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
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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
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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)
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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
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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
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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
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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
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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
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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
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Indoor Air Quality – Indoor Air Quality – SchoolsSchools
• 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
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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
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Indoor Air Quality – Indoor Air Quality – SchoolsSchools
• 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
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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
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CockroachesCockroaches
• Need warmth• Need water• Need source of food – same as us
KitchenWhere food is consumed
– At home – where we watch TV
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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
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Cockroach ControlCockroach Control
• Limit their access to foodKeep food in sealed containersClean up all spilled food
• Eliminate water - leaky plumbing, leaky roof
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House Dust MitesHouse Dust Mites
• Need warmth• Need high humidity• Need source of food • Live in mattresses, upholstered
furniture and carpet
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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
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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
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MoldsMolds
• Need water• Need source of food – wallpaper,
wood, or cardboard• Can cause both allergic and irritant
effects
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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
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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
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Asthma & Indoor Air Asthma & Indoor Air PollutionPollution
• PreventionNo smokingControl moisture
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Outdoor Air PollutionOutdoor Air Pollution
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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
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Sources of Air Sources of Air PollutantsPollutants
• Mobile sources: cars and trucks• Power plants• Other industry• Incinerators• Minor sources
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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
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Asthma & Outdoor Air Asthma & Outdoor Air PollutionPollution
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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.
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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.
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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
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Control and Prevention Control and Prevention of Outdoor Air of Outdoor Air
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
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Control and Prevention Control and Prevention of Outdoor Air of Outdoor Air
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
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Control and Prevention Control and Prevention of Outdoor Air of Outdoor Air
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
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)
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