Reducing childhood asthma through community-based service delivery--New York City, 2001-2004

Since 1980, asthma prevalence, hospitalization, and mortality have been increasing in the United States. Because of concern about asthma-related morbidity among children in Central Harlem, New York City (NYC), the Harlem Children's Zone Asthma Initiative (HCZAI) was established in 2001 to reduce asthma-related morbidity through improved surveillance, health-care use, and health-care service delivery for children aged < or =12 years living in a 60-block radius of Central Harlem known as the Harlem Children's Zone Project. Families of children with asthma or asthma-like signs or physical findings consistent with asthma are invited to participate in the program. This report summarizes preliminary data collected during 2001-2004 on the effectiveness of the program in reducing asthma-related morbidity; data indicate decreased parental/guardian reports of school absences among children enrolled in the program, both for any reason and because of asthma. In addition, emergency department and unscheduled physician office visits for treatment of asthma decreased from 35% to 8% after 18 months of the program, indicating improved asthma management and appropriate use of health-care services by program enrollees. The effectiveness of HCZAI underscores the utility of community-based public health programs in reducing asthma morbidity.     

Childhood Asthma and Extreme Values of Body Mass Index: The Harlem Children’s Zone Asthma Initiative

To examine the association between body mass index (BMI) percentile and asthma in children 2-11 years of age, we performed a cross-sectional analysis of 853 Black and Hispanic children from a community-based sample of 2- to 11-year olds with measured heights and weights screened for asthma by the Harlem Children's Zone Asthma Initiative. Current asthma was defined as parent/guardian-reported diagnosis of asthma and asthma-related symptoms or emergency care in the previous 12 months. Among girls, asthma prevalence increased approximately linearly with increasing body mass index (BMI) percentile, from a low of 12.0% among underweight girls (BMI 95th percentile). After adjusting for age, race/ethnicity, and household smoking, among girls, having asthma was associated with being at risk for overweight (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.4-5.0) and being overweight (OR, 2.1; 95% CI, 1.2-3.8) compared to normal weight; among boys, having asthma was associated both with overweight (OR, 2.4; 95% CI, 1.4-4.3) and with underweight (OR, 2.9; 95% CI, 1.1-7.7). Large, prospective studies that include very young children are needed to further explore the observed association between underweight and asthma among boys. Early interventions that concomitantly address asthma and weight gain are needed among pre-school and school-aged children.     

Asthma and wheezing symptoms in young people in six Western countries

BACKGROUND: Asthma diagnosed in children shows wide geographical variations. Large scale surveys identify children with diagnosed asthma, but neglect the group of youngsters with multiple asthmatic complaints. METHODS: A short validated asthma questionnaire was included in six national surveys of the Health Behaviour in School-Aged Children Study. Prevalence rates are presented by country, gender and age. Gender and age differences are analysed using binary and multinomial logistic regressions controlling for age and smoking. RESULTS: Large country differences are observed in the prevalence rates of diagnosed asthma (8.6%-20.9% in boys, 6.9%-18.5% in girls) and young people with "asthma-like symptoms" (9.6%-20.2% in boys, 9.2%-23.1% in girls). When controlling for age and smoking, significant gender differences are observed (more diagnosed asthma in boys, more asthmatic symptoms in girls). Age differences were observed in adolescents with "asthma-like symptoms", but not in diagnosed asthma. CONCLUSIONS: Using a short asthma questionnaire, large differences in diagnosed asthma and wheezing symptoms are observed between the countries. A considerable group of youngsters with "asthma-like symptoms" is detected in all countries, and may be an unrecognised risk group in health promotion.     

