Breathing Easy: Solutions in Pediatric Asthma, by Lauren Raskin

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Breathing Easy: Solutions in Pediatric Asthma
Lauren Raskin, M.P.H.

National Center for Education in Maternal and Child Health

Georgetown University

February 2000

Table of Contents

Introduction
Table 1: Snapshot of Pediatric Asthma

What is Asthma?
Why is Asthma an Important Health Concern?

Table 2: Prevalence of Pediatric Asthma

The Costs of Asthma

Table 3: Costs Associated with Pediatric Asthma

What is Being Done About Pediatric Asthma?

Federal Initiatives

Table 4: Healthy People 2010 Objectives

Regulatory and Legislative Efforts

Surveillance and Research

Medical Community

Asthma Program Initiatives

Conclusion

References

Appendix A: Innovations in Pediatric Asthma

Initiatives Sponsored by the U.S. Environmental Protection Agency
Initiatives Sponsored by the Centers for Disease Control and Prevention

Initiatives Sponsored by the Maternal and Child Health Bureau

Other Federal and Organizational Initiatives

Appendix B: Organizations Working in Asthma

Advocacy and Education
Professional Associations

Governmental Organizations

Data and Statistics

Introduction

Asthma is the most common chronic disease of childhood and is responsible for significant morbidity and health care expenditures,^a. The prevalence of asthma, especially pediatric asthma, has increased dramatically in the United States since 1980. The rate of asthma in children less than 5 years of age has risen by 160 percent over the past 15 years,and asthma is now considered a national epidemic¹. The rate of asthma-related deaths has also increased. Among 5- to 14-year-olds the rate of asthma-related deaths doubled from 1980 to 1993.² The alarming increase in asthma prevalence, and, consequently, in asthma-related deaths and health expenditures has prompted widespread efforts to address the problem in the public health, medical, and policy sectors. Federal agencies, professional associations, community-based organizations, and policymakers are focusing attention on programs and policies to reduce asthma-related morbidity and costs.

The recent push to address pediatric asthma is beginning to yield promising results. However, more preventive approaches are needed. Continued attempts to create bridges across disciplines (including families and communities) must also be made if pediatric asthma is to be managed appropriately. This paper provides an overview of the factors contributing to the prevalence of pediatric asthma and highlights select asthma-prevention and management initiatives. Contact and other information for organizations working in asthma prevention and education are included in the appendices.

Table 1: A Snapshot of Pediatric Asthma

Asthma is a chronic disease caused by a combination of allergenic, genetic, environmental, infectious, and socioeconomic influences. It is triggered by allergies or stimuli in the environment.

Over 5.3 million U.S. children less than 18 years of age suffer from asthma,³ and the rate of asthma in children less than 5 years of age has increased by 160 percent over the past 15 years.¹

The asthma costs to the United States in 1998 were $11.3 billion.⁴

Asthma accounts for 14 million ambulatory care visits per year⁵ and for one in six pediatric emergency visits.³

Nearly 25 percent of U.S. children live in areas that do not meet national air quality standards.⁶ African-American, Hispanic, and Asian/Pacific Islander children are also disproportionately represented in areas where ozone levels are unacceptable.

Over 50 percent of U.S. schools have indoor-air-quality problems, which potentially diminish a child’s health and ability to learn.

What Is Asthma?

Asthma is a chronic disease of the passageways (known as airways) that carry air to the lungs. When asthma strikes, these airways become constricted, and their linings become swollen, irritated, and inflamed. Asthma is a complex condition caused by a combination of allergenic, genetic, environmental, infectious, and socioeconomic influences. While little is known about the factors that influence asthma’s development, we have a better understanding of the agents that contribute to its exacerbation. These agents stem from an allergic basis or from stimuli in the environment; they include allergens, tobacco smoke, airway infections, ozone, sulfur dioxide, particulate matter, dust, molds, pollen, cockroaches, exercise, and emotional stress.

Indoor and outdoor air quality is believed to be a major contributor to pediatric asthma. Compared to outdoor air pollutants, indoor air pollutants such as environmental tobacco smoke (ETS), house dust mites, and cockroaches have been shown to be more strongly associated with asthma exacerbations.^7,8 A recent Institute of Medicine report found a causal association between exposure to the allergens produced by cats, cockroaches, and house dust mites and asthma exacerbations in sensitized individuals.⁸ ETS is the most common irritant contributing to pediatric asthma exacerbation, and it is causally associated with asthma in preschool-aged children.⁹ The Centers for Disease Control and Prevention (CDC) estimates that children exposed to ETS in their homes have 18 million more days of restricted activity and 10 million more days of bed confinement, and miss 7 million more school days per year than do other children.¹⁰

Why Is Pediatric Asthma an Important Health Concern?

