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Devorah Adler's Files
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EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF MANAGEMENT AND BUDGET
Route Slip
To: Devorah Adler
Take necessary action
[
]
Approval or signature
[
]
Comment
[ ]
Prepare reply
[ ]
Discuss with me
[ ]
For your information
[x]
See remarks below
[x]
From: Claudia Magdalena Abendroth
Date: January 5, 1999
SUBJECT: EPA's Children's Asthma Initiative - FY 2000 request
As you requested, attached please find information on EPA's FY 2000 budget request for
children's asthma. The first table presents the funding request and OMB Final levels among
research, education and outreach, and air monitoring components. The second table is EPA's
table for its FY 2000 request, detailed by program activity and by FY 99 enacted level, FY 2000
guidance, and FY 2000 above guidance request. I understand that you have received the Asthma
in America: Our Children at Risk Draft Workplan, drafted by the Task Force on Environmental
Health Risks and Safety Risk to Children, dated November 19, 1998; therefore, I have not
included it as an attachment.
EPA's Children's Asthma Initiative
1999
2000
2000 OMB
OMB Final from
Pres Bud
Request
Final
1999 Enacted
EPA Total
5
29
23
+18
research
3
11
5
+2
education and outreach
2
14
14
+12
air monitoring
-
4
4
+4
05. january 1999
DOUG SOH 2604724
EPA Asthma Initiative
President's Task Force on Environmental Health Risks and Safety Risks to Children
FY99 Presidents Budget
FY2000 OMB Submission
'Over target" Request to OMB
$6,800 K
$17,000 K
"Level
'Level 2"
Activity/Output
$$
Activity/Output
$$
Activity/Output
$$
3.3
2.
ORD (Goal 8)
$AM
$ M
$6 M
Centers for Children's
$ M
Role of Environmental
$ .9 M
Role of Environmental
$1.5 M
Environmental Health and
Pollutants in the Induction
Pollutants in the Exacerbation
Prevention Research
3.3
of Asthma A multi-
of Asthma A multi-
Program
disciplinary approach
disciplinary approach
incorporating human exposure,
incorporating human
toxicologic, clinical and
exposure, toxicologic,
epidemiologic studies would
clinical and epidemiologic
be employed to evaluate the
studies would be employed
role of exposure to ambient air
to evaluate the role of
pollutants and indoor air
exposure to ambient air
contaminants on the frequency
pollutants, indoor air
and severity of asthma attacks
in children.
contaminants, pesticides,
and other volatile organic
Role of Environmental
compounds in the induction
Pollutants in Allergic
$ 1.5 M
of asthma.
Sensitization - A multi-
disciplinary approach
incorporating human exposure,
toxicologic, clinical and
epidemiologic studies would
be employed to evaluate the
role of exposure to ambient air
pollutants indoor air
contaminants, and pesticides in
the development of allergic
sensitization and asthma in
children.
Multimedia pollutants and
childhood experience of
$ 3 M
asthma - A longitudinal study
(prenatal through adolescence)
of the role of exposure to
ambient air pollutant, indoor
air contaminants, and
pesticides on allergic
sensitization, incidence of
asthma, asthma severity, and
the timing of asthma attacks in
one or more well-characterized
birth cohorts of children at
high risk for the development
of asthma.
Buy Clean (joint w/
$ .4 M
OPPTS)
EPA Asthma Initiative
President's Task Force on Environmental Health Risks and Safety Risks to Children
FY99 Presidents Budget
FY2000 OMB Submission
"Over target" Request to OMB
$6,800 I K
+ $17,000 K
Level I
Level 2"
Activity/Output
$$
Activity/Output
$$
Activity/Output
$$
Indoor Air (IED/OAR)
$1.5 M
$5.0 I M
$7.5 M
Open Airways
$ M
Open Airways
$ 1.5M
Open Airways program in
$2 M
Support to American Lung
Expand implementation of
1700 additional elementary
Association to implement
the ALA Open Airways
schools
asthma management
asthma management
program in elementary
program to 1250
A is for Asthma program
$ .5 M
schools.
elementary schools.
for pre-school children to
89 ALA affiliates.
Managed Care/Health Care
$ 2M
Managed Care/Health Care
$1 M
Economic analysis to
develop incentives for
--Cabinet level summit with
managed care
managed care CEOs
--State-wide urban
environmental asthma
summits in 5 states
--National Environmental
Asthma Caucus for
practitioners, researchers,
industry and government
National Asthma Media
$ .6 M
Expand National Asthma
$.5 M
Expand National Asthma
$.4 M
Campaign
Media Campaign
Media Campaign One
National asthma prevention
National asthma prevention
additional wave of
campaign targeted to urban
campaign targeted to urban
multimedia national asthma
residents
residents
prevention campaign.
IAQ Tools for Schools
$ .3
IAQ Tools for Schools
$1.5M
IAQ Tools for Schools
$2.5 M
Expand implementation of
--Develop and implement
Tools for Schools program
partnership/recognition
to 1250 schools
program for schools.
--Expand implementation
of Tools for Schools
program to 3250 schools
ETS
ETS
ETS
Media Campaign
$ .5 M
$ .8 M
Media Campaign
Fund local communities
$ 1.1 M
One wave of ETS media
Two additional waves of
through established tobacco
campaign to get "smoke
national ETS media
control programs to work
outside" message to
campaign to get multiple
through doctors, health
smoking parents.
messages to smoking
clinics, civic groups to
parents.
discourage children's
exposure to ETS.
G8 ETS Implementation
Strategy
$ .5 M
EPA Asthma Initiative
President's Task Force on Environmental Health Risks and Safety Risks to Children
FY99 Presidents Budget
FY2000 OMB Submission
"Over target" Request to OMB
$6,800 K
+ $17,000 K
"Level
"Level 2"
Activity/Output
$$
Activity/Output
$$
Activity/Output
$$
Ambient Air Pollution (OAQPS/OAR)
$3.5 M
Expand ambient
monitoring network for
ozone and particulates to
areas downwind of 3-5
urban areas to increase
exposure information
that can be correlated
with asthma surveillance
data.²
OPPTS
$.5M
Buy Clean
$.5M
I $1.5 M included for Regional implementation plus $.5 M for G 8 Implementation requested by the Office of International
Activities.
2 Traditional ozone monitoring network is found within urban areas. With increasing urban sprawl, exposure of
populations downwind of high ozone areas is believed to be significant. Enhanced monitoring capability for ozone
and PMoutside the immediate urban area would add improved understanding of human exposure on a regional
scale for ozone and PM problem.
Bill Summary & Status
http://thomas.loc.gov/cgi-bin/bdqu./-bd4nBq:@@@L/bss/d106query.html)
Bill Summary & Status for the 106th Congress
ASTHMA
Item 10 of 17
PREVIOUS BILL I NEXT BILL
PREVIOUS BILL:ALL
I
NEXT BILL:ALL
NEW SEARCH I HOME I HELP
S.805
SPONSOR: Sen Durbin, Richard J. (introduced 04/15/99)
Jump to: Titles, Status, Committees, Amendments, Cosponsors, Summary
TITLE(S):
SHORT TITLE(S) AS INTRODUCED:
Children's Asthma Relief Act of 1999
OFFICIAL TITLE AS INTRODUCED:
A bill to amend title V of the Social Security Act to provide for the establishment and operation of
asthma treatment services for children, and for other purposes.
STATUS: Floor Actions
***NONE***
STATUS: Detailed Legislative Status
Senate Actions
Apr 15, 99:
Read twice and referred to the Committee on Finance.
STATUS: Congressional Record Page References
04/15/99 Introductory remarks on Measure (CR S3777)
04/15/99 Full text of Measure as introduced printed (CR S3777-3779)
COMMITTEE(S):
COMMITTEE(S) OF REFERRAL:
Senate Finance
AMENDMENT(S):
***NONE***
COSPONSORS(3):
Sen DeWine, Michael - 04/15/99 Sen Kennedy, Edward M. - 04/15/99
Sen Schumer, Charles E. - 04/15/99
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Bill Summary & Status
http://thomas.loc.gov/cgi-bin/bdqu..-bd4nBq.@@@L/bss/d106query.html]
SUMMARY:
***NONE***
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S 805 IS
106th CONGRESS
1st Session
S. 805
To amend title V of the Social Security Act to provide for the establishment and operation of asthma
treatment services for children, and for other purposes.
IN THE SENATE OF THE UNITED STATES
April 15, 1999
Mr. DURBIN (for himself, Mr. DEWINE, Mr. KENNEDY, and Mr. SCHUMER) introduced the
following bill; which was read twice and referred to the Committee on Finance
A BILL
To amend title V of the Social Security Act to provide for the establishment and operation of asthma
treatment services for children, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in
Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Children's Asthma Relief Act of 1999'.
SEC. 2. FINDINGS.