Overlooked and underserved in Harlem: a population-based survey of adults with asthma

The prevalence of asthma has increased over the past two decades; if this trend persists over the next two decades, the number of individuals with asthma in the United States will double by 2020, affecting 29 million Americans. Many of these individuals will be adults. Recent community-based participatory research in Harlem has focused on children with asthma, but little is known about the prevalence and burden of asthma among adults. We conducted a population-based probability sample of Central Harlem adults 18-65 years of age from 1992 to 1994. Asthma was one of three ambulatory care-sensitive conditions surveyed. We used an additional set of questions regarding asthma management and burden for those respondents who reported they had asthma. The prevalence of self-reported asthma was 14% in this population-based sample of Central Harlem adults. Respondents with asthma reported remarkably high rates of emergency department (ED) visits for asthma, but women were more likely than men to report two or more ED visits in the year prior to interview (38% vs. 18%). Women with asthma were also more likely than men with asthma to report activity restrictions because of asthma (61% vs. 26%). The burden of asthma among adults in Central Harlem is considerable. We urgently need comprehensive health approaches to address the high prevalence of health risks related to multiple chronic diseases, notably smoking and obesity. Key priorities are to determine which community education, prevention, and promotion programs are most effective and will best serve Harlem adults.     

The Impact of Food Histamine Intake on Asthma Activity: A Pilot Study

Asthma is a complex chronic inflammatory disorder. Diet’s impact on asthma symptoms is controversial. The objective of this pilot crossover, randomized, two-period study was to examine the effect of dietary histamine intake on asthma symptoms in twenty-one children with mild intermittent asthma. Children were randomly assigned to either a high- or low-histamine diet, based on the Mediterranean pattern, for 4 weeks. After a 2-week washout period, patients crossed to the alternative diet for 4 additional weeks. Asthma symptoms were assessed at baseline and after the completion of each diet period by a clinician. Daily symptoms and peak flow were recorded throughout the intervention. Adherence to the dietary intervention was assessed via analysis of four random 24-h recalls, for each intervention period. Eighteen children completed the study. Significantly higher mean air flow obstruction was recorded and a trend for prolonged and more severe symptoms was observed during the high-histamine period. Diet may have an active and direct impact on asthma symptoms. Food choice is affected and/or may affect symptoms in children with mild asthma. Diet intervention is promising yet challenging, for asthma control.     

Partners in school asthma management: evaluation of a self-management program for children with asthma

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.     

Assessing the efficacy of a school-based asthma education program for children: a pilot study

BACKGROUND: Asthma diminishes the health-related quality of life for many school-aged children. This study sought to explore the effect of a School-Based Asthma Education Program (SBAEP) on quality of life. METHODS: Children with asthma who attended grades 1-5 at two selected schools were requested to participate in this pilot study. Participants at one school were provided with a SBAEP, those at another school (control group) were provided with written educational material about asthma. The children completed the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) before and one month after the educational interventions. RESULTS: There were clinically important improvements in the SBAEP group in quality of life, specifically in the symptom subdomain. CONCLUSIONS: The "Air Force" SBAEP appears to result in a favourable trend in quality of life for children. A larger scale trial is required following revisions to the program.     

School-based asthma case finding: the Arkansas experience

This population-based case-finding study sought to determine asthma prevalence and characterize disease severity and burden among school-aged children in the Little Rock School District. Asthma cases were identified by validated algorithm and parental report of asthma diagnosis. The overall response rate was low. Among schools with greater than 50% response rate, prevalence of physician-diagnosed asthma was comparable to other studies in public school settings. Prevalence of symptoms in cases identified as current is suggestive of poor asthma control. Improved systems for case identification of children with asthma are needed in schools. Efforts should focus on strategies to improve asthma control.     

Impact of ambient air pollution on the prevalence of main symptoms of asthma in children

The impact of ambient air pollution on the prevalence of main symptoms of asthma was analyzed in children. A total of 3,506 children were interviewed using the ISAAC questionnaire. The prevalence of the abnormality was studied via continuous questioning in children aged 7-8 and 13-14 years, who lived in areas with varying aerogenic loads. The higher rates of main asthma-like symptoms and clinically diagnosed asthma were ascertained in the children living in higher ambient air pollution areas.     