Children are particularly vulnerable to environmental influences because of their narrow airways and rapid respiration rate. Compared to adults, children’s fast metabolism, ongoing physical development, and daily behavior place them at increased risk from exposure to environmental pollutants. Moreover, exposures that may not harm adults can cause permanent damage in children.¹¹

Asthma is a condition that disproportionately affects children and minorities. Over 5.3 million American children less than 18 years of age have asthma.³ The condition is 26 percent more prevalent among African-American children than it is among their white counterparts, and African-American children experience more severe disability and are hospitalized more frequently as a result of asthma than white children.¹² Asthma-related mortality is also significantly higher among African-American children than among their white counterparts. In 1995 the asthma-related death rate for African-American children was 11.5 per million, compared to 2.6 per million for white children.¹

Table 2: Prevalence of Pediatric Asthma

Asthma is 26 percent more common among African-American children than among white children, and African-American children experience more severe disabilities and are hospitalized more frequently as a result of asthma than white children.¹²

Asthma-related mortality is significantly higher among African Americans than among whites. African Americans ages 5 to 24 years are four to six times more likely to die from asthma than are whites.²

In 1995 the rate of asthma-related deaths among African-American children was 11.5 per million, compared to 2.6 per million for white children.¹

The combination of poverty and environmental exposure (e.g., to high levels of indoor and outdoor pollution) place nonwhite children (who are more likely than white children to be from families with low incomes) at risk for illness. African-American, Hispanic, and Asian/Pacific Islander children are disproportionately represented in areas in which ozone levels are unacceptable.¹³ Poverty compounds the effects of environmental exposure because poverty is often associated with poor housing conditions, increased environmental degradation, inadequate nutrition, and limited access to health care.

The Costs of Asthma

The costs of asthma management include direct health care expenditures and the indirect costs associated with decreased productivity and quality of life. In 1990 asthma cost the United States $6.2 billion, of which 43 percent was associated with emergency room use, hospitalization, and death.¹⁴ In 1998 this figure rose to an estimated $11.3 billion, with direct costs accounting for $7.5 billion and indirect costs accounting for $3.2 billion.⁴Hospitalizations represented the single largest portion of this cost. The estimated annual cost of treating pediatric asthma (in children less than 18 years of age) is $3.2 billion.³ The disproportionate use of the health care system among children and minorities suffering from asthma is also well documented. Asthma accounts for 14 million ambulatory care visits per year⁵ and for one in six pediatric emergency visits.³ Asthma hospitalization rates are three times higher among African-American children than among their white counterparts (74 per 10,000 vs. 21 per 10,000, respectively).¹ In general, children with asthma use considerably more medical services than do other children. One study reported that the former were given 3.1 times as many prescriptions and had 1.9 times as many ambulatory visits and 3.5 times as many hospitalizations as the latter.¹⁵

Asthma poses significant limitations on quality of life for many children and families. It is the most common reason for school absence; it is responsible for 10 million lost school days each year and results in an estimated $1 billion in medical costs and missed time from work and school.³ Asthma affects children’s physical and psychological functioning and can limit and disrupt usual activities. The impact of asthma extends to caregivers, families, and communities; it directly affects the child’s education and attendance, requires parents to miss work, and can negatively affect school funding. Data from the National Cooperative Inner-City Asthma Study (NCICAS) show a reciprocal influence of psychosocial factors, such as social support and life stress, on children’s asthma morbidity and their caregivers’ ability to successfully manage a child’s asthma.¹⁶

Table 3. Costs Associated with Asthma

In 1996 asthma cost the United States an estimated $14 billion, which accounted for 1 percent to 3 percent of all health care expenditures.¹

The estimated annual cost of treating pediatric asthma (children less than 18 years of age) is $3.2 billion.³

Asthma accounts for 14 million ambulatory care visits per year⁵ and one in six pediatric emergency visits.³

Asthma is the most common reason for school absence; it is responsible for 10 million lost school days each year and costs an estimated $1 billion per year.³

Children exposed to ETS in their homes have 18 million more days of restricted activity and 10 million more days of bed confinement than those who are not exposed, and the former miss 7 million more school days per year.¹⁰

What Is Being Done About Pediatric Asthma?

A variety of public health efforts to prevent and manage asthma are under way; these include regulatory, surveillance, and medical measures that are being put into place at the national, state, and local levels. Program initiatives are described in detail in Appendix A.

Federal Initiatives

Federal agencies play a vital leadership role in reducing environmental risks for children with asthma or who are at risk for developing asthma. In April 1997 President Clinton’s Executive Order 13045 on Protection of Children from Environmental Health Risks and Safety Risks directed federal agencies to assign a high priority to identifying and addressing children’s environmental health risks and resulted in the creation of the interagency Task Force on Environmental Health Risks and Safety Risks to Children. In 1997 the Environmental Protection Agency (EPA) established the Office of Children’s Health Protection (OCHP) to coordinate this national agenda.¹⁰The following year the task force declared asthma a national epidemic. It released a report, Asthma and the Environment: A Strategy to Protect Children, and formed the Asthma Priority Areas Work Group, which is co-chaired by the EPA and the Department of Health and Human Services (DHHS).