(a) FINDINGS- Congress makes the following findings:
(1) Asthma is one of the Nation's most common and costly diseases. It affects an estimated
14,000,000 to 15,000,000 individuals in the United States, including almost 5,000,000
children.
(2) Asthma is often a chronic illness that is treatable with ambulatory care, but over 43
percent of its economic impact comes from use of emergency rooms, hospitalization, and
death.
(3) In Illinois, the mortality rate for blacks from asthma is the highest in the nation with 60.8
deaths per every 1,000,000 population. In Ohio, the mortality rate for blacks from asthma is
32.2 per 1,000,000 population and the mortality rate for whites from asthma is 11.7 per
1,000,000.
(4) In 1995, there were more than 1,800,000 emergency room visits made for asthma-related
attacks and among these, the rate for emergency room visits was 48.8 per 10,000 visits
among whites and 228.9 per 10,000 visits among blacks.
(5) Hospitalization rates were highest for individuals 4 years old and younger, and were
10.9 per 10,000 visits for whites and 35.5 per 10,000 visits for blacks.
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(6) From 1979 to 1992, the hospitalization rates among children due to asthma increased 74
percent.
(7) It is estimated that more than 7 percent of children now have asthma.
(8) Although asthma can occur at any age, about 80 percent of the children who will
develop asthma do so before starting school.
(9) From 1980 to 1994, the most substantial prevalence rate increase for asthma occurred
among children aged 0-4 years (160 percent) and persons aged 5-14 years (74 percent).
(10) Asthma is the most common chronic illness in childhood, afflicting nearly 5,000,000
children under age 18, and costing an estimated $1,900,000,000 to treat those children. The
death rate for children age 19 and younger increased by 78 percent between 1980 and 1993.
(11) Children aged 0 to 5 years who are exposed to maternal smoking are 201 times more
likely to develop asthma compared with those free from exposure.
(12) Morbidity and mortality related to childhood asthma are disproportionately high in
urban areas.
(13) Minority children living in urban areas are especially vulnerable to asthma. In 1988,
national prevalence rates were 26 percent higher for black children than for white children.
(14) Certain pests known to create public health problems occur and proliferate at higher
rates in urban areas. These pests may spread infectious disease and contribute to the
worsening of chronic respiratory illnesses, including asthma.
(15) Research supported by the National Institutes of Health demonstrated that the
combination of cockroach allergen, house dust mites, molds, tobacco smoke, and feathers
are important causes of asthma-related illness and hospitalization among children in
inner-city areas of the United States.
(16) Cities outside the United States have developed and implemented effective systems of
cockroach management.
(17) Integrated pest management is a cost-effective approach to pest control that emphasizes
prevention and uses a range of techniques, including property maintenance and cleaning,
and pesticides as a means of last resort.
(18) Reducing exposure to cockroach allergen, as part of an integrated approach to asthma
management, may be a cost-effective way of reducing the social and economic costs of the
disease.
(19) No current Federal funding exists specifically to assist cities in developing and
implementing integrated strategies to reduce cockroach infestation.
(20) Asthma is the most common cause of school absenteeism due to chronic illness with
10,100,000 days missed from school per year in the United States.
(21) According to a 1995 National Institute of Health workshop report, missed school days
accounted for an estimated cost of lost productivity for parents of children with asthma of
almost $1,000,000,000 per year.
(22) According to data from the 1988 National Health Interview Survey (NHIS), which
surveyed children for their health experiences over a 12-month period, 25 percent of those
children reported experiencing a great deal of pain or discomfort due to asthma either often
or all the time during the previous 12 months.
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(23) Managing asthma requires a long-term, multifaceted approach, including patient
education, behavior changes, avoidance of asthma triggers, pharmacologic therapy, and
frequent medical follow-up.
(24) Enhancing the available prevention, educational, research, and treatment resources with
respect to asthma in the United States will allow our Nation to address more effectively the
problems associated with this increasing threat to the health and well-being of our citizens.
SEC. 3. CHILDREN'S ASTHMA RELIEF.
Title V of the Social Security Act (42 U.S.C. 701 et seq.) is amended by adding at the end the
following:
'SEC. 511. ASTHMA TREATMENT GRANTS PROGRAM.
(a) PURPOSES- The purposes of this section are as follows:
'(1) To provide access to quality medical care for children who live in areas that have a high
prevalence of asthma and who lack access to medical care.
'(2) To provide on-site education to parents, children, health care providers, and medical
teams to recognize the signs and symptoms of asthma, and to train them in the use of
medications to prevent and treat asthma.
'(3) To decrease preventable trips to the emergency room by making medication available to
individuals who have not previously had access to treatment or education in the prevention
of asthma.
'(4) To provide other services, such as smoking cessation programs, home modification, and
other direct and support services that ameliorate conditions that exacerbate or induce
asthma.
`(b) AUTHORITY TO MAKE GRANTS-
`(1) IN GENERAL- In addition to any other payments made under this title, the Secretary
shall award grants to eligible entities to carry out the purposes of this section, including
grants that are designed to develop and expand projects to--
'(A) provide comprehensive asthma services to children, including access to care and
treatment for asthma in a community-based setting;
'(B) fully equip mobile health care clinics that provide preventive asthma care
including diagnosis, physical examinations, pharmacological therapy, skin testing,
peak flow meter testing, and other asthma-related health care services;
'(C) conduct study validated asthma management education programs for patients
with asthma and their families, including patient education regarding asthma
management, family education on asthma management, and the distribution of
materials, including displays and videos, to reinforce concepts presented by medical
teams; and
`(D) identify eligible children for the medicaid program under title XIX, the State
Children's Health Insurance Program under title XXI, or other children's health
programs.
'(2) AWARD OF GRANTS-
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'(A) APPLICATION-
`(i) IN GENERAL- An eligible entity shall submit an application to the
Secretary for a grant under this section in such form and manner as the
Secretary may require.
`(ii) REQUIRED INFORMATION- An application submitted under this
subparagraph shall include a plan for the use of funds awarded under the grant
and such other information as the Secretary may require.
'(B) REQUIREMENT- In awarding grants under this section, the Secretary shall give
preference to eligible entities that demonstrate that the activities to be carried out
under this section shall be in localities within areas of known
high prevalence of childhood asthma or high asthma-related mortality (relative to the average asthma
incidence rates and associated mortality rates in the United States). Acceptable data sets to demonstrate a
high prevalence of childhood asthma or high asthma-related mortality may include data from Federal,
State, or local vital statistics, title XIX or XXI claims data, other public health statistics or surveys, or
other data that the Secretary, in consultation with the Director of the Centers for Disease Control and
Prevention, deems appropriate.
'(3) DEFINITION OF ELIGIBLE ENTITY- In this section, the term `eligible entity' means
a State agency or other entity receiving funds under this title, a local community, a nonprofit
children's hospital or foundation, or a nonprofit community-based organization.
`(c) COORDINATION WITH OTHER CHILDREN'S PROGRAMS- An eligible entity shall
identify in the plan submitted as part of an application for a grant under this section how the entity
will coordinate operations and activities under the grant with--
'(1) other programs operated in the State that serve children with asthma, including any
such programs operated under this title, title XIX, and title XXI; and
'(2) one or more of the following--
'(A) the child welfare and foster care and adoption assistance programs under parts B
and E of title IV;
'(B) the head start program established under the Head Start Act (42 U.S.C. 9831 et
seq.);
'(C) the program of assistance under the special supplemental nutrition program for
women, infants and children (WIC) under section 17 of the Child Nutrition Act of
1966 (42 U.S.C. 1786);
'(D) local public and private elementary or secondary schools; or
`(E) public housing agencies, as defined in section 3 of the United States Housing Act
of 1937 (42 U.S.C. 1437a).
`(d) EVALUATION- An eligible entity that receives a grant under this section shall submit to the
Secretary an evaluation of the operations and activities carried out under the grant that includes--
'(1) a description of the health status outcomes of children assisted under the grant;
'(2) an assessment of the utilization of asthma-related health care services as a result of
activities carried out under the grant;
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'(3) the collection, analysis, and reporting of asthma data according to guidelines prescribed
by the Director of the Centers for Disease Control and Prevention; and
'(4) such other information as the Secretary may require.
'(e) APPLICATION OF OTHER PROVISIONS OF TITLE-
'(1) IN GENERAL- Except as provided in paragraph (2), the other provisions of this title
shall not apply to a grant made under this section.
'(2) EXCEPTIONS- The following provisions of this title shall apply to a grant made under
this section to the same extent and in the same manner as such provisions apply to
allotments made under section 502(c):
'(A) Section 504(b)(4) (relating to expenditures of funds as a condition of receipt of
Federal funds).
'(B) Section 504(b)(6) (relating to prohibition on payments to excluded individuals
and entities).
'(C) Section 506 (relating to reports and audits, but only to the extent determined by
the Secretary to be appropriate for grants made under this section).