Underdiagnosis of childhood asthma: A comparison of survey estimates to clinical evaluation

Objectives

Diagnostic patterns play a role in asthma prevalence estimates and could have implications for disease management. We sought to determine the extent to which questionnaire-derived estimates of childhood asthma reflect the disease’s true occurrence.

Materials and Methods

Children aged 6–12 years from Katowice, Poland, were recruited from a cross-sectional survey (N = 1822) via primary schools. Students were categorized into three mutually exclusive groups based on survey responses: “Asthma” (previously diagnosed asthma); “Respiratory symptoms” (no previous diagnosis of asthma and one or more respiratory symptoms during last year), “No respiratory symptoms” (no previous diagnosis of asthma or respiratory symptoms). A sample of children from each group (total N = 456) completed clinical testing to determine asthma presence according to GINA recommendations.

Results

Based on the survey, 5.4% of children were classified with asthma, 27.9% with respiratory symptoms, and 66.7% with no respiratory symptoms or asthma. All previously known 41 cases of asthma were confirmed. New diagnoses of asthma were made in 21 (10.9%) and 8 (3.6%) of subjects from the “Respiratory symptoms” (N = 192) and “No respiratory symptoms” (N = 223) groups, respectively. The overall prevalence of childhood asthma, incorporating the results of clinical examination, was 10.8% (95% CI: 9.4–12.2), compared to the questionnaire-derived figure of 5.4% (95% CI: 4.4–6.5%) and affected females more than males.

Conclusions

Asthma prevalence was underestimated in this population possibly resulting from under-presentation or under-diagnosis. This could have potential implications for proper management and well-being of children. Questionnaire estimates of prevalence should be considered carefully in the context of regional diagnostic patterns.     

The social and economic consequences of childhood asthma across the lifecourse: a systematic review

BACKGROUND: Asthma prevalence rates are high, and may be increasing in the Western world, particularly among children. The aim of this study was to evaluate the longer-term social and economic consequences of having asthma as a child and to determine whether adverse consequences are more severe for poorer children. METHODS: Results from published and unpublished, quantitative and qualitative studies were synthesized narratively to examine the impact of childhood-onset asthma on school attendance, academic achievement and employment in adulthood. The question of whether the impact differed for different social groups was also examined. FINDINGS: Twenty-nine good quality studies were identified, including in total 12 183 children with asthma or wheeze. Compared with asymptomatic children, those with asthma missed more days of school (additional absence as a result of asthma ranged from 2.1 to 14.8 days). Studies of academic achievement found that children with asthma performed as well as their healthy peers. The existing evidence on labour market performance is sparse, but there is an indication that people with asthma during childhood experience disadvantage in later employment. In an examination of consequences by social position, children with asthma from deprived areas were more likely to miss school than their more affluent peers, and minority ethnic children were also more likely to have poor school attendance. The only qualitative study suggested that children with asthma strove to participate fully in every aspect of their daily lives. INTERPRETATION: Although asthma limits children's daily activities and affects their social activities, this research synthesis found little evidence of major, adverse long-term social and economic consequences in studies reviewed. Further longitudinal research using comparison groups is needed to fill key gaps in the existing evidence base.     

中山市居室装修对儿童哮喘样症状的影响

目的 探究中山市居室装修对儿童哮喘及哮喘样症状的影响。方法 于2016年3-7月在中山市城区采用随机整群抽样方法,抽取小学和初中各5所共11 611名儿童,采用国际统一的标准问卷ATS调查表调查所选学生的哮喘及哮喘样症状及家庭装修等情况,分析居室装修对儿童哮喘和哮喘样症状的影响。结果 学生年龄介于5~17岁,平均年龄是（11.49±2.66)岁,持续咳嗽、持续咳痰、喘鸣、哮喘和哮喘现患的患病率分别是2.85%、1.20%、6.93%、5.70%和1.46%。单因素分析显示,家庭2年内住房装修,装修材料中的油漆和墙壁涂料壁纸和新家具均是儿童哮喘和哮喘样症状危险因素(P＜0.05);多因素二分类非条件Logistic回归分析结果显示,油漆是儿童持续咳嗽和哮喘现患的危险因素(OR:1.38-1.51,P＜0.05),墙涂料壁纸是儿童喘鸣和哮喘的危险因素(OR:1.24-1.29,P＜0.01)。结论 中山市居室装修是儿童患有哮喘及哮喘样症状的危险因素,不同的装修材料危害不一,应注意装修材料的使用。     