DHHS has recognized the severity of asthma as a national health problem in both Healthy People 2000. National Health Promotion and Disease Prevention Objectives and Healthy People 2010. National Health Promotion and Disease Prevention Objectives.^17,18 Table 4 includes the Healthy People 2010 objectives. In fiscal year 2000 DHHS will provide grants for state demonstration projects to test methods for improving the health of children with asthma enrolled in Medicaid and the Children’s Health Insurance Program (SCHIP).¹⁹

The Maternal and Child Health Bureau (MCHB) of the Health Resources Services Administration (HRSA), DHHS, sponsors several programs that focus on improving the quality of health care for children with asthma. Leading these efforts, the Division of Services for Children with Special Health Care Needs (DSCSHCN) of MCHB has advanced a national agenda, Measuring Success, for children with special health care needs (CSHCN) to ensure that all children receive coordinated ongoing comprehensive care within a medical home. This agenda includes a 10-year action plan and six core outcomes for the nation. These efforts influenced specific Healthy People 2010 objectives, such as increasing the proportion of CSHCN who have access to a medical home, and increasing the proportion of territories and states that have service systems for CSHCN. Future efforts will provide grants to states and community organizations to support asthma education, treatment, and prevention programs.

Table 4: Healthy People 2010 Objective¹⁸

Baseline

2010 Target

16-22. Increase the proportion of CSHCN who

have access to a medical home

16-23. Increase the proportion of territories and states that have service systems for CSHCN

1997 baseline

15.7%

100%

24-1. Reduce Asthma Deaths (rate per million)

24-1a. Children <5 years

24-1b. Children/adolescents 5 - 14 years

24-1c. Adolescents/adults 15 - 34 years

1997 baseline

1.7

3.2

5.9

1.0

1.0

3.0

24-2. Reduce Hospitalizations for Asthma (rate per 10,000)

24-2a. Children <5 years

24-2b. Children/adolescents/adults 5 - 64 years

1997 baseline

60.9

13.8

25.0

8.0

24-3. Reduce Hospital Emergency Department Visits for

Asthma (rate per 10,000)

24-3a. Children <5 years

24-3b. Children/adolescents/adults 5 - 64 years

1995 - 97 baseline

150.0

71.1

80.0

50.0

Reduce the number of school or work days missed by persons with asthma as a result of asthma

Increase the proportion of persons with asthma who receive formal patient education, including information about community and self-help resources, as an essential part of the management of their condition

1998 baseline

6.4%

30%

24-7. Increase the proportion of persons with asthma who receive appropriate asthma care according to National Asthma Education and Prevention Program (NAEPP) guidelines

24-8. Establish in at least 15 states a surveillance system for tracking asthma, illness, disability, impact of occupational and environmental factors on asthma, access to medical care, and asthma management

Regulatory and Legislative Efforts

Environmental health regulations have typically based their standards on adults, overlooking the unique vulnerabilities of children. To address this shortcoming, in 1996 the EPA, in setting health standards, began to acknowledge environmental health risks to children. Since then, attention to and legislation surrounding children’s environmental health has increased. For instance, the Clean Air Standards of 1997 mandated more rigid air-quality standards for ozone and particulate matter to account for children’s susceptibility to air pollution. The Asthma Initiative, announced in January 1999, targets pediatric asthma through increased funding of research on the environmental causes of asthma and through funding for states and providers to implement effective management strategies.²⁰ Other regulatory measures, such as mandating smoke-free environments in public places, demonstrate that significant progress can be achieved. Future changes to EPA emission standards that will go into effect in 2004 have the potential to prevent 260,000 asthma attacks per year.²¹

It was not until 1998 that state legislation targeting children’s special vulnerabilities to environmental hazards appeared. This legislation has consisted mostly of bills addressing specific issues, such as creating advisory councils on children’s environmental health, reviewing air quality, making available more asthma education, and allowing children to carry and use inhalers in schools. Currently, there are a number of proposed bills in the House, Senate, and state legislatures about children’s environmental health, several of which pertain exclusively to asthma. However, significant variations between states exist in terms of legislative action in general and in terms of the approaches taken in particular. Additional regulatory and legislative information can be obtained from the EPA Web site at <http://www.epa.gov/epahome/rules.html#legislation>

or <http://www.epa.gov/epahome/laws.htm>, from the National Conference on State Legislatures at <http://www.ncsl.org/programs/esnr>, and from the Children’s Environmental Health Network at <http://www.cehn.org>.

Surveillance and Research

Heightened surveillance is needed to inform and support appropriate legislative efforts to reduce the incidence of pediatric asthma. At present there is no national system for collecting state data, and surveillance relies primarily on survey data collected by the National Center for Health Statistics on asthma prevalence, physician office visits, emergency room visits, and hospitalization and mortality rates. Except for mortality, information on these topics is only available at the national and regional levels. Yet data on patterns of asthma occurrence at the state and local levels can provide states with the necessary information to identify high-risk populations and factors specific to communities. These data can enable states and public health professionals to design appropriate health interventions, to evaluate the impact of local air pollution, and to identify gaps in care.¹

While surveillance data are lacking overall, the National Center for Environmental Health of the Centers for Disease Control and Prevention (CDC) and the Office of Children’s Health of the EPA are leading a number of surveillance activities. Together the CDC and the EPA have funded four state health agencies (in Arizona, California, Minnesota, and Washington) and two local health departments (in Chicago, IL, and New York City, NY) to develop model surveillance programs as a first step in building state- and local-based asthma surveillance programs. Thirteen states and territories (Arizona, Delaware, Florida, Georgia, Hawaii, Maryland, Massachusetts, Minnesota, Nevada, New York, Pennsylvania, Puerto Rico, and the Virgin Islands) have identified asthma as a state priority need through their 1999 Title V Block Grant application or have initiated a state "negotiated" performance measure for asthma.

