Asthma Air Quality Issues Jerome A Paulson

Asthma & Air Quality Issues Jerome A. Paulson, MD Professor 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 conflicts of interest to declare. • This material was developed by the Mid-Atlantic Center for Children’s health & the Environment and funded under the cooperative agreement award number 1 U 61 TS 000118 -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

OBJECTIVES • After attending this presentation, the listener will be able to: ØDescribe environmental issues related to asthma ØDescribe measures to improve air quality The Mid-Atlantic Center for Children’s Health & the Environment

Children Are Different • Lungs not completely formed at birth • Continued development until adolescence Ø The bronchial tree Ø The alveoli (air sacs) • More lung surface area per unit body weight • Different respiratory pattern • Different activity pattern The Mid-Atlantic Center for Children’s Health & the Environment

Asthma • Most common disease of childhood ØOver 7 million children • Number one cause of school absenteeism Ø 10. 5 million missed school days per year ØMillions 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 The Mid-Atlantic Center for Children’s Health & the Environment

Asthma Prevalence Rates • Asthma prevalence rates increased approximately 4 percent per year between 1980 and 1996. Rates in subsequent years (19972007), 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. view. Ind&lv=list. By. Alpha&r= 201583&subtop=381 The Mid-Atlantic Center for Children’s Health & the Environment

Asthma Mortality Numbers of asthmarelated 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 Ø 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. 2000; 90: 1923– 5. Akinbami LJ. 2009. Status of childhood asthma in the United States, 1980 -2007. Pediatrics. 123 Suppl 3: S 131 -145

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

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

Indoor Air Quality http: //www. epa. gov/apti/course 422/ap 4. html The Mid-Atlantic Center for Children’s Health & the Environment

Indoor Air Quality • In the US, children spend more time indoors than out of doors ØMay 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 The Mid-Atlantic Center for Children’s Health & the Environment

Asthma & Indoor Air Pollution • Indoor air pollutants that can set off asthma attacks Ø Dust mites Ø Animals – cats, dogs, rats or mice Ø Environmental tobacco smoke Ø Molds Ø Chemicals in the air: wood smoke, paint, perfume, cosmetics, pesticides, cleaning agents The Mid-Atlantic Center for Children’s Health & the Environment

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

Indoor Air Quality – Schools • An issue for staff as well as students • Outdoor air quality affects indoor air quality ØDiesel exhaust - air intake for building ØPollens • Indoor air quality varies with time of day and day of week The Mid-Atlantic Center for Children’s Health & the Environment

Indoor Air Quality – Schools and Home • Symptoms commonly attributed to poor IAQ Øheadache, fatigue, shortness of breath Øsinus congestion, coughing , sneezing Øeye, nose, throat or skin irritation Ødizziness and nausea Ønose bleeds (after exposure to formaldehyde) • From AAP Handbook of Pediatric Environmental Health The Mid-Atlantic Center for Children’s Health & the Environment

Indoor Air Quality – Schools • Clues to indoor air problems ØSymptoms widespread within class or school ØSymptoms diminish or disappear after leaving school ØSudden onset after a change in school; i. e. , painting, pesticide application ØThose with allergies and asthma have reactions indoors but not outdoors • From AAP Handbook of Pediatric Environmental Health The Mid-Atlantic Center for Children’s Health & the Environment

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

Cockroaches • Need warmth • Need water • Need source of food – same as us ØKitchen ØWhere food is consumed – At home – where we watch TV The Mid-Atlantic Center for Children’s Health & the Environment

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

Cockroach Control • Limit their access to food ØKeep food in sealed containers ØClean up all spilled food • Eliminate water - leaky plumbing, leaky roof The Mid-Atlantic Center for Children’s Health & the Environment

House Dust Mites • • Need warmth Need high humidity Need source of food Live in mattresses, upholstered furniture and carpet The Mid-Atlantic Center for Children’s Health & the Environment

Asthma Morbidity Associated with House Dust Mite Sensitivity Peat et al. Aust NZ J Med 1994; 24: 270 -6 The Mid-Atlantic Center for Children’s Health & the Environment

House dust mite control • Keep humidity below 50% air conditioner in summer (In school buildings - even if closed) • Remove carpeting • Damp mop floor surface The Mid-Atlantic Center for Children’s Health & the Environment

Molds • Need water • Need source of food – wallpaper, wood, or cardboard • Can cause both allergic and irritant effects The Mid-Atlantic Center for Children’s Health & the Environment

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

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

Asthma & Indoor Air Pollution • Prevention ØNo smoking ØControl moisture The Mid-Atlantic Center for Children’s Health & the Environment

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

The Major Air Pollutants • • CO SOx (SO 2) NOx (NO, NO 2) “criteria” pollutants Particulates (PM) Ozone Lead Volatile organic compounds (Hydrocarbons) Air toxics (solvents, pesticides, metals, etc. ) The Mid-Atlantic Center for Children’s Health & the Environment

Sources of Air Pollutants • • • Mobile sources: cars and trucks Power plants Other industry Incinerators Minor sources The Mid-Atlantic Center for Children’s Health & the Environment

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. SO 2 H 2 SO 4), aerosol formation through condensation and accumulation The Mid-Atlantic Center for Children’s Health & the Environment

Asthma & Outdoor Air Pollution The Mid-Atlantic Center for Children’s Health & the Environment

Asthma & Outdoor Air Pollution • Ozone and ER Visits: Atlanta Children ØEach increase of 20 ppb ozone associated with 4% increase in ER visits ØOther 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 The Mid-Atlantic Center for Children’s Health & the Environment

Ozone & Asthma • 1996 Summer Olympics - Atlanta ØGround level ozone 28% – decreased traffic and increased public transportation Ø 42% reduction in asthma acute care events for Medicaid kids Friedman MS, Powell KE, Hutwanger L, et al. JAMA 285: 897 -905, 2001. The Mid-Atlantic Center for Children’s Health & the Environment

CHS: Ozone and New-onset Asthma Mc. Connell 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. The Mid-Atlantic Center for Children’s Health & the Environment

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, tripstacking, off-hours refueling The Mid-Atlantic Center for Children’s Health & the Environment

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

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

Control and Prevention of Outdoor Air Pollution Toyota Prius Honda Insight GM EV 1 Nissan LEAF

Air Quality Index Descriptors Good Cautionary Statement 0 – 50 No message Moderate 51 – 100 Unhealthy for Sensitive Groups 101 – 150 Unhealthy 151 – 200 Very Unhealthy Unusually sensitive individuals Identifiable groups at risk - different groups for different pollutants General public at risk; sensitive groups at greater risk General public at greater risk; sensitive groups at greatest risk

AIRNow - www. airnow. gov

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