Asthma in Inner-City Children at 5–11 Years of Age and Prenatal Exposure to Phthalates: The Columbia Center for Children’s Environmental Health Cohort

Background: Studies suggest that phthalate exposures may adversely affect child respiratory health.Objectives: We evaluated associations between asthma diagnosed in children between 5 and 11 years of age and prenatal exposures to butylbenzyl phthalate (BBzP), di-n-butyl phthalate (DnBP), di(2-ethylhexyl) phthalate (DEHP), and diethyl phthalate (DEP).Methods: Phthalate metabolites were measured in spot urine collected from 300 pregnant inner-city women. Children were examined by an allergist or pulmonologist based on the first parental report of wheeze, other respiratory symptoms, and/or use of asthma rescue/controller medication in the preceding 12 months on repeat follow-up questionnaires. Standardized diagnostic criteria were used to classify these children as either having or not having current asthma at the time of the physician examination. Children without any report of wheeze or the other asthma-like symptoms were classified as nonasthmatics at the time of the last negative questionnaire. Modified Poisson regression analyses were used to estimate relative risks (RR) controlling for specific gravity and potential confounders.Results: Of 300 children, 154 (51%) were examined by a physician because of reports of wheeze, other asthma-like symptoms, and/or medication use; 94 were diagnosed with current asthma and 60 without current asthma. The remaining 146 children were classified as nonasthmatic. Compared with levels in nonasthmatics, prenatal metabolites of BBzP and DnBP were associated with a history of asthma-like symptoms (p < 0.05) and with the diagnosis of current asthma: RR = 1.17 (95% CI: 1.01, 1.35) and RR = 1.25 (95% CI: 1.04, 1.51) per natural log-unit increase, respectively. Risk of current asthma was > 70% higher among children with maternal prenatal BBzP and DnBP metabolite concentrations in the third versus the first tertile.Conclusion: Prenatal exposure to BBzP and DnBP may increase the risk of asthma among inner-city children. However, because this is the first such finding, results require replication.Citation: Whyatt RM, Perzanowski MS, Just AC, Rundle AG, Donohue KM, Calafat AM, Hoepner LA, Perera FP, Miller RL. 2014. Asthma in inner-city children at 5–11 years of age and prenatal exposure to phthalates: the Columbia Center for Children’s Environmental Health Cohort. Environ Health Perspect 122:1141–1146; http://dx.doi.org/10.1289/ehp.1307670     

Kickin’ Asthma: School‐Based Asthma Education in an Urban Community

BACKGROUND: In urban communities with high prevalence of childhood asthma, school‐based educational programs may be the most appropriate approach to deliver interventions to improve asthma morbidity and asthma‐related outcomes. The purpose of this study was to evaluate the implementation of Kickin’ Asthma, a school‐based asthma curriculum designed by health educators and local students, which teaches asthma physiology and asthma self‐management techniques to middle and high school students in Oakland, CA. METHODS: Eligible students were identified through an in‐class asthma case identification survey. Approximately 10‐15 students identified as asthmatic were recruited for each series of the Kickin’ Asthma intervention. The curriculum was delivered by an asthma nurse in a series of four 50‐minute sessions. Students completed a baseline and a 3‐month follow‐up survey that compared symptom frequency, health care utilization, activity limitations, and medication use. RESULTS: Of the 8488 students surveyed during the first 3 years of the intervention (2003‐2006), 15.4% (n = 1309) were identified as asthmatic; approximately 76% of eligible students (n = 990) from 15 middle schools and 3 high schools participated in the program. Comparison of baseline to follow‐up data indicated that students experienced significantly fewer days with activity limitations and significantly fewer nights of sleep disturbance after participation in the intervention. For health care utilization, students reported significantly less frequent emergency department visits or hospitalizations between the baseline and follow‐up surveys. CONCLUSIONS: A school‐based asthma curriculum designed specifically for urban students has been shown to reduce symptoms, activity limitations, and health care utilization for intervention participants.     