A 1996 Council of State and Territorial Epidemiologists (CSTE) and a CDC survey of state and asthma territorial surveillance and control efforts found that the majority of public health departments lacked coordinated asthma programs and that only 8 of the 51 respondents had implemented an asthma-control program in the past 10 years.⁷ Lack of funds and a shortage of staff were cited as the primary barriers to creating a program. Efforts to establish surveillance systems at the state and local levels have the potential to expand into a nationally coordinated surveillance system. Such a system would be a powerful tool for collecting health-outcome and risk-factor data at all levels, which could lead to better prevention strategies.

Medical Community

The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, was developed to improve the early detection and treatment of asthma. The NAEPP convened two expert panels to prepare evidence-based guidelines for the best diagnosis and management practices of asthma (NAEPP).²² The guidelines were released in 1991 and updated in 1997. They can be found at <http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm>. In October 1999 a consortium of pediatricians, nurses, allergists, and others produced a practical, user-friendly guide to managing asthma for physicians and children: Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children. This guide, which is based on the 1997 recommendations, is intended to promote accurate diagnosis and management of asthma and is also the first pediatric guide to be unanimously endorsed by the NAEPP, the American Academy of Pediatrics, and the American Academy of Allergy, Asthma, and Immunology.²³

Despite the existence of the NAEPP guidelines, however, studies have found low compliance for asthma care among emergency department and hospital patients, health plans, and children and families managing asthma at home, which results in more hospitalizations and increased use of the emergency department.^24,25,26 Compliance is particularly low among primary care physicians, as compared to specialists.^25,26 These findings point to a need for additional interventions to improve the dissemination of NAEPP guidelines among the medical community and to increase that community’s compliance with them. An initiative of the National Initiative for Children’s Healthcare Quality demonstrates one effort to improve the quality of care for children with asthma in the primary care setting. Their programs in Alaska, Massachusetts, North Carolina, and Vermont provide training in asthma care to practitioners and ongoing office support to help implement the guidelines. (See Appendix A for information.)

Medical efforts to increase patient education about asthma must be an ongoing priority. Current management approaches require children with asthma and their families to effectively follow complex pharmacological regimens, implement environmental control strategies at home, and detect and treat asthma exacerbations. Because of the variable nature of asthma, asthma management is more successful when families are adept at self-care - when they can recognize asthma symptoms, address exacerbations, and follow appropriate treatment plans. Data show an uneven distribution of asthma costs that are incurred as a result of unscheduled acute or emergency care, which is an indication of poor asthma management.¹⁸ There is a significant lack of understanding about medications among children with asthma and their parents, and many families do not adhere to prescribed regimens.^27,28 A study of inner-city children previously hospitalized for asthma exacerbations found that parents take their children to the emergency department without first attempting home management, and that few families have the recommended resources at home to manage their child’s asthma.²⁹ These findings highlight the need for partnerships between health professionals and families to help families implement and adhere to management plans and to help ensure that all children have a medical home. Successful interventions must also address the psychosocial factors that promote or hinder a family’s ability to manage asthma.

The importance of access to consistent, quality health care cannot be overlooked in the attempt to reduce the incidence of pediatric asthma. Children without access to such care may not receive appropriate asthma education. Families with low incomes who live in an urban environment often rely on emergency departments for primary care; this has a direct impact on the financial burden imposed by asthma. Therefore, emergency departments and urgent care facilities must provide patient education. Creating alternatives to emergency departments and urgent care facilities is critical to improving efforts to manage pediatric asthma and to reducing costs.

Asthma Program Innovations

While regulatory measures have primarily focused on improving outdoor air quality, some true innovations involving families, communities, and health professionals have made inroads into improving indoor air quality for children. Several federal and local partnerships have emerged in the past decade to address pediatric asthma in a variety of settings. Some examples include the following:

The EPA’s School Air Quality and Asthma Workshop’s "Indoor Air Quality Tools for Schools Action Kit" is a program that was launched in 1996 to help schools carry out a practical plan of action to improve indoor air quality at little or no cost using current staff.³⁰

The EPA’s Child Health Campaign Projects are designed to empower local citizens to take steps to protect children from general environmental health threats.³⁰

Open Airways for Schools, which the EPA sponsors in collaboration with the American Lung Association, is a program that teaches 8- to 11-year-olds how to detect the warning signs of asthma and the environmental factors that can trigger an attack and empowers them to manage their asthma more effectively with the assistance of parents, teachers, school nurses, and physicians.

The Healthy Tomorrows Partnership for Children is a coalition of pediatricians, parents, and other health professionals that intervene in the home environment to eliminate or control asthma allergens.

