Asthma & Air Quality Issues

1. 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

2. 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 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

3. 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 Children’s Health & the Environment

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

5. 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. 95:245–249 The Mid-Atlantic Center for Children’s Health & the Environment

6. 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?fuseaction=detail.viewInd&lv=list.listByAlpha&r=201583&subtop=381 The Mid-Atlantic Center for Children’s Health & the Environment

7. 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. 2000;90:1923–5. Akinbami LJ. 2009. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 123 Suppl 3:S131-145

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

9. 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

10. Indoor Air Quality http://www.epa.gov/apti/course422/ap4.html The Mid-Atlantic Center for Children’s Health & the Environment

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

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

13. 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

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

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

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

17. 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

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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. Asthma & Indoor Air Pollution • Prevention • No smoking • Control moisture The Mid-Atlantic Center for Children’s Health & the Environment

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

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

30. 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

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

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

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

34. 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 285:897-905, 2001. The Mid-Atlantic Center for Children’s Health & the Environment

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

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

37. 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

38. 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

39. Control and Prevention of Outdoor Air Pollution Toyota Prius Honda Insight  GM EV1 Nissan LEAF

40. Air Quality Index

41. AIRNow - www.airnow.gov

42. THE MID-ATLANTIC CENTER FOR CHILDREN’S HEALTH & THE ENVIRONMENT(MACCHE) A PEDIATRIC ENVIRONMENTAL HEALTH SPECIALTY UNIT (PEHSU) The Mid-Atlantic Center for Children’s Health & the Environment

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