Implementation of Evidence-based Asthma Interventions in Post-Katrina New Orleans: The Head-off Environmental Asthma in Louisiana (HEAL) Study

Background: Childhood asthma morbidity and mortality in New Orleans, Louisiana, is among the highest in the nation. In August 2005, Hurricane Katrina created an environmental disaster that led to high levels of mold and other allergens and disrupted health care for children with asthma.Objectives: We implemented a unique hybrid asthma counselor and environmental intervention based on successful National Institutes of Health asthma interventions from the National Cooperative Inner City Asthma (NCICAS) and Inner-City Asthma (ICAS) Studies with the goal of reducing asthma symptoms in New Orleans children after Hurricane Katrina.Methods: Children (4–12 years old) with moderate-to-severe asthma (n = 182) received asthma counseling and environmental intervention for approximately 1 year. HEAL was evaluated employing several analytical approaches including a pre–post evaluation of symptom changes over the entire year, an analysis of symptoms according to the timing of asthma counselor contact, and a comparison to previous evidence-based interventions.Results: Asthma symptoms during the previous 2 weeks decreased from 6.5 days at enrollment to 3.6 days at the 12-month symptom assessment (a 45% reduction, p < 0.001), consistent with changes observed after NCICAS and ICAS interventions (35% and 62% reductions in symptom days, respectively). Children whose families had contact with a HEAL asthma counselor by 6 months showed a 4.09-day decrease [95% confidence interval (CI): 3.25 to 4.94-day decrease] in symptom days, compared with a 1.79-day decrease (95% CI: 0.90, 2.67) among those who had not yet seen an asthma counselor (p < 0.001).Conclusions: The novel combination of evidence-based asthma interventions was associated with improved asthma symptoms among children in post-Katrina New Orleans. Post-intervention changes in symptoms were consistent with previous randomized trials of NCICAS and ICAS interventions.     

Prevalence of childhood asthma in urban communities: the impact of ethnicity and income

PURPOSE: The goal of this study was to assess the relationship between hospitalization rates and asthma prevalence in New York City children and investigate the role that sociodemographic factors play in asthma. METHODS: A parent-report questionnaire was distributed in 26 randomly selected New York City public elementary schools, stratified according to neighborhood hospitalization rates. RESULTS: The overall student response rate was 76.9% (5250 students). Prevalence of current asthma was 17.9%, 9.59%, 6.39% (p < .001) in areas of high, median, and low asthma hospitalization rates, respectively. The overall prevalence of current asthma was 13.0%. Children living in predominantly low socioeconomic status (SES) communities had a 70% greater risk of current asthma, independent of their own ethnicity and income level. Asthma prevalence within different ethnic and income groups was consistently lower in neighborhoods of greater socioeconomic status, except among Puerto Rican children, who had high asthma prevalence, regardless of school attended or income. CONCLUSIONS: Prevalence of current asthma is strongly associated with attending a school in a low-income neighborhood. Although hospitalization rates have been used as an indicator of the burden of asthma in a neighborhood, it alone does not reflect the level of disparities that exist among communities with different socioeconomic backgrounds.     