Studies such as the NCICAS, a multiphase project launched by the National Institute of Allergy and Infectious Diseases (NIAID) in 1991 to fund research centers to identify the factors responsible for the rise in pediatric asthma among children living in urban areas,³¹ can yield important data.

Certain programs, (e.g., Advances in Pediatric Pulmonary Care: Interdisciplinary Approaches to Asthma and Home Care of Technology Dependent Children, a program run by the University of Alabama at Birmingham, and the Department of Pediatrics, Children’s Hospital) focus primarily on physician education and diagnostic practices.

For a more complete list of initiatives, see Appendix A.

Conclusion

Federal and regulatory agencies, professional associations, and community-based organizations have advanced a national framework to address pediatric asthma. Innovative partnerships have emerged, and they promise to reduce the prevalence and improve the management of pediatric asthma. Yet a number of challenges remain. Heightened school- and community-based efforts are needed to promote healthy environments and to improve asthmatic children’s self-management. While treatment and management efforts are important, prevention and education must also be a priority. The development of a national tracking system to record asthma incidence, prevalence, and exposures is also vital to the success of these efforts.

Additional research is needed to identify the environmental factors that contribute to the onset of asthma and to understand the interplay of genetic susceptibility and environmental exposures, the patterns of environmental diseases in children, and the developmental process and critical periods of vulnerability in children. Other areas warranting study include the relationship between asthma prevalence and indoor exposures and the health effects of strategies that limit indoor exposures. Research into and surveillance of asthma prevalence and prevention strategies must continue to inform and influence policy. And evaluating interventions and examining their feasibility for target populations is crucial, especially to help those who may not be able to control certain aspects of their indoor environment. Although a number of needs must still be addressed, the recent emphasis on issues related to pediatric asthma shows a national commitment to improving the prevention and management of pediatric asthma, reducing health costs, and increasing the quality of life for children and families.

References
1. President’s Task Force on Environmental Health Risks and Safety Risks to Children. Asthma and the Environment: A Strategy to Protect Children. [Web site]. Cited January 5, 2000; available at http://www.epa.gov

2. Centers for Disease Control and Prevention. 1996. Asthma mortality and hospitalization among children and young adults-United States, 1980-1993. Morbidity and Mortality Weekly 45:350-353.

3. American Lung Association. 1999. Asthma in Children. [fact sheet]. [Web site]. Cited November 11, 1999; available at http://www.lungusa.org.

4. National Heart, Lung, and Blood Institute, National Institutes of Health. 1999. Data Fact Sheet. [Web site]. Cited November, 1999; available at http://www.nhlbi.nih.gov.

5. National Center for Health Statistics. 1996. Ambulatory Care Visits for Asthma: United States, 1993-94. Advanced Data Report. No. 277. [Web site]. Cited December 1, 1999; available at http://www.cdc.gov/nchs.

6. Children’s Environmental Health Network. Asthma and Respiratory Diseases. [fact sheet]. [Web site] Cited November 22, 1999; available at http://www.cehn.org.

7. Brown CM, Anderson HA, Etzel RA. 1997. Asthma: The states’ challenge. Public Health Reports 112(3):198-205.

8. Rosenstreich DL, Eggleston P, Kattan M. 1997. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. The New England Journal of Medicine 336(19):1356-63.

9. Committee on the Assessment of Asthma and Indoor Air, Institute of Medicine. 2000. Clearing the Air: Asthma and Indoor Exposures. Division of Health Promotion and Disease Prevention. Washington, DC: National Academy of Sciences.

10. U.S. Environmental Protection Agency. 1998. EPA’s Children’s Environmental Health Yearbook. [Web site]. Cited January 5, 2000; available at http://www.epa.gov/children/info/ochp_pub.htm.

11. Children’s Environmental Health Network. 1997. Children’s Environmental Health: Research Practice Prevention Policy. Conference Report. Children’s Environmental Health Network/Public Health Institute. [Web site] Cited November 22, 1999; available at http://www.cehn.org.

12. National Institute of Allergy and Infectious Diseases. 1996. Asthma: A Concern for Minority Populations. [fact sheet]. [Web site]. Cited November 11, 1999; available at http://www.niaid.nih.gov.

13. Children’s Environmental Health Network. 1997. Resource Guide on Children’s Environmental Health. Public Health Institute/Children’s Environmental Health Network.

14. Weiss KB, Gergen PJ, Hodgson TA. 1992. An economic evaluation of asthma in the U.S. The New England Journal of Medicine 326(13):862-866.

15. Lozano P, Sullivan SD, Smith DH, Weiss KB. 1999. The economic burden of asthma in US children: Estimates from the National Medical Expenditure Survey. Journal of Allergy and Clinical Immunology 104(5):957-963.

16. Weil, CM, Wade SL, Bauman, LJ. 1999. The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics 104(6):1274-1280.

17. U.S. Department of Health and Human Services. 1991. Healthy People 2000. National Health Promotion and Disease Prevention Objectives. (DHHS Publication No. (PHS) 91-50213). Washington, DC: U.S. Government Printing Office.