`(D) Section 508 (relating to nondiscrimination).
`(f) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated to
carry out this section $50,000,000 for each of the fiscal years 2000 through 2004.'.
SEC. 4. INCORPORATION OF ASTHMA PREVENTION TREATMENT AND
SERVICES INTO STATE CHILDREN'S HEALTH INSURANCE PROGRAMS.
(a) IN GENERAL- The Secretary of Health and Human Services shall, in accordance with
subsection (b), carry out a program to encourage States to implement plans to carry out activities
to assist children with respect to asthma in accordance with guidelines of the National Asthma
Education and Prevention Program (NAEPP) and the National Heart, Lung and Blood Institute.
(b) RELATION TO CHILDREN'S HEALTH INSURANCE PROGRAM-
(1) IN GENERAL- Subject to paragraph (2), if a State child health plan under title XXI of
the Social Security Act (42 U.S.C. 1397aa et seq.) provides for activities described in
subsection (a) to an extent satisfactory to the Secretary, the Secretary shall, with amounts
appropriated under subsection (c), make a grant to the State involved to assist the State in
carrying out such activities.
(2) CRITERIA REGARDING ELIGIBILITY FOR GRANT- The Secretary shall publish in
the Federal Register criteria describing the circumstances in which the Secretary will
consider a State plan to be satisfactory for purposes of paragraph (1).
(3) REQUIREMENT OF MATCHING FUNDS-
(A) IN GENERAL- With respect to the costs of the activities to be carried out by a
State pursuant to paragraph (1), the Secretary may make a grant under such paragraph
only if the State agrees to make available (directly or through donations from public
or private entities) non-Federal contributions toward such costs in an amount that is
not less than 15 percent of the costs.
(B) DETERMINATION OF AMOUNT CONTRIBUTED- Non-Federal contributions
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required in subparagraph (A) may be in cash or in kind, fairly evaluated, including
equipment or services. Amounts provided by the Federal Government, or services
assisted or subsidized to any significant extent by the Federal Government, may not
be included in determining the amount of such non-Federal contributions.
(4) TECHNICAL ASSISTANCE- With respect to State child health plans under title XXI
of the Social Security Act (42 U.S.C. 1397aa et seq.), the Secretary, acting through the
Director of the Centers for Disease Control and Prevention, in consultation with the heads
of other Federal agencies involved in asthma treatment and prevention, shall make available
to the States technical assistance in developing the provision of such plans that will provide
for activities pursuant to paragraph (1).
(c) FUNDING- For the purpose of carrying out this section, there is authorized to be appropriated
$5,000,000 for each of the fiscal years 2000 through 2004.
SEC. 5. PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT;
SYSTEMS FOR REDUCING ASTHMA AND ASTHMA-RELATED ILLNESSES
THROUGH URBAN COCKROACH MANAGEMENT.
Section 1904(a)(1) of the Public Health Service Act (42 U.S.C. 300w-3(a)(1)) is amended--
(1) by redesignating subparagraphs (E) and (F) as subparagraphs (F) and (G), respectively;
(2) by adding a period at the end of subparagraph (G) (as so redesignated);
(3) by inserting after subparagraph (D), the following:
`(E) The establishment, operation, and coordination of effective and cost-efficient systems
to reduce the prevalence of asthma and asthma-related illnesses among urban populations,
especially children, by reducing the level of exposure to cockroach allergen through the use
of integrated pest management, as applied to cockroaches. Amounts expended for such
systems may include the costs of structural rehabilitation of housing, public schools, and
other public facilities to reduce cockroach infestation, the costs of building maintenance,
and the costs of programs to promote community participation in the carrying out at such
sites integrated pest management, as applied to cockroaches. For purposes of this
subparagraph, the term `integrated pest management' means an approach to the management
of pests in public facilities that minimizes or avoids the use of pesticide chemicals through a
combination of
appropriate practices regarding the maintenance, cleaning, and monitoring of such sites.';
(4) in subparagraph (F) (as so redesignated), by striking `subparagraphs (A) through (D)'
and inserting subparagraphs (A) through (E)'; and
(5) in subparagraph (G) (as so redesignated), by striking `subparagraphs (A) through (E)'
and inserting subparagraphs (A) through (F)'.
SEC. 6. COORDINATION OF FEDERAL ACTIVITIES TO ADDRESS
ASTHMA-RELATED HEALTH CARE NEEDS.
(a) IN GENERAL- The Director of the National Heart, Lung, and Blood Institute shall, through
the National Asthma Education Prevention Program Coordinating Committee--
(1) identify all Federal programs that carry out asthma-related activities;
(2) develop, in consultation with appropriate Federal agencies and professional and
voluntary health organizations, a Federal plan for responding to asthma; and
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(3) not later than 12 months after the date of enactment of this Act, submit
recommendations to Congress on ways to strengthen and improve the coordination of
asthma-related activities of the Federal Government.
(b) REPRESENTATION OF THE DEPARTMENT OF HOUSING AND URBAN
DEVELOPMENT- A representative of the Department of Housing and Urban Development shall
be included on the National Asthma Education Prevention Program Coordinating Committee for
the purpose of performing the tasks described in subsection (a).
(c) AUTHORIZATION OF APPROPRIATIONS- Out of any funds otherwise appropriated for the
National Institutes of Health, $5,000,000 shall be made available to the National Asthma
Education Prevention Program for the period of fiscal years 2000 through 2004 for the purpose of
carrying out this section. Funds made available under this subsection shall be in addition to any
other funds appropriated to the National Asthma Education Prevention Program for any fiscal year
during such period.
SEC. 7. COMPILATION OF DATA BY THE CENTERS FOR DISEASE
CONTROL AND PREVENTION.
(a) IN GENERAL- The Director of the Centers for Disease Control and Prevention, in
consultation with the National Asthma Education Prevention Program Coordinating Committee,
shall--
(1) conduct local asthma surveillance activities to collect data on the prevalence and severity
of asthma and the quality of asthma management, including--
(A) telephone surveys to collect sample household data on the local burden of asthma;
and
(B) health care facility specific surveillance to collect asthma data on the prevalence
and severity of asthma, and on the quality of asthma care; and
(2) compile and annually publish data on--
(A) the prevalence of children suffering from asthma in each State; and
(B) the childhood mortality rate associated with asthma nationally and in each State.
(b) COLLABORATIVE EFFORTS- The activities described in subsection (a)(1) may be
conducted in collaboration with eligible entities awarded a grant under section 511 of the Social
Security Act (as added by section 3).
END
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DRAFT
10/22/98
Asthma in America:
Our Children at Risk
A Plan for Environmental Action
to Protect Children from Asthma
President's Task Force on Environmental Health
Risks and Safety Risks to Children
ABOUT THE PRESIDENT'S TASK FORCE ON
ENVIRONMENTAL HEALTH RISKS AND SAFETY RISKS TO
CHILDREN
In recognition of the growing body of scientific information demonstrating that America's
children suffer disproportionately from environmental health risks and safety risks, President
Clinton issued Executive Order 13045 on April 21, 1997, directing each Federal Agency to
make it a high priority to identify, assess, and address those risks. In issuing this order, the
President also created the Task Force on Environmental Health Risks and Safety Risks to
Children, co-chaired by Donna Shalala, Secretary of the Department of Health and Human
Services, and Carol M. Browner, Administrator of the Environmental Protection Agency. The
Task Force was charged with recommending strategies for protecting
children's environmental health and safety. Two subcommittees were
established in the Executive Order to carry out this directive: a
subcommittee directed to review and foster public access to federal
government sponsored research on environmental health and safety
risks to children, and a subcommittee directed to identify priority public
outreach activities related to protecting children's environmental health
and safety.
In April 1998, the Task Force identified four priority areas for immediate attention: childhood
asthma, unintentional injuries, developmental disorders, and childhood cancer. The Task Force
created and charged the Asthma Priority Area Workgroup with reviewing current Federal efforts
to address the many facets of the issue and, most importantly, to make appropriate
recommendations for action by the Federal government. This report is the result of that effort.
TABLE OF CONTENTS
ABOUT THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH RISKS
AND SAFETY RISKS TO CHILDREN
1
MEMBERS OF THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH
RISKS AND SAFETY RISKS TO CHILDREN
3
ASTHMA PRIORITY AREA WORKGROUP MEMBERS
5
EXECUTIVE SUMMARY
6
INTRODUCTION
8
The Growing Problem of Asthma in Children
8
What We Know About Childhood Asthma
9
Why Has Asthma Reached Epidemic Proportions in Children?