Differences in asthma prevalence between samples of American Indian and Alaska Native children

OBJECTIVES: To better understand the prevalence of asthma among American Indian and Alaska Native (AI/AN) children and to explore the contribution of locale to asthma symptoms and diagnostic assignment, the authors surveyed AI/AN middle school students, comparing responses from metropolitan Tacoma, Washington (metro WA) and a non-metropolitan area of Alaska (non-metro AK). METHODS: Students in grades 6-9 completed an asthma screening survey. The authors compared self-reported rates of asthma symptoms, asthma diagnoses, and health care utilization for 147 children ages 11-16 self-reporting as AI/AN in metro WA and 365 in non-metro AK. RESULTS: The prevalences of self-reported asthma symptoms were similar for the metro WA and non-metro AK populations, but a significantly higher percentage of metro WA than of non-metro AK respondents reported having received a physician diagnosis of asthma (OR 2.33; 95% CI 1.23, 4.39). The percentages of respondents who reported having visited a medical provider for asthma-like symptoms in the previous year did not differ. CONCLUSIONS: The difference in rates of asthma diagnosis despite similar rates of asthma symptoms and respiratory-related medical visits may reflect differences in respiratory disease patterns, diagnostic labeling practices, or environmental factors. Future attempts to describe asthma prevalence should consider the potential contribution of non-biologic factors such as diagnostic practices.     

兰州市城区0～14岁儿童哮喘流行病学调查

目的了解兰州市城区0~14岁儿童哮喘患病率、发病规律及其诊治情况。方法采用多阶段分层随机整群抽样方法,向1996年7月1日零点-2010年7月1日零点出生的兰州市儿童或外地出生但在兰州居住和生活半年以上的儿童家长发放2010年第三次全国儿童哮喘流行病学调查统一问卷,筛查儿童哮喘及过敏疾病。筛查阳性儿童由临床医生明确哮喘诊断后做进一步问卷调查,了解其哮喘诊治情况及伴发过敏性疾病情况。所有数据使用Epi-Info3.5.3软件进行双录入,用SPSS 19.0进行统计分析。结果共抽取儿童11 068名,完成初筛问卷10 566份(95.46%)。共诊断哮喘298例2.82%,其中典型哮喘患病率2.51%(265/10 566)、咳嗽变异性哮喘患病率0.31%(33/10 566);54.36%(162/298)为既往已诊断哮喘;男性患病率3.31%(180/5 440),女性患病率2.30%(118/5 126)(χ2=9.761,P0.01)。不同发育阶段儿童以学龄前儿童(3~7岁)患病率最高为4.31%(116/2 690)。84.90%(253/298)的患儿近2年内仍存在哮喘症状,2年现患率为2.39%(253/10 566)。既往已诊断哮喘患儿中,按全球哮喘防治创议(Global Initiative for Asthma,GINA)方案使用过吸入激素的为87.65%(142/162),而抗生素的使用率高达87.04%(141/162)。结论兰州市城区0~14岁儿童哮喘总患病率较十年前明显增加,不同性别和不同年龄阶段儿童存在明显差异,仍有部分患儿未得到及时诊治,哮喘的管理水平亦亟待提高。     

Prevalence of symptoms of severe asthma and allergies in Irish school children: an ISAAC protocol study, 1995-2007

Childhood asthma is a recurring health burden and symptoms of severe asthma in children are also emerging as a health and economic issue. This study examined changing patterns in symptoms of severe asthma and allergies (ever eczema and hay fever), using the Irish International Study of Asthma and Allergies in Childhood (ISAAC) protocol. ISAAC is a cross-sectional self-administered questionnaire survey of randomly selected representative post-primary schools. Children aged 13-14 years were studied: 2,670 (in 1995), 2,273 (in 1998), 2,892 (in 2002-2003), and 2,805 (in 2007). Generalized linear modelling using Poisson distribution was employed to compute adjusted prevalence ratios (PR). A 39% significant increase in symptoms of severe asthma was estimated in 2007 relative to the baseline year 1995 (adjusted PR: 1.39 [95% CI: 1.14-1.69]) increasing from 12% in 1995 to 15.3% in 2007. Opposite trends were observed for allergies, showing a decline in 2007, with an initial rise. The potential explanations for such a complex disease pattern whose aetiological hypothesis is still evolving are speculative. Changing environmental factors may be a factor, for instance, an improvement in both outdoor and indoor air quality further reinforcing the hygiene hypothesis but obesity as a disease modifier must also be considered.