicaid would demonstrate the efficacy of this approach in improving children’s health.

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