Asthma & Air Quality Issues Jerome A. Paulson, MD Professor of Pediatrics & Environmental and Occupational Health George Washington University Director,

Asthma & Air Quality IssuesAsthma & Air Quality IssuesJerome A. Paulson, MDProfessor of Pediatrics

& Environmental and Occupational Health George Washington University

Director, Mid-Atlantic Center for Children’s Health & the Environment

Medical Director for National & Global Affairs, Child Health Advocacy Institute

Children’s National Medical Center

The Mid-Atlantic Center for Children’s Health & the Environment

Dr Paulson has NO Dr Paulson has NO conflicts of interest to conflicts of interest to

declare. declare. • This material was developed by the Mid-Atlantic

Center for Children’s 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 Children’s Health & the Environment - MACCHE

OBJECTIVESOBJECTIVES

• After attending this presentation, the listener will be able to: Describe environmental issues related

to asthmaDescribe measures to improve air

quality


Children Are DifferentChildren 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


AsthmaAsthma

• Most common disease of childhoodOver 7 million children

• Number one cause of school absenteeism10.5 million missed school days per yearMillions 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. 95:245–249

Asthma Prevalence Asthma Prevalence RatesRates

• 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?fuseaction=detail.viewInd&lv=list.listByAlpha&r=201583&subtop=381


Asthma MortalityAsthma Mortality

• 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

Numbers of asthma-Numbers of asthma-related deaths per 1 related deaths per 1 million children 0 to 17 million children 0 to 17 years of age in the United years of age in the United States in 1980 –2005States in 1980 –2005

Grant EN, Lyttle CS, Weiss KB. The relation of socioeconomic factors and racial/ethnic difference in US asthma mortality. Am J Public Health. 2000;90:1923–5. Akinbami LJ. 2009. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 123 Suppl 3:S131-145

Cost of AsthmaCost of Asthma

• Children with asthma had 92% higher total direct medical expenditures than those without asthma (parameter estimate: 1.92; p < 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. 46:73-80


AsthmaAsthma

• 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


Indoor Air QualityIndoor Air Quality

The Mid-Atlantic Center for Children’s Health & the Environmenthttp://www.epa.gov/apti/course422/ap4.html

Indoor Air QualityIndoor Air Quality

• In the US, children spend more time indoors than out of doorsMay 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


Asthma & Indoor Air Asthma & Indoor Air PollutionPollution

• 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


Indoor Air Quality – Indoor Air Quality – SchoolsSchools

• 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



• An issue for staff as well as students• Outdoor air quality affects indoor air

qualityDiesel exhaust - air intake for buildingPollens

• Indoor air quality varies with time of day and day of week


Indoor Air Quality Indoor Air Quality – Schools and Home– Schools and Home

• Symptoms commonly attributed to poor IAQheadache, fatigue, shortness of breathsinus congestion, coughing , sneezingeye, nose, throat or skin irritationdizziness and nauseanose bleeds (after exposure to

formaldehyde)

• From AAP Handbook of Pediatric Environmental Health



• Clues to indoor air problemsSymptoms widespread within class or

schoolSymptoms diminish or disappear after

leaving schoolSudden onset after a change in school;

i.e., painting, pesticide applicationThose with allergies and asthma have

reactions indoors but not outdoors• From AAP Handbook of Pediatric Environmental Health


Environmental Environmental Tobacco Smoke (ETS)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


CockroachesCockroaches

• Need warmth• Need water• Need source of food – same as us

KitchenWhere food is consumed

– At home – where we watch TV


Asthma Morbidity Asthma Morbidity Associated with Associated with

Cockroach AntigenCockroach Antigen• -/- no allergy/low

exposure• -/+ no allergy/high

exposure• +/- allergy/low

exposure• +/+ allergy/high

exposure 0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

-/- -/+ +/- +/+

ER visits/yrHsptl/yr

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


Cockroach ControlCockroach Control

• Limit their access to foodKeep food in sealed containersClean up all spilled food

• Eliminate water - leaky plumbing, leaky roof


House Dust MitesHouse Dust Mites

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

furniture and carpet


Asthma Morbidity Asthma Morbidity Associated with House Associated with House Dust Mite SensitivityDust Mite Sensitivity

0

10

20

30

40

50

60

0-2 mm 3-4 mm 5-6 mm >/= 7 mm

Freq wheezeRecent medsReg morbidityUrgent visit

Peat et al. Aust NZ J Med 1994;24:270-6


House dust mite House dust mite controlcontrol

• Keep humidity below 50% air conditioner in summer (In school buildings - even if closed)

• Remove carpeting • Damp mop floor surface


MoldsMolds

• Need water• Need source of food – wallpaper,

wood, or cardboard• Can cause both allergic and irritant

effects


Mold controlMold 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


PetsPets

• 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


Asthma & Indoor Air Asthma & Indoor Air PollutionPollution

• PreventionNo smokingControl moisture


Outdoor Air PollutionOutdoor Air Pollution


The Major Air The Major Air PollutantsPollutants

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

“criteria” pollutants


Sources of Air Sources of Air PollutantsPollutants

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


ParticulatesParticulates

• 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. SO2H2SO4), aerosol formation through condensation and accumulation


Asthma & Outdoor Air Asthma & Outdoor Air PollutionPollution


Asthma & Outdoor Air Asthma & Outdoor Air PollutionPollution

• Ozone and ER Visits: Atlanta Children Each increase of 20 ppb ozone

associated with 4% increase in ER visitsOther 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

riskThe Mid-Atlantic Center for Children’s Health & the Environment

Ozone & AsthmaOzone & Asthma

• 1996 Summer Olympics - AtlantaGround 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 285:897-905, 2001.


CHS: Ozone and New-CHS: Ozone and New-onset Asthmaonset 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.


Control and Prevention Control and Prevention of Outdoor Air of Outdoor Air

PollutionPollution• 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



PollutionPollution• 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



PollutionPollution• 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



PollutionPollution

Toyota Prius Honda Insight

GM EV1

Nissan LEAF

Air Quality IndexAir Quality Index

DescriptorsDescriptors Cautionary StatementCautionary Statement

Good 0 – 50Good 0 – 50 No messageNo message

Moderate 51 – 100Moderate 51 – 100 Unusually sensitive individualsUnusually sensitive individuals

Unhealthy for Unhealthy for Sensitive GroupsSensitive Groups

101 – 150101 – 150

Identifiable groups at risk - different groups Identifiable groups at risk - different groups for different pollutantsfor different pollutants

Unhealthy 151 – Unhealthy 151 – 200200

General public at risk; sensitive groups at General public at risk; sensitive groups at greater riskgreater risk

Very UnhealthyVery Unhealthy

201 - 300201 - 300

General public at greater risk; sensitive General public at greater risk; sensitive groups at greatest risk groups at greatest risk

AIRNowAIRNow - www.airnow.gov - www.airnow.gov

THE MID-ATLANTIC THE MID-ATLANTIC CENTER FOR CHILDREN’S CENTER FOR CHILDREN’S

HEALTH & THE HEALTH & THE ENVIRONMENTENVIRONMENT

(MACCHE)(MACCHE)A PEDIATRIC

ENVIRONMENTAL HEALTH SPECIALTY UNIT (PEHSU)


MACCHEMACCHE

• 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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Asthma & Air Quality Issues Jerome A. Paulson, MD Professor of Pediatrics & Environmental and Occupational Health George Washington University Director,