18. U.S. Department of Health and Human Services. 2000. Healthy People 2010. National Health Promotion and Disease Prevention Objectives. [Web site]. Cited May 2000; available at http://www.health.gov/healthypeople.

19. U.S. Department of Health and Human Services. 1999. HHS Targets Efforts on Asthma. [fact sheet]. [Web site]. Cited January 10, 2000; available at http://www.hhs.gov.

20. Andersen G. 1999. Children’s Health and the Environment. Environmental Health Series. No. 2. National Council of State Legislatures.

21. Kaiser Family Foundation. 1999. New EPA Standards Will Help Americans Breathe Easier. [Press Release]. [Web site]. Cited December 22, 1999; available at http://www.kff.org.

22. National, Heart, Lung and Blood Institute, National Institute of Health. 1997. National Asthma Education Program: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Department of Health and Human Services publication (NIH) 97-4051.

23. Marwick C. 1999. Consortium concurs on care for children with asthma. Journal of the American Medical Association 282(19):1804.

24. Halterman JS, Aligne CA, Auinger P. 2000. Inadequate therapy for asthma among children in the United States. Pediatrics 105(1):272-276.

25. Legorreta AP, Christina-Herman J, O’Connor RD. 1998. Compliance with national asthma management guidelines and specialty care. A health maintenance organization experience. Archives of Internal Medicine 158(5):457-464.

26. Meng, YY, Leung KM, Berkbigler D. 1999. Compliance with US asthma management guidelines and specialty care: a regional variation or national concern? Journal of Evaluation in Clinical Practice 5(2):213-21.

27. American Lung Association. 1998. American Lung Association Survey Reveals Startling Misunderstandings About Living With Asthma. [Web site]. Cited November 11, 1999; available at http://www.lungusa.org.

28. Heinrich P, Homer CJ. 1999. Improving the care of children with asthma in pediatric practice: The HIPPO Project. Pediatric Annals 28(1):6

29. Warman KL, Silver E, McCourt MP. 1999. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? Pediatrics 103:422-427.

30. U.S. Environmental Protection Agency. 1999. An update of EPA activities to protect children from environmental health hazards. In KidsFlash. [Web site]. Cited November 11, 1999; available at http://www.epa.gov.

31. National Institute of Allergy and Infectious Diseases. NIAID inner-city asthma study finds multiple factors lead to increased asthma morbidity. NIAID News Release. [Web site]. Cited November 11, 1999; available at http://www.niaid.nih.gov.

Appendix A
Innovations in Pediatric Asthma

Initiatives sponsored by the EPA include the following:

Indoor Air Quality Tools for Schools Action Kit, EPA - To address indoor air quality in schools, the EPA established School Air Quality and Asthma Workshops, which promote Indoor Air Quality Tools for Schools. These tools help schools carry out practical action plans to improve indoor air quality at little or no cost using common-sense activities and in-house staff. Additional information can be found at http://www.epa.gov/iaq/schools.

Open Airways for Schools, The American Lung Association, and the EPA - The Open Airways for Schools program teaches 8- to 11-year-olds how to recognize the warning signs of asthma (including the environmental factors that can trigger an attack) and empowers them to more effectively manage their asthma with the help of parents, teachers, school health professionals, and physicians. The program is used in over 18,600 schools nationwide and reaches over 197,000 students. Program evaluations indicate that students who have completed the lessons took more steps to manage their asthma, improved their academic performance, and had fewer and less severe asthma episodes. Additional information can be found at http://www.lungusa.events/astopen.html.

Child Health Champion Campaign Pilots, EPA - These projects, which have been implemented in 11 communities beginning in 1998, empower communities to take steps to protect children from general environmental health threats and to reduce their exposure to local environmental hazards, such as lead paint and asthma-causing pollutants. Additional information can be found at http://www.epa.gov or by calling Liz Blackburn at (202) 260-7778.

Centers of Excellence in Children’s Environmental Health Research, EPA and DHHS - Eight Centers of Excellence were established in 1998; they include the University of Southern California, School of Medicine; the University of Iowa, College of Medicine; the University of Michigan, School of Public Health; The Johns Hopkins University Children’s Center; the University of California at Berkeley, School of Public Health; the University of Washington Department of Environmental Health; the Mount Sinai School of Medicine; and Columbia University, School of Public Health. Additional information can be found at http://www.epa.gov/children.

Michigan Center for Environment and Children’s Health (MCEH), University of Michigan, the National Center for Environmental Research and Quality Assurance, EPA - MCEH has funded three research projects focusing on environmental triggers of asthma, indoor and outdoor air contaminant exposures and asthma aggravation, and chemokines. Additional information can be found at http://es.epa.gov/ncerqa/centers/michigankids.html.

NHLBI, National Institutes of Health (NIH) - NHLBI is sponsoring asthma coalitions in seven communities with high asthma rates. These grants will establish partnerships between NHLBI and local coalitions to develop model programs for improving asthma care. The coalitions will target limiting health disparities in asthma morbidity and mortality. The projects are as follows:

Arkansas Asthma Coalition/Arkansas Children’s Hospital Research Institute, Little Rock, AR

Central California Asthma Project/San Joaquin Valley Health Consortium, Fresno, CA

Chicago Asthma Consortium, Chicago, IL

Columbia University Asthma Coalition/Columbia University College of Physicians and Surgeons, New York, NY

Asthma Community Development Coalition/Health and Hospital Corporation of Marion County, Indianapolis, IN

Southeast Regional Clinicians’ Network/Morehouse School of Medicine, Atlanta, GA

Tacoma - Pierce County Asthma Prevention Partnership, Tacoma, WA

Additional information can be found at http://www.nhlbi.nih.gov.

There are a number of projects sponsored by the CDC and its state and local affiliates. Additional information can be found at http://www.cdc.gov/nceh/programs/asthma/ataglance/asthmaag2.htm. Some of the programs are

California Community-Based Asthma Intervention Demonstrations Project, CDC - The goal of this project is to study whether reducing exposure to ETS reduces hospitalization of children for asthma-related problems in Fresno, CA.

The Wisconsin Community-Based Asthma Intervention Project, CDC, Wisconsin Department of Health and Social Services, the American Lung Association of Wisconsin, Fight Asthma Milwaukee, and the Medical College of Wisconsin - This collaboration in Madison, WI, is designed to reduce the exposure of children with asthma to indoor allergens and to document any reduction in asthma-related problems.

Wisconsin Asthma Education for Welfare to Work Project, the Wisconsin Department of Health and Social Services - The goal of this project is to develop an asthma education and management program for families enrolled in Wisconsin Works, a welfare-to-work program in Milwaukee. Families receive information about allergens and about tools for monitoring and treating asthma, as well as information about other aspects of asthma.

ZAP Asthma Project, CDC, and 16 public, private, and community organizations - This community-based coalition was formed to improve the lives and health of children with asthma. The program goal is to determine whether reducing children’s exposure to known triggers in the home and educating families about asthma decreases the number of asthma attacks and the costs associated with the treatment of asthma. The project targets 5- to 12-year-olds in a low-income urban area in Atlanta.

CDC/Health Department Interaction - The CDC provides training and networking opportunities to staff of all states and territorial health agencies to help build their capacity to prevent and manage asthma.

Initiatives sponsored by MCHB, HRSA, DHHS include the following:

Preschool Asthma Education Project, the Boston Medical Center, MCHB - The Preschool Asthma Education Project in Boston, MA, is designed to reduce the morbidity levels experienced by young urban children with asthma by providing Head Start - based asthma education and support. The program also seeks to enable families to adopt improved management strategies and to enhance preventive care. For more information contact Suzanne Steinbach, M.D., or Jeanne McBride, R.N., at (601) 534-2450.

Managed Care for Children with Special Health Care Needs, the New York State Department of Health and Health Research, Inc., MCHB - The goal of this program is to develop guidelines and outcome indicators for asthma, spina bifida, and sickle cell disease for managed care providers. For more information contact Christopher Kus, M.D., M.P.H., at (518) 473-4233.

Healthy Tomorrows Partnership for Children, The East Harlem Pediatric Asthma Working Group in East Harlem, NY, MCHB - The East Harlem Pediatric Asthma Working Group is a coalition of parents, pediatricians, and other health professionals who are trying to improve the health of children with asthma by intervening in the home environment to eliminate or control asthma allergens, to empower children and their parents to understand the appropriate use of their medications, and to ensure that children have a medical home. For more information contact Suzanne Gaynor, R.N., Dr.P.H., at (212) 241-3185.

Advances in Pediatric Pulmonary Care: Interdisciplinary Approaches to Asthma and Home Care of Technology Dependent Children, the University of Alabama at Birmingham, and the Children’s Hospital Department of Pediatrics, MCHB - This continuing education and development project is intended to improve the health of CSHCN, specifically those with chronic respiratory conditions, by improving the clinical competence and leadership skills of their health care providers. The program provides regional continuing education to health care providers in state-of-the-art pediatric pulmonary care relevant to maternal and child health/Title V programs. For more information contact Raymond Lyrene, M.D. at (205) 939-9583.

Predicting the Need for Hospitalization in Childhood Asthma, the University of Pennsylvania, School of Medicine, Department of Pediatrics, Center for Epidemiology and Biostatistics, and the Children’s Hospital of Philadelphia, MCHB - This project is designed to identify the signs and symptoms associated with the need to admit children with acute asthma, and to develop and validate a clinical prediction rule to differentiate between children requiring admission and those who can be discharged. For more information contact Marc Gorelick, M.D., at (215) 898-1484.

Use of Child Health Services by Hispanic Families, University of Illinois at Chicago, School of Public Health, MCHB - This study will examine the influence of social context, health service availability and accessibility, and provider outreach on the use of health services for preschool-aged Mexican-American and Puerto Rican children. For more information contact Sharon Telleen, Ph.D., at (312) 996-3818.

Other federal and organizational initiatives include the following:

NCICAS, NIAID - In 1991 NIAID launched the first NCICAS and funded eight centers to identify factors responsible for the rise in asthma among urban children in seven cities and to test strategies for intervention. The success of the initial NCICAS influenced NIAID to launch a second study in partnership with the National Institute of Environmental Health Sciences (NIEHS). Additional information can be found at <http://www.niaid.nih.gov>.

The Pediatric Comprehensive Asthma Management Program, The Women and Children’s Health Center of Western Queens Borough, and The New York Hospital - Cornell Medical Center - This program was launched in 1992 with the goal of reducing asthma/bronchitis hospitalization rates for enrolled children through comprehensive examinations and treatment plans, including education and case management for children living in public housing. Additional information can be found at <http://www.aap.org/advocacy/NMNY/html>.

War on Asthma: The East Harlem Asthma Working Group Attacks Pediatrics Asthma Rates in East Harlem, The Mount Sinai School of Medicine - Established in 1997, this program is designed to reach vulnerable children in a low-income community by intervening in the home to eliminate and/or control asthma allergens, to empower families to appropriately manage asthma medications and devices, to ensure that children have a medical home, and to train community workers. Additional information can be found at <http://www.aap.org/advocacy/NMNY/html>.

Evaluating Quality Improvement Strategies (EQUIS), National Initiative for Children’s Healthcare Quality and Care Group PSN, Boston, MA - By offering training in asthma care and ongoing support to office staff, EQUIS strives to help primary care health professionals provide better care for children with asthma. The program helps establish "asthma care improvement teams" in primary care settings to implement recommended asthma guidelines. EQUIS also has programs in Alaska, North Carolina, and Vermont. For additional information contact Patricia Heinrich, R.N., at (617) 754-4875 or pheinrich@ihi.org.

Children’s Environmental Health Network (CEHN) - In 1999 CEHN held its first symposium, Pediatric Environmental Health: Putting it into Practice, to address a national research and policy agenda for pediatric environmental health. The symposium brought together over 200 experts to establish a framework for pediatric environmental health research and policy, including recommendations for action for the federal government, the research community, and health administrators. CEHN also has a training manual for health care faculty, Training Manual on Pediatric Environmental Health: Putting it into Practice, which aims to help faculty incorporate environmental health in their curriculum. Additional information can be found at <http://www.cehn.org>.

HUD Asthma Initiative, The U.S. Department of Housing and Urban Development, and the New York Office of Housing and Urban Development - The objective of this initiative is to develop public awareness and policy responses to pediatric asthma by controlling the indoor environmental factors (e.g., cockroaches, dust mites) that contribute to asthma. Additional information can be found at <http://www.hud.gov:80/local/nyn/nynasthma.html> or by calling Steve Savarse, Community Builder, at (212) 264-8000, ext. 3178.

Appendix B
Organizations Working in Asthma

Advocacy and Education

Allergy and Asthma Network, Mothers of Asthmatics Inc. (http://www.aanma.org)

Children’s Environmental Health Network (http://www.cehn.org)

Connect For Kids (http://www.campaign.com)

Environmental Defense Fund (http://www.edf.gov)

Institute of Medicine (http://www.iom.edu)

National Education Association (http://www.nea.org)

National Initiative for Children’s Healthcare Quality (http://www.nichq.org)

Pew Environmental Health Commission (http://pewenvirohealth.jhsph.edu)

Professional Associations

American Academy of Allergy, Asthma and Immunology (http://www.aaaai.org)

American Academy of Pediatrics (http://www.aap.org)

American College of Allergy, Asthma, and Immunology (http://allergy.mcg.edu)

American Lung Association (http://www.lungsusa.org)

American Medical Association - The Asthma Information Center (http://www.ama-assn.org/special/asthma)

American Thoracic Society (http://www.thoracic.org)

Asthma and Allergy Foundation of America (http://www.aafa.org)

National Association of City and County Health Officials (http://www.naccho.org)

National Association of School Nurses (http://www.nasn.org)

National Conference of State Legislatures, Environmental Health Project (http://www.ncsl.org)

Physicians for Social Responsibility (http://www.psr.org)

Governmental Organizations

Agency for Healthcare Research and Quality (http://www.ahrq.gov)

National Center for Environmental Health, Centers for Disease Control and Prevention (http://www.cdc.gov/nceh)

National Heart, Lung, and Blood Institute, National Institutes of Health (http://www.nhlbi.nih.gov)

National Institute of Allergy and Infectious Diseases, National Institutes of Health (http://www.niaid.nih.gov)

National Institute of Environmental Health Sciences, National Institutes of Health (http://www.niehs.nih.gov)

Office of Children’s Health, US Environmental Protection Agency (http://www.epa.gov/children)

Office of Minority Health, Department of Health and Human Services (http://www.omhrc.gov)

U.S. Department of Health and Human Services (http://www.hhs.gov)

U.S. Department of Housing and Urban Development (http://www.hud.gov)

U.S. Environmental Protection Agency (http://www.epa.gov)

Data and Statistics

National Center for Health Statistics, Centers for Disease Control and Prevention (http://www.cdc.gov/nchs)

Title V Information System (http://www.mchdata.net)