11
Scope of the Plan for Environmental Action to Protect Children
11
GOALS OF THE ACTION PLAN
12
VISION FOR THE 21ˢᵗ CENTURY
13
GUIDING PRINCIPLES
14
RECOMMENDATIONS
16
RESEARCH
16
PROGRAMS TO IMPROVE PUBLIC HEALTH
19
SURVEILLANCE
23
DISPROPORTIONATE IMPACTS ON THE POOR AND MINORITIES
24
GLOSSARY
26
ADDITIONAL READING
27
TIPS FOR AVOIDING AND CONTROLLING ASTHMA TRIGGERS
28
2
MEMBERS OF THE PRESIDENT'S TASK FORCE ON
ENVIRONMENTAL HEALTH RISKS AND SAFETY RISKS TO
CHILDREN
Honorable Donna E. Shalala
Honorable Rodney Slater
Co-chair
Secretary
Secretary
Department of Transportation
Department of Health and Human Services
Honorable Jacob J. Lew, Director
Honorable Carol M. Browner
Office of Management and Budget
Co-chair
Administrator
Honorable Kathleen McGinty, Chair
Environmental Protection Agency
Council on Environmental Quality
Honorable Alexis Herman
Honorable Ann Brown
Secretary
Chairman
Department of Labor
Consumer Product Safety Commission
Honorable Janet Reno
Honorable Janet Yellen
Attorney General
Chair
Department of Justice
Council of Economic Advisors
Honorable Andrew Cuomo
Honorable Neal Lane Director
Secretary
Office of Science and Technology Policy
Department of Housing and Urban
Development
Honorable Gene Sperling
Assistant to the President for Economic Policy
Honorable Elizabeth A. Moler
Acting Secretary
Honorable Bruce Reed
Department of Energy
Assistant to the President for Domestic Policy
Honorable Richard Riley
Secretary
Department of Education
Honorable Dan Glickman
Secretary
Department of Agriculture
3
ASTHMA PRIORITY AREA WORKGROUP MEMBERS
Stephen Redd, MD (Co-chair)
Virginia Taggart, M.P.H.
National Center for Environmental Health
National Heart, Lung. and Blood Institute
Centers for Disease Control and Prevention
National Institutes of Health
Robert Axelrad (Co-chair)
Hillel Koren, PhD.
Office of Children's Health Protection
National Health and Environmental Effects Laboratory
Environmental Protection Agency
Office of Research and Development
Environmental Protection Agency
Adele C. Morris
Senior Economist
Caroline Freeman
Council of Economic Advisers
Occupational Safety and Health Administration
Department of Labor
Mary White, Sc.D
Division of Health Studies
George Malindzak. PhD
Agency for Toxic Substances and Disease Registry
National Institute of Environmental Health Sciences
National Institutes of Health
John Talbott
Office of Building Technologies
Lucas Neas, PhD
Department of Energy
National Health and Environmental Effects Laboratory
Office of Research and Development
Ron Ashford
Environmental Protection Agency
Department of Housing and Urban Development
Edward Chu
Warren Friedman, Ph.D, CIH
Office of Children's Health Protection
Office of Lead Hazard Control
Environmental Protection Agency
Department of Housing and Urban Development
Marilyn Wind
Tracey Mitchell
Consumer Product Safety Commission
Indoor Environments Division
Environmental Protection Agency
Stacey Katz
Office of Science Policy
Marshall Plaut, M.D.
Department of Health and Human Services
National Institute of Allergy and Infectious Diseases
National Institutes of Health
Polly Hoppin, ScD
Office of Science Policy
Jerry Phelps
Department of Health and Human Services
National Institute of Environmental Health Sciences
National Institutes of Health
4
EXECUTIVE SUMMARY
An epidemic of asthma is occurring in the United States. While the epidemic affects people of
all ages, children are particularly affected. Nearly I in 13 school-aged children has asthma, and
the percentage of children with asthma (i.e., prevalence rate) is rising more rapidly in preschool-
aged children than in any other age group.
There is no national system to collect data from states specifically on
An epidemic
asthma, although several states are developing systems to collect such
of asthma is
data. Although national data do not provide the resolution necessary to
occurring in
identify particular geographic areas hardest hit by the asthma epidemic,
the United
surveys undertaken in a number of large cities in the United States
States.
indicate that the prevalence and severity of asthma are greatest in the
large, urban inner cities.
Asthma is one of the leading causes of school absenteeism, accounting for over 10 million
missed school days per year. Asthma also accounts for many nights of interrupted sleep,
limitation of activity, and disruptions of family and care-giver routines. Asthma symptoms that
are not severe enough to require a visit to an emergency room or to a physician can still be
severe enough to prevent a child with asthma from living a fully active life.
In 1990, the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the
majority of the expense attributed to direct medical expenses. A 1996 analysis found the cost of
asthma to be $14 billion, indicating a rapidly increasing financial burden. These estimates,
which are not limited to the costs of childhood asthma, indicate that the direct medical costs of
asthma account for between 1% and 3% of all health care expenditures in the United States.
Asthma is a particularly important disease to consider in the context of environmental hazards
to which children are exposed. Children breathe more air, eat more food, and drink more liquid
in proportion to their body weight than do adults, and their developing respiratory,
immunological, and digestive systems may be more susceptible to environmental exposures than
those of adults. In a typical day, children may be exposed to a wide array of environmental
agents at home, in day care centers, schools and while playing outdoors. There is substantial
evidence that environmental exposures, including viruses and allergens, play a major role in
triggering asthma symptoms. Airborne allergens include those from house dust mites,
cockroaches, mold and animal dander. In addition, exposure to environmental tobacco smoke
has been shown to be a major determinant of asthma symptoms. Elevated levels of outdoor air
pollutants, particularly ozone, are associated with increased symptoms and an increased risk of
emergency department visits for asthma, as well.
In addition, environmental factors such as airborne allergens and environmental tobacco smoke
(i.e., secondhand smoke) may play a major role in the onset of asthma. Other pollutants may
also play a role, although the scientific data are inadequate to offer firm conclusions. Genetic
5
predisposition is the strongest known risk factor for developing asthma, but the rapidly rising
number of cases of childhood asthma cannot be solely genetic because the genetic composition
of the population changes slowly. Rather, some interaction between genetic predisposition and
environmental exposures, and possibly other factors such as diet or lack of exercise are likely to
be responsible for the increase. Further work is essential to clarify how genetic susceptibility
and environmental exposures interact to cause asthma.
Reducing exposures of children with asthma to airborne allergens and pollutants will reduce the
health burden of asthma and significantly improve their quality of life. It is not yet certain, but
it is possible that reducing the exposure of infants and young children at risk of developing
asthma may prevent its onset. Environmental control methods and asthma treatments are
available now that can help children and their families control asthma and lead healthy, active
lives. Yet not all children have access to these measures. Too many children miss school, limit
their physical activity, and are seriously ill because of asthma.
The environmental action plan for asthma outlined in this report is
designed to promote concerted Federal action to protect all children
with asthma from environmental risks that worsen their disease and
to expand federal research to reveal how reducing environmental
risks might prevent children from getting asthma.
GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this initiative are
predicated on the principles that federal action must have:
A focus on efforts to eliminate the disproportionate impact of asthma in minority
populations and those living in poverty.
An emphasis on partnerships and community based programs.
A commitment to setting measurable and consistent goals for childhood asthma under
the Healthy People 2010 program.
An investment in evaluation to identify those strategies that are most effective in
reducing the burden of asthma so that they may be replicated.
6
RECOMMENDATIONS FOR ACTION
RESEARCH
Strengthen and accelerate focused research into the environmental factors that cause or worsen
childhood asthma.
Strengthen and accelerate research into the environmental factors
This year 2000
that may contribute to the onset of asthma in children.
initiative is
about
Expand and accelerate research to develop and evaluate
protecting
environmental strategies that will improve the quality of life of
children from
people with asthma.
asthma..
PUBLIC HEALTH PROGRAMS
Implement public health programs that foster improved use of current scientific knowledge to reduce
environmental exposures to prevent and reduce the severity of symptoms for those with asthma.
Promote clinician and patient implementation of national guidelines for reducing
environmental risks that worsen asthma.
Expand support for state and local public health action.
Reduce children's exposure to environmental tobacco smoke and other indoor triggers in
their homes.
Establish school based asthma programs in every community that help reduce or
eliminate allergens and irritants and that promote student's self management of asthma
and full participation in school activities.
Continue to reduce outdoor air pollution.
SURVEILLANCE
Establish a coordinated, integrated, and systematic nationwide asthma surveillance system for collecting
and analyzing health outcome and risk factor data at the state, regional and local levels.
DISPROPORTIONATE IMPACT ON THE POOR AND MINORITIES
Eliminate the disproportionate burden of asthma among different racial and ethnic groups and those
living in poverty.
Conduct research and surveillance activities to improve
understanding of the problem.
Implement activities to eliminate the disproportionate impact
of asthma in minority populations and those living in poverty.
7
INTRODUCTION
The Growing Problem of Asthma in Children
Asthma is a chronic lung disease characterized by recurrent episodes of breathlessness,
wheezing, coughing, and chest tightness; these episodes are also known as exacerbations or
attacks. The severity of exacerbations can range from mild to life threatening. Both the
frequency and severity of asthma symptoms can be reduced by the use of medications and by
reducing exposure to the environmental triggers of asthma attacks.
For the past 15 years, an epidemic of asthma has occurred in the United
States. By all indications, this epidemic is continuing. Although asthma
has become a major public health problem affecting Americans of all ages,
races and ethnic groups, children have been particularly severely affected.
National survey data -- the responses of randomly selected U.S. residents
being asked whether they had symptoms of physician diagnosed asthma in the previous 12
months -- indicate that the number of children with asthma in the United States has more than
doubled in the past 15 years. In 1980, 2.3 million American children had asthma. In 1995, the
most recent year for which data are available, the number of affected children had risen to 5.5
million. Based on these trends, it is estimated that in 1998 more than 6 million children in the
United States have asthma. Prevalence rates of asthma are highest in boys and are increasing in
both boys and girls, and in all race and ethnic groups. The prevalence of asthma in children
under age 18 is 7.3%. The most rapid increase has occurred in children under 5 years old, with
rates increasing over 160% over the past 15 years.
The number of deaths attributed to asthma in children has also increased. In 1977, 84 deaths in
children 18 and younger were recorded; the number of deaths has risen to 280 in 1995, a more
than 3-fold increase. Although the death rate due to asthma has increased in all racial and ethnic
groups, minority populations experience a disproportionately higher death rate from asthma. In
1995, the death rate from asthma in African-American children, 11.5 per million, was over four
times the rate in white Americans, 2.6 per million. The higher death rates among African-
American children are especially troubling.
The number of hospitalizations and emergency room visits for asthma have increased in all
population groups. Asthma accounts for one-third of all pediatric emergency room visits and is
the fourth most common cause for physician office visits. The variation in the impact of asthma
across racial and ethnic groups is significant. African American children have an annual rate of
hospitalization of 74 per 10,000, over 3 times that for whites, 21 per 10,000. In addition,
African American children are approximately 4 times more likely than white children to seek
care at an emergency room. In short, African-American children have a slightly higher risk of
getting asthma, but have a much higher risk of hospitalization or death due to the disease.
8
At the present time, surveillance for asthma in children is limited to analyses of ongoing surveys
and data systems on health events such as mortality, hospitalization, and outpatient visits. Other
than for African Americans, such information is extremely limited for most ethnic groups.
There is no national system to collect data from states specifically on asthma, although several
states are developing systems to collect such data. Although national data do not provide the
resolution necessary to identify particular geographic areas hardest hit by the asthma epidemic,
surveys undertaken in a number of large cities in the United States indicate
that the prevalence and severity of asthma are greatest in the large, urban
There is no
inner cities.
national system
to collect data
These measures, particularly for death, hospitalization, and emergency room
from states
visits, give an incomplete picture of the true burden of asthma in the United
specifically on
States. For example, one follow-up study of children with asthma in inner
asthma,
city areas found a nearly 10 times higher likelihood of a child suffering
although several
symptoms of asthma on a given day than visiting an emergency room.
states are
Asthma is one of the leading causes of school absenteeism, accounting for
developing
over 10 million missed school days per year. Asthma also accounts for many
systems to
nights of interrupted sleep, limitation of activity, and disruptions of family
collect such
and care-giver routines. Asthma symptoms that are not severe enough to
data.
require a visit to an emergency room or to a physician can still be severe
enough to prevent a child with asthma from living a fully active life.
Estimating the costs of asthma is an indirect way to measure its health burden. In 1990, the cost
of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority of the expense
attributed to direct medical expenses. A 1996 analysis found the cost of asthma to be $14
billion, indicating a rapidly increasing financial burden. These estimates indicate that the direct
medical costs of asthma for all ages account for between 1% and 3% of all health care
expenditures in the United States.
What We Know About Childhood Asthma
Over the past 15 years, there have been major advances in the scientific understanding of
asthma. Asthma is now known to be a disease of airway inflammation resulting from a complex
interplay between environmental exposures and genetic and other factors. This has implications
for the medical treatment and for the environmental management of asthma.
In contrast to the limited understanding of the relationship of environmental exposures to the
onset of asthma, the environmental triggers of asthma attacks for children with asthma have
become increasingly well characterized. House dust mites, cockroaches, mold and animal
dander have been identified as the principal allergens that trigger asthma symptoms. Reducing
exposure to these allergens has been shown not only to reduce asthma symptoms and the need
for medication, but also to improve lung function. Environmental tobacco smoke (also called
secondhand smoke) is an important irritant that can trigger an asthma episode and possibly
9
potentiate the effects of allergens. Upper respiratory viral infections are also recognized as
important triggers for asthma episodes.
Children with asthma have long been recognized as particularly sensitive to outdoor air
pollution. Many common air pollutants, such as ozone, sulfur dioxide, and particulate matter
are respiratory irritants and can exacerbate asthma. Air pollution also might
act synergistically with other environmental factors to worsen asthma. For
Children with asthma
example, some evidence suggests that exposure to ozone can enhance a
have long been
person's responsiveness to inhaled allergens. Whether long term exposure to
recognized as
these pollutants can actually contribute to the development of asthma is not
particularly sensitive
known, though scientists do not believe that outdoor air pollution is a major
to outdoor air
contributor to the current epidemic. To date, little research has examined the
pollution.
role of other air pollutants in the development or exacerbation of asthma,
although this is an issue of increasing public concern.
In addition to improved understanding of appropriate environmental management of asthma, the
medical management of asthma has changed significantly. Inhaled anti-inflammatory
medications have become the mainstay of medical management to prevent asthma episodes and
lessen chronic symptoms of asthma. In addition, improvements in monitoring techniques now
permit objective measures of lung function that are easy for patients and physicians to use in
assessing asthma severity and monitoring changes in the disease. In a disease like asthma that
varies considerably over time and where changes in lung function can occur before symptoms
develop, these objective measures are essential tools for making management decisions.
As a result of these advances, the medical and environmental management of asthma is better
defined and the knowledge exists to manage asthma better than ever before. One especially
important finding is that patient education has been documented to be cost effective. Teaching
patients and their families specific management skills improves asthma management, reduces
the use of emergency services, and improves quality of life. This is particularly important for
asthma management, since the environmental management of asthma requires knowledge of
asthma triggers and specific actions that can be undertaken to reduce exposure to these triggers.
The treatment goal for almost all individuals with asthma should be for that person to lead a life
unrestricted because of asthma.
Reducing exposure to environmental allergens and pollutants will reduce the frequency and
severity of attacks for children with asthma, reduce their need for medicine, and improve their
lung function. Children are exposed to many environmental agents that could trigger asthma
attacks. For example, 25% of children in America live in areas that regularly exceed EPA limits
for ozone. Approximately 38% of children are exposed to environmental tobacco smoke in the
home on a regular basis and exposure to environmental tobacco smoke is so widespread that
approximately 88% of all children have some level of documented exposure. A high proportion
of children living in the inner city are exposed to high levels of cockroach antigen.
10
Why Has Asthma Reached Epidemic Proportions in Children?
The causes of the increasing rate of asthma over the past 15 years and the particular role that
environmental exposures play are not known, but there are some clues. Atopy, the genetically
inherited susceptibility to become allergic, is the most important predictor of a child developing
asthma. A substantial research effort is underway to identify the genes that are responsible for
susceptibility to asthma. Because the genetic make-up of the population changes slowly, genetic
susceptibility alone cannot be responsible for the epidemic of asthma that has occurred in the
United States over the past 15 years. Further work is essential to clarify how genetic
susceptibility and environmental exposures interact to cause asthma. Factors such as the
intensity of environmental exposure and the age of the person being exposed are likely to be
important.
Exposure to allergens found indoors is a strong risk factor for developing asthma. Children are
spending increasing amounts of time indoors, thus increasing their exposure to indoor allergens.
The environmental exposures most strongly suspected of causing asthma to develop include
environmental tobacco smoke and allergens such as house dust mites, cockroaches, mold, and
animal dander. Exposures that stimulate the immune system may also be significant, such as
diet during the prenatal period and early infancy, the pattern of respiratory infections early in
life, and even decreasing rates of exercise have all been suggested as risk factors for the
development of asthma. In the broadest sense, many environmental exposures are suspected of
contributing to the epidemic of asthma in children.
Scope of the Plan for Environmental Action to Protect Children With
Asthma
This action plan is about protecting children from asthma and the consequences of asthma. To
accomplish this goal, the environmental aspects of asthma must be considered in the context of
other aspects of asthma prevention and management, such as early access to quality medical
care and efforts to understand the disproportionate health impact of asthma among minority
populations. Childhood asthma is a multi-factorial disease, and efforts to improve its
management and to prevent it will require multi-dimensional, multi-disciplinary efforts that
must occur simultaneously. This action plan focuses on improving the environment in which
children with asthma live, learn, play and work so that they can live productive, active lives and
so that future generations of children might be spared the disease altogether.
II
GOALS OF THE CHILDREN'S ENVIRONMENTAL
HEALTH ASTHMA ACTION PLAN
BY THE YEAR 2005, THE NUMBER OF HOUSEHOLDS IN WHICH CHILDREN ARE REGULARLY
EXPOSED TO SECONDHAND SMOKE WILL BE REDUCED TO 15%.¹
BY THE YEAR 2010, GUIDELINES FOR PREVENTING THE ONSET OF ASTHMA WILL BE DEVELOPED.
BY THE YEAR 2010, THE INCREASING RATE OF ASTHMA PREVALENCE IN CHILDREN WILL BE
HALTED.
BY THE YEAR 2010, EVERY CHILD IN AMERICA WILL HAVE PROMPT, AFFORDABLE, AND
CONVENIENT ACCESS TO THE MOST EFFECTIVE ASTHMA MANAGEMENT TECHNIQUES
AVAILABLE.
BY THE YEAR 2010, ASTHMA HOSPITALIZATION RATES IN CHILDREN WILL HAVE FALLEN TO NO
MORE THAN 10 HOSPITALIZATIONS PER 10,000 PEOPLE.² (HP 2010 DRAFT)
BY THE YEAR 2010, EMERGENCY DEPARTMENT VISITS WILL BE REDUCED TO NO MORE THAN 46
PER 10,000 PEOPLE.³ (HP 2010 DRAFT)
BY THE YEAR 2010, NO MORE THAN 10% OF PEOPLE WITH ASTHMA WILL EXPERIENCE ACTIVITY
LIMITATIONS.⁴ (HP 2010 DRAFT)
I Baseline: 29% in 1994. Source: Biennial Radon and ETS Survey of the Conference of Radiation Control
Program Directors and EPA.
2 Baseline: Hospitalization rate per 10,000 population in 1993-94: 18 for total population; 50 for children 0-4 yrs
of age and 18 for children 5-14 yrs. Source: HP2010 Draft
3 Baseline: Emergency room visits 71 per 10,000 population for total population in 1992-94; 121 for children 0-4
yrs of age and 81 for children 5-14 yrs. Source: HP2010 Draft
4 Baseline: Activity limitation for persons with asthma 22 percent for overall population in 1992-94. No children-
specific data available. Source: HP2010 Draft
12
VISION FOR THE 21ST CENTURY
Every child in America will live,
learn, work, and play in
environments that do not cause or
worsen asthma.
Asthma will no longer inhibit
children from leading full and active
lives.
More cost-effective medical and
environmental asthma prevention
and management tools will enhance
the lives of children and their
families.
13
GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this plan are
predicated on the principles that federal action must have:
1. A focus on efforts to better understand and eliminate the disproportionate impact of
asthma in minority populations and those living in poverty.
The health burden of asthma is not shared equally throughout the U.S. population. Although the
rising prevalence of asthma has affected all populations, poor and minority children are much
more likely than white, non-Hispanic children to visit an emergency room, to be hospitalized, or
to die from asthma. The reasons for this inequity are not known, although environmental
exposures and limited access to quality medical care may all play a role.
The focus on eliminating disparities across racial and ethnic groups has to be considered in all
efforts to prevent asthma and its health impact; however, because of the importance of this issue
the committee has included a specific recommendation in this action plan to examine,
understand, and ultimately eliminate disparities.
2. An emphasis on partnerships and community based programs.
A successful effort to reduce childhood asthma will depend in part on the level of success
achieved in enlisting all sectors of society in efforts to implement effective programs to prevent
and manage the disease. Federal agencies have already forged effective partnerships with many
health and professional organizations, corporations, and foundations to conduct training,
educate health care providers and the public, and to implement a wide
range of prevention activities at the national, state, and local levels.
The challenge for
Expanded partnerships both within government and between government
the 21st century
and the private sector are needed. With increasing knowledge about the
will be to learn to
primary causes of asthma and triggers of asthma attacks, the challenge for
integrate
the 21st century will be to learn to integrate successfully these findings into
successfully these
more effective environmental, medical and educational programs.
findings into more
effective
Partnerships will be critical to implementing this broad vision of asthma
environmental,
control. In particular, community-based programs should integrate asthma
medical and
control activities into existing systems such as schools, child care, youth
educational
programs, workplaces, primary health, correctional facilities, and job
programs.
training programs.
14
3. A commitment to setting measurable and consistent goals for childhood asthma
under the Healthy People 2010 program.
Health objectives are now being developed for the year 2010 and represent a significant revision
of the goals set for the year 2000. These objectives will set the nation's health agenda for
increasing years of healthy life and reducing disparities among the entire American population.
Draft objectives currently encompass an expanded set of asthma-related objectives as well as a
series of environmental objectives addressing known asthma triggers such as indoor allergens,
secondhand smoke and outdoor air pollution.
The goals embodied in the final Healthy People 2010 document will serve as the tools to
measure progress towards control of asthma. Although some of the goals are likely to measure
aspects of asthma clinical management that will not be directly affected by this action plan, the
primary objectives of morbidity reduction and reducing exposures to environmental hazards will
be addressed.
4. Investment in evaluation of programs to identify those strategies that are most
effective in reducing the burden of asthma so that they may be replicated.
Asthma intervention programs and related activities need to be fully evaluated to determine
those techniques which are successful and should be replicated. Evaluation should be
incorporated in the planning and should include:
identification of desired health outcomes of the program:
measurement of effectiveness of the intervention activities and processes used to
implement them:
identification of unforseen obstacles;
assessment of the cost-effectiveness of the program;
a prediction of long term sustainability of the program.
15
RECOMMENDATIONS FOR ACTION
I. RESEARCH
Strengthen and accelerate focused research into the
environmental factors that cause or worsen childhood asthma.
A. EXPAND RESEARCH INTO THE ENVIRONMENTAL FACTORS THAT
CONTRIBUTE TO THE ONSET OF ASTHMA IN CHILDREN.
Though progress has been made in understanding what causes asthma, there is currently
insufficient scientific information to establish specific guidelines and recommendations for
public health practices to prevent the onset of asthma in children (i.e. primary prevention).
In order to establish primary prevention guidelines, the top priority for
research is to determine the causes of asthma in children and
particularly the role of the environment. To understand what causes
asthma, research must identify the basic cellular and molecular
mechanisms that cause airway inflammation and sensitization and, in
particular, the interaction of environmental exposures and genetic
susceptibility. In addition, clinical and epidemiologic studies are
needed to examine the relationship between environmental exposures and the onset of asthma.
Because of promising preliminary work on the relationship of indoor allergens and asthma onset,
as well as the much greater proportion of time that children spend indoors, greater emphasis on
examining the relationship of indoor exposures to the development of asthma is warranted.
Exposures to high levels of allergens in the indoor environment have been shown in some
studies to be associated with the subsequent development of asthma. However, few studies have
examined the influence of geographic location on the role of allergens. In studies evaluating the
role of indoor allergens on exacerbations of asthma, different allergens, such as those associated
with cockroaches, dust mites, and mold, have been implicated in different locations. This
suggests that different allergens can exacerbate asthma, and that different allergens may be
capable of inducing the new onset of asthma.
In one study, avoiding exposure to dust mite and food allergens early in life was found to reduce
the risk of developing asthma in the first year of life. However, this effect was not statistically
significant at 2 to 4 years of age. Whether such allergen avoidance strategies are feasible and
effective in reducing the development of asthma is not known.
16
The complex interactions between outdoor air pollutants and
Exposures to high
allergens and the development of asthma have not been adequately
levels of allergens in
evaluated. Some epidemiologic studies have suggested a
the indoor
relationship between exposure to volatile organic compounds and
environment have
prevalence rates of childhood asthma. Because adult-onset asthma is
been shown in some
known to be associated with occupational exposures to volatile
studies to be
organic compounds including formaldehyde, ethylene oxide, and
associated with the
isocyanates, further work to assess the possible etiologic role of
subsequent
specific pollutants in childhood asthma is appropriate.
development of
asthma.
KEY ACTIONS:
NIH, CDC, and EPA will conduct and fund studies to determine the causes of asthma. Such studies
should include the following:
examine the role of genetic susceptibility to specific environmental exposures in the
development of asthma;
assess the importance of early life events, such as in utero viral infections, viral
infections during infancy, specific antigen exposures and exposures to maternal
smoking on the development of asthma;
examine the effects of pollutants and allergens on immune responses in animal models
and in preclinical studies;
Identify the clinical characteristics of asthma associated with different genetic,
physiologic, immunologic and environmental factors;
examine the effectiveness of combinations of immune modulation to reduce IgE
responses to allergen and allergen avoidance as a means to reduce the risk of
developing asthma;
examine the epidemiology of asthma in different populations to identify risk factors for
the onset of asthma.
ATSDR, in partnership with state and local health departments and community groups, will investigate
childhood asthma in 5-7 communities where sources of emissions from hazardous waste facilities have
already been identified. These investigations will characterize any associations between hazardous
materials and the burden of asthma in children.
In addition to intramural and extramural grant programs, NIH, CDC, and EPA will fund medical centers to
conduct comprehensive research on environmental aspects of asthma.
The National Academy of Sciences, with support of EPA, will complete its assessment of asthma
associated with indoor pollutants. These findings will be used to guide research efforts on the causes of
asthma.
17
B. EXPAND AND ACCELERATE RESEARCH TO DEVELOP AND EVALUATE
ENVIRONMENTAL STRATEGIES THAT WILL IMPROVE THE QUALITY OF LIFE
FOR CHILDREN WITH ASTHMA.
It is well established that inhaled allergens and irritants and outdoor pollutants provoke asthma
symptoms. Research is needed to identify if other environmental exposures are significant.
Further, the relative importance of various exposures is not well understood. Cost effective
strategies for reducing exposures are not well developed.
Patient education strategies in certain populations have profound impacts on reducing the
frequency and severity of exacerbations and improving the quality of life for children. But many
of these programs are not responsive to the cultural, ethnic, and economic diversity of the
American population. Innovative strategies are urgently needed for reaching a wide range of
children and their families, for tailoring recommendations for reducing environmental exposures
to their needs, and for providing support to follow the recommendations.
KEY ACTIONS:
NIH and EPA will conduct studies to examine the interrelationship between indoor allergen exposures,
viral infections, ambient air pollutants, and exacerbations of asthma. This research will include
identifying and evaluating cost effective methods to reduce allergen exposures, as well as methods to
render the immune system less susceptible to environmental exposures.
NIH, CDC and EPA will conduct studies to improve and evaluate interventions designed to teach families
and patients how to minimize exposure to environmental asthma triggers.
CDC and NIH will work with state and local health departments to develop and evaluate the cost-
effectiveness of model public health intervention programs.
NIH and HUD will complete the first National Allergen Survey to provide estimates of allergen exposure
for the U.S. population; this survey will provide much needed information about the apparent regional
differences in allergen exposures.
NIH, with support from EPA for particulate air monitoring, will continue to fund the National Cooperative
Inner-City Asthma Study (NCICAS), 1996-2000, which will determine the capacity of interventions to
reduce asthma morbidity among inner city children.
EPA, NIH, and CDC will fund and conduct research in collaboration with the private sector to identify
home construction, maintenance and occupancy practices that will reduce children's exposure to
environmental agents that trigger asthma episodes.
As part of its program on energy efficient buildings, DOE will study the relative effectiveness of energy
conservation strategies and technologies on reducing exposures to allergens.
18
2. PROGRAMS TO IMPROVE PUBLIC HEALTH
Implement public health programs that improve use of scientific
knowledge to prevent and reduce the severity of asthma
symptoms by reducing environmental exposures.
Despite uncertainty about the causes of the increase in asthma prevalence rates, much can and
should be done to prevent severe illness and death from asthma and improve the quality of life
of persons with asthma. Experts convened by the National Asthma Education and Prevention
Program (NAEPP) coordinated by the National Institutes of Health (NIH) have reviewed the
scientific literature and produced guidelines for managing asthma. These include specific
recommendations for controlling environmental factors that contribute to asthma severity.
While there is consensus that NAEPP guidelines define the best diagnosis and management
practices for asthma, dissemination of the guidelines must be expanded and adoption improved.
Many clinicians do not include advice about environmental control in
their patient education. Among families who do receive
recommendations, adherence is generally low. Asthma is highly
variable, and families need help establishing priorities for
environmental control measures that will be suitable for their
individual child's asthma and their family circumstances. Effective
public health programs can provide this education and support.
For children without access to quality health care, appropriate instruction on the environmental
triggers of asthma is impossible or severely limited. Emergency rooms or urgent care facilities
may serve as the only source of primary care for such children. These settings should be
recruited to provide the kind of education and links to chronic disease management services that
are essential to reducing the severity and frequency of asthma attacks.
A. PROMOTE CLINICIAN AND PATIENT IMPLEMENTATION OF NATIONAL
GUIDELINES FOR REDUCING ENVIRONMENTAL RISKS THAT WORSEN ASTHMA.
KEY ACTIONS:
NIH will use appropriate existing partnerships and innovative mechanisms to ensure wider use of the
most up-to-date Guidelines for the Diagnosis and Management of Asthma published and periodically
updated by the NAEPP/NIH. These guidelines offer specific advice on the environmental management
of asthma.
19
Encourage and assist health care practitioners, including doctors, nurses, and personnel in emergency
rooms and urgent care facilities, to provide high quality patient education on reducing exposure to
pollutants that trigger asthma.
NIH, CDC, and EPA will establish partnerships with managed care organizations to integrate strong
messages about management of asthma into existing health education programs, emphasizing the
environmental management of asthma.
HCFA will investigate ways to improve the management of asthma, following the NAEPP guidelines, in
care provided to Medicaid beneficiaries under 18 years old in the Managed Care Program.
ATSDR will expand to ten the number of pediatric environmental health specialty units across the
country. These specialty units will develop environmental medicine materials, health education activities,
and risk communication strategies on issues related to asthma and the environment well as other
environmental health hazards to children; these educational activities will target both primary care
providers and persons potentially exposed to harmful pollutants. In addition, these speciality units will
provide consultation services to primary care as well as clinical diagnostic services to patients upon
referral.
B. EXPAND SUPPORT FOR STATE AND LOCAL PUBLIC HEALTH ACTION.
Recent advances in the treatment of asthma and in identifying the environmental triggers of
asthma attacks make it possible to control and prevent symptoms at a level unheard of just ten
years ago. But these gains have not been realized by many of our children. Public health
agencies have a critical role in helping to reduce environmental factors affecting asthma and the
human and financial toll of the disease. These programs should include the following
components:
(1) Education and training
(2) Asthma surveillance
(3) Coalitions for prevention
KEY ACTION:
CDC, in collaboration with NIH, will provide grants to 12 state health departments in FY 2000 to ensure
that effective asthma education, prevention, and public health outreach activities in local communities
are developed and sustained.
20
C. REDUCE CHILDREN'S EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE
AND OTHER INDOOR TRIGGERS IN THEIR HOMES.
Secondhand tobacco smoke and indoor allergens are major
contributors to the incidence of wheezing in young children and play
a significant role in the number and severity of asthma attacks.
Reducing smoking in homes with young children will improve the
health status of the estimated 2 million children with asthma who are
exposed to secondhand smoke. In addition, exposure to allergens
such as cockroach, house dust mite, mold, and animal dander causes
many attacks of asthma that are preventable.
KEY ACTIONS:
EPA, CDC, and NIH will conduct a national public information campaign to reduce children's exposure to
environmental tobacco smoke.
EPA, HUD, and CDC will work within existing public health programs that visit homes to increase the
avenues through which parents and children receive key messages about asthma prevention and
management. For example, partnerships with the extensive lead paint home
intervention network, the AmeriCorps volunteers program, VISTA volunteer
Exposure to
program, U.S. Department of Agriculture Extension Service, and the "Welfare to
secondhand smoke
Work" program could all be used to bring asthma prevention messages (e.g.,
smoking and controlling allergens through techniques such as Integrated Pest
and allergens such as
Management) directly into millions of homes in a cost-effective manner.
cockroach, house
dust mite, mold, and
EPA and DHHS, under the coordination of the National Asthma Education and
animal dander causes
Prevention Program and in close cooperation with the private sector, will undertake
many attacks of
a national asthma awareness campaign, targeted at parents and emphasizing
asthma that are
avoidable asthma triggers such as environmental tobacco smoke, indoor allergens,
preventable.
and outdoor air pollution episodes as well as early diagnosis and effective
management.
HUD will collaborate with health departments with authority over low-income housing, home health
educators, and building operators to implement appropriate guidance on building operation and
maintenance practices, including ventilation, moisture control and integrated pest management
techniques.
EPA will develop innovative means to disseminate information to persons and families with asthma on
the health impact of ambient air pollutants, particularly ozone and particulate matter.
21
D. ESTABLISH SCHOOL BASED ASTHMA PROGRAMS IN EVERY COMMUNITY.
The educational system is a critical component of effective efforts to reduce illness due to
asthma in children. Programs need to be implemented at the local school level to assure a
healthy physical environment at the school and to promote improved self-management of asthma
through education.
KEY ACTIONS:
Develop and expand partnerships between EPA, NIH, CDC, the Department of Education, and non-
governmental public and private organizations to implement programs to assure that the school
environment is safe for children with asthma. Such efforts should include expanding programs such as
the Indoor Air Quality Tools for Schools Program.
EPA and NIH will collaborate with private and voluntary organizations to expand their successful school-
based asthma management programs.
E. CONTINUE TO REDUCE OUTDOOR AIR POLLUTION
The U.S. EPA set national ambient air quality standards (NAAQS) for six air pollutants in 1971,
in part based on evidence of associations between air pollutants such as ozone, particulate
matter, and sulfur dioxide and asthma. Since that time substantial new epidemiological
evidence has been published supporting the association between levels
of ozone and particulate matter and increased hospitalization for
respiratory causes, such as childhood asthma. In 1997, NAAQS for
both ozone and particulate matter were strengthened to improve the
protection afforded by these standards and to help reduce the risk of
ambient exposures that aggravate asthma in children.
Federal, State, local, and private sector efforts to implement the original NAAQS resulted in
substantial improvements in air quality, yet notable problems remain. Following the 1990 Clean
Air Act Amendments, efforts were expanded to improve nationwide air quality and reduce
related health effects. In conjunction with the strengthening of the ozone and particulate matter
NAAQS, EPA has taken steps to integrate implementation measures for these pollutants and to
improve the effectiveness of control programs. EPA has also taken steps to inform the public
about air pollution that may affect children.
KEY ACTIONS:
EPA has proposed that twenty-two States revise their implementations programs in order to provide
widespread regional reductions in ozone and related pollutants.
22
Revisions will be made to strengthen the Pollutant Standards Index (PSI) to help make the public more
aware of days when air pollution levels could affect health and to alert individuals to steps which could be
taken to mitigate health effects associated with exposure to air pollution.
The Environmental Monitoring for Public Access and Community Tracking (EMPACT) program will
increase the availability of real time ozone data over the Internet and through local TV weather
broadcasts.
3. SURVEILLANCE
Establish a coordinated nationwide asthma surveillance system for
collecting and analyzing health outcome and risk factor data at the
state, regional and local levels.
Current national surveillance permits tracking of asthma prevalence, asthma physician office
visits, asthma emergency room visits, asthma hospitalizations and asthma mortality at a national
level and in four geographic regions (i.e., Northeast, Midwest, South, and West) through surveys
conducted by the National Center for Health Statistics. Surveillance information on asthma,
with the exception of mortality data, are not available at the state or local level. This
information is needed to identify high risk populations and environmental risk factors of
relevance to particular communities and to design and implement interventions that will be most
suitable for, and therefore most likely to succeed, in that community. State and local health
agencies also need this information to evaluate the impact of local sources of air pollution on
childhood asthma in specific communities. A significantly enhanced and expanded surveillance
program will be essential to study issues related to race and gender differences in asthma
morbidity and mortality among children, identify gaps in providing comprehensive care, and
monitor trends in asthma morbidity and mortality at the community level.
KEY ACTIONS:
CDC, in collaboration with NIH, will work with state and local health departments to build a national
asthma surveillance system. The first priority in this work will be to develop the state and local
infrastructure that will be needed to collect, analyze, and interpret data at the local level. The
surveillance system will consist of the following components:
Annual surveys of states and major metropolitan areas using standard instruments and methods
to define the prevalence of asthma, to characterize the severity of asthma and the quality of life
for persons with asthma, and to assess the quality of asthma management
Systematic, periodic examinations of existing mortality and morbidity data at state/city or county
level to determine: deaths, hospitalizations, and emergency room visits for asthma.
23
Expanded capability to integrate analysis of ambient air monitoring data with asthma morbidity
and mortality data.
Modify existing data collection systems as needed, to ensure the ability to measure progress
toward the Healthy People 2010 goals, now under development.
Follow-up studies of geographic and population groups with elevated asthma prevalence rates
and elevated rates of morbidity.
4. DISPROPORTIONATE IMPACTS ON THE POOR AND
MINORITIES
Identify the reasons for and eliminate the disproportionate burden of
asthma among different racial and ethnic groups and those living in
poverty.
Poor and minority children are disproportionately affected by asthma,
which has reached epidemic proportions in many American inner cities.
Poor and minority
Prevalence rates vary only by a few percentage points among different
children are
race and ethnic groups, yet emergency room use, hospitalization, and
disproportionately
mortality rates vary 3- to 4-fold. Understanding the factors that
affected by asthma,
contribute to the disproportionate impact of asthma on minority and
which has reached
lower income populations is the critical first step to reducing and
epidemic
eventually eliminating the disparities between rich and poor, minority
proportions in
and non-minority children. Such factors may include differing
many American
intensities of environmental exposures, such as exposure to cockroach
inner cities.
antigen and access to and quality of care, among others.
A. CONDUCT RESEARCH AND SURVEILLANCE ACTIVITIES TO IMPROVE
UNDERSTANDING OF THE PROBLEM
CDC, NIH and ATSDR will conduct research and collect surveillance data to better define factors
contributing to asthma morbidity and asthma prevalence in minority and lower socioeconomic
populations. Such data will:
Separate roles of geography and environmental factors from ethnicity and socio-cultural
variables in assessing their contribution to asthma prevalence.
24
Examine the differences in asthma prevalence in Hispanics of different origins in order to
provide some clues on risk factors contributing to higher rates of asthma.
Examine the influence of poverty versus racial and ethnic group on use of emergency room
services and hospitalization rates.
B. IMPLEMENT PROGRAMS TO ELIMINATE THE DISPROPORTIONATE IMPACT
OF ASTHMA IN MINORITY POPULATIONS AND THOSE LIVING IN POVERTY.
KEY ACTIONS:
NIH, EPA, and CDC will implement public health interventions directed specifically to relieve the impact
of asthma on vulnerable populations, particularly targeting the environmental exposures of vulnerable
populations
Ensure a substantial and appropriate focus of public health asthma initiatives on
vulnerable populations.
Make culturally and linguistically appropriate information on asthma widely available.
Expand the availability of services, particularly emphasizing the need to modify the
environment to reduce exposure to known asthma triggers, to the under-served in lower
socioeconomic communities.
EPA will collaborate with state environmental protection programs to establish targeted compliance
monitoring and enforcement efforts in communities with higher than average childhood asthma morbidity
and mortality rates.
25
GLOSSARY
Acute: Brief (days to weeks).
Allergen: A chemical or biological substance (e.g. pollen, animal dander, or house dust mite proteins)
that causes an allergic reaction, characterized by hypersensitivity.
Asthma: A chronic lung disease with chronic inflammation of the airways and recurring exacerbations of
airflow limitation that result in wheezing, cough, chest tightness, and difficulty breathing.
Atopy: The genetically inherited susceptibility to become allergic.
Chronic: Remains for several years, possibly a lifetime.
Exacerbate: To aggravate or make asthma worse.
Genome: The inherited genetic composition of an organism.
Incidence: The number of individuals that develop an abnormality within a given time (usually a year)
expressed as a percentage of the population.
Irritant: Risk factor or trigger that may cause increased symptoms and/or airflow limitation via a neural
pathway.
Primary Prevention: Interventions designed to prevent the development of asthma.
Prevalence: The percentage of the population with a disease, disorder, or abnormality.
Secondary Prevention: Interventions designed to prevent the worsening of asthma among individuals
who already have the disease.
Surveillance: The ongoing collection, analysis, interpretation, and dissemination of health outcome
data used to plan and evaluate public health programs.
Trigger: An exposure that causes symptoms or exacerbations of asthma.
26
ADDITIONAL READING
Technical
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert
Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health
pub no 97-4051. Bethesda, MD, 1997.
Mannino DM, Homa DM, Pertowski CA, et al., Surveillance for Asthma, United States, 1960-1995.
MMWR 1998;47(No. SS-1):1-27.
Institute of Medicine. Indoor Allergens. Assessing and Controlling Adverse Health Effects. National
Academy Press. Washington, D.C. 1993
Families
American Lung Association. Family Guide to Asthma and Allergies. How You and Your Children Can Breath
Easier. Little, Brown and Company. New York. 1997
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Asthma,
Physical Activity and School. National Institutes of Health pub no 95-3651. Bethesda, MD, 1995.
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Facts About
Controlling Your Asthma. National Institutes of Health pub no 97-2339. Bethesda, MD, 1997.
National Heart, Lung, and Blood Institute. Global Initiative for Asthma. What You and Your Family Can Do
About Asthma. National Institutes of Health pub no 96-3659C. Bethesda, MD, 1996.
Indoor Air Pollution
EPA's Indoor Air Quality Tools for Schools. Available from:
Indoor Air Quality Information Clearinghouse: 1-800-438-4318
Indoor Air Quality Web Site: www.epa.gov/iag/
27
TIPS FOR AVOIDING AND CