Asthma

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Asthma Air Quality Issues

• Jerome A. Paulson, MD
• Professor of Pediatrics
• Environmental and Occupational Health
• George Washington University
• Director, Mid-Atlantic Center for Childrens
  Health the Environment
• Medical Director for National Global Affairs,
  Child Health Advocacy Institute
• Childrens National Medical Center

The Mid-Atlantic Center for Childrens Health
the Environment
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Dr Paulson has NO conflicts of interest to
declare.

• This material was developed by the Mid-Atlantic
  Center for Childrens health the Environment
  and funded under the cooperative agreement award
  number 1U61TS000118-03 from the Agency for Toxic
  Substances and Disease Registry (ATSDR).
• Acknowledgement The U.S. Environmental
  Protection Agency (EPA) supports the PEHSU by
  providing funds to ATSDR under Inter-Agency
  Agreement number DW-75-92301301-0. Neither EPA
  nor ATSDR endorse the purchase of any commercial
  products or services mentioned in PEHSU
  publications.

Mid-Atlantic Center for Childrens Health the
Environment - MACCHE
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OBJECTIVES

• After attending this presentation, the listener
  will be able to
• Describe environmental issues related to asthma
• Describe measures to improve air quality

The Mid-Atlantic Center for Childrens Health
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Children Are Different

• Lungs not completely formed at birth
• Continued development until adolescence
• The bronchial tree
• The alveoli (air sacs)
• More lung surface area per unit body weight
• Different respiratory pattern
• Different activity pattern

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Asthma

• Most common disease of childhood
• Over 7 million children
• Number one cause of school absenteeism
• 10.5 million missed school days per year
• Millions of hours of lost work per year for
  parents
• The prevalence of asthma among children in 2008
  was estimated at 10
• Some communities up to 25 of children (Central
  Harlem)

Nicholas et al. 2005. Am J Public Health.
95245249
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Asthma Prevalence Rates

• Asthma prevalence rates increased approximately 4
  percent per year between 1980 and 1996. Rates in
  subsequent years (1997-2007), reported in three
  asthma categories, show no sharp upward or
  downward change through most of the time period

http//cfpub.epa.gov/eroe/index.cfm?fuseactiondet
ail.viewIndlvlist.listByAlphar201583subtop38
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Asthma Mortality
Numbers of asthma-related deaths per 1 million
children 0 to 17 years of age in the United
States in 1980 2005

• Asthma-related death rates increased by an
  average of 3.2 per year from 1980 through 1996
  and then decreased by an average of 3.9 per year
  from 1996 through 2005
• 2005 2.3 asthma-related deaths per 1 million
  children
• 167 deaths. nationally
• High rates of asthma mortality among African
  Americans, low-income populations, and
  populations with low educational levels

Grant EN, Lyttle CS, Weiss KB. The relation of
socioeconomic factors and racial/ethnic
difference in US asthma mortality. Am J Public
Health. 20009019235.
Akinbami LJ. 2009. Status of childhood asthma in
the United States, 1980-2007. Pediatrics. 123
Suppl 3S131-145
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Cost of Asthma

• Children with asthma had 92 higher total direct
  medical expenditures than those without asthma
  (parameter estimate 1.92 p lt 0.0001)
• Annual adjusted mean incremental total
  expenditure associated with asthma was 1,004.6
  (SE 326.1 p 0.002) per person among children
  
• Prescription medications and physician office
  visits constituted approximately 38 of the total
  incremental expenditures for asthma in children

Kamble S. Bharmal M. 2009. Incremental direct
expenditure of treating asthma in the United
States. Journal of Asthma. 4673-80
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Asthma

• Cause unknown
• Indoor and outdoor air pollution can make it
  worse
• Children in urban settings at increased risk for
  asthma
• Death more likely among blacks, Puerto Ricans and
  poor

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Indoor Air Quality
http//www.epa.gov/apti/course422/ap4.html
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Indoor Air Quality

• In the US, children spend more time indoors than
  out of doors
• May spend 30-50 hours/wk in and around school
  buildings
• before school/after school care
• school day
• Indoor air is unregulated except for smoking laws

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Asthma Indoor Air Pollution

• Indoor air pollutants that can set off asthma
  attacks
• Dust mites
• Animals cats, dogs, rats or mice
• Environmental tobacco smoke
• Molds
• Chemicals in the air wood smoke, paint, perfume,
  cosmetics, pesticides, cleaning agents

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Indoor Air Quality Schools

• Report by the U.S. Government Accounting Office,
  the Condition of America's Schools, over half the
  schools surveyed reported at least one
  environmental problem which affects indoor air
  quality

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Indoor Air Quality Schools

• An issue for staff as well as students
• Outdoor air quality affects indoor air quality
• Diesel exhaust - air intake for building
• Pollens
• Indoor air quality varies with time of day and
  day of week

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Indoor Air Quality Schools and Home

• Symptoms commonly attributed to poor IAQ
• headache, fatigue, shortness of breath
• sinus congestion, coughing , sneezing
• eye, nose, throat or skin irritation
• dizziness and nausea
• nose bleeds (after exposure to formaldehyde)
• From AAP Handbook of Pediatric Environmental
  Health

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Indoor Air Quality Schools

• Clues to indoor air problems
• Symptoms widespread within class or school
• Symptoms diminish or disappear after leaving
  school
• Sudden onset after a change in school i.e.,
  painting, pesticide application
• Those with allergies and asthma have reactions
  indoors but not outdoors
• From AAP Handbook of Pediatric Environmental
  Health

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Environmental Tobacco Smoke (ETS)

• Consists of more than 3800 chemical compounds
• Decreasing exposure to ETS over last decade
• Children exposed to ETS in utero or infancy are
  more likely to develop asthma
• Children with asthma who are exposed to ETS are
  more likely to have an asthma attack

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Cockroaches

• Need warmth
• Need water
• Need source of food same as us
• Kitchen
• Where food is consumed
• At home where we watch TV

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Asthma Morbidity Associated with Cockroach Antigen

• -/- no allergy/low exposure
• -/ no allergy/high exposure
• /- allergy/low exposure
• / allergy/high exposure

Rosenstreich, et al. NEJM. 336(19)1356-63, 1997
May 8
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Cockroach Control

• Limit their access to food
• Keep food in sealed containers
• Clean up all spilled food
• Eliminate water - leaky plumbing, leaky roof

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House Dust Mites

• Need warmth
• Need high humidity
• Need source of food
• Live in mattresses, upholstered furniture and
  carpet

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Asthma Morbidity Associated with House Dust Mite
Sensitivity
Peat et al. Aust NZ J Med 199424270-6
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House dust mite control

• Keep humidity below 50 ? air conditioner in
  summer (In school buildings - even if closed)
• Remove carpeting
• Damp mop floor surface

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Molds

• Need water
• Need source of food wallpaper, wood, or
  cardboard
• Can cause both allergic and irritant effects

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Mold control

• Keep humidity below 50 ? air conditioner in
  summer (In school buildings - even if closed)
• Fix leaks and clean up spills with in 48 hours

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Pets

• Cats
• Dogs
• Rodents
• Birds - possibly from dust mites in feathers
• Danders can track from home to car to school

• Personal choice at home
• NO PETS in school

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Asthma Indoor Air Pollution

• Prevention
• No smoking
• Control moisture

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Outdoor Air Pollution
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The Major Air Pollutants

• CO
• SOx (SO2)
• NOx (NO, NO2)
• Particulates (PM)
• Ozone
• Lead
• Volatile organic compounds (Hydrocarbons)
• Air toxics (solvents, pesticides, metals, etc.)

criteria pollutants
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Sources of Air Pollutants

• Mobile sources cars and trucks
• Power plants
• Other industry
• Incinerators
• Minor sources

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Particulates

• Mixture of solid and liquid particles
• Natural sources dust from soil, evaporation of
  sea water
• Combustion and metallurgical processes (e.g fly
  ash from coal diesel exhaust)
• Secondary formation oxidation of atmospheric
  gases (e.g. SO2?H2SO4), aerosol formation through
  condensation and accumulation

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Asthma Outdoor Air Pollution
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Asthma Outdoor Air Pollution

• Ozone and ER Visits Atlanta Children
• Each increase of 20 ppb ozone associated with 4
  increase in ER visits
• Other risk factors
• black race (2.2-fold increase)
• male (1.4-fold increase)
• on Medicaid (1.25-fold increase)
• pollen, mold, temperature no increases in risk

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Ozone Asthma

• 1996 Summer Olympics - Atlanta
• Ground level ozone ? 28
• decreased traffic and increased public
  transportation
• 42 reduction in asthma acute care events for
  Medicaid kids

Friedman MS, Powell KE, Hutwanger L, et al. JAMA
285897-905, 2001.
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CHS Ozone and New-onset Asthma
McConnell R. Berhane K. Gilliland F. London SJ.
Islam T. Gauderman WJ. Avol E. Margolis HG.
Peters JM. Asthma in exercising children exposed
to ozone a cohort study. Lancet.
359(9304)386-91, 2002 Feb 2.
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Control and Prevention of Outdoor Air Pollution

• Control of mobile sources
• ? emissions through cleaner gasoline and diesel
  engines
• alternative fuel vehicles e.g. natural gas,
  electric, hybrid
• ? motor vehicle use e.g. mass transit, carpools,
  biking
• changes in driving habits e.g. slower starts,
  trip-stacking, off-hours refueling

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Control and Prevention of Outdoor Air Pollution

• Control of fixed sources
• ? power plant emissions through cleaner
  construction and operation, and use of cleaner
  fuels
• ? industrial emissions through advanced
  production techniques
• ? production through reduce/reuse/recycle
  initiatives

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Control and Prevention of Outdoor Air Pollution

• Control of fixed sources
• ? consumer energy demand through more efficient
  appliances, improved home and office insulation,
  behavioral changes
• ? reliance on renewable energy sources e.g.
  solar, wind, hydroelectric

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Control and Prevention of Outdoor Air Pollution
Toyota Prius
Honda Insight
?
GM EV1
Nissan LEAF
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Air Quality Index
Descriptors Cautionary Statement
Good 0 50 No message
Moderate 51 100 Unusually sensitive individuals
Unhealthy for Sensitive Groups 101 150 Identifiable groups at risk - different groups for different pollutants
Unhealthy 151 200 General public at risk sensitive groups at greater risk
Very Unhealthy 201 - 300 General public at greater risk sensitive groups at greatest risk
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AIRNow - www.airnow.gov
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THE MID-ATLANTIC CENTER FOR CHILDRENS HEALTH
THE ENVIRONMENT(MACCHE)

• A PEDIATRIC ENVIRONMENTAL HEALTH SPECIALTY UNIT
  (PEHSU)

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MACCHE

• Region 3
• Pennsylvania, Delaware, Maryland, Virginia, West
  Virginia, the District of Columbia
• 1-866-622-2431 (1-866-MACCHE1)
• 202-994-1166
• www.health-e-kids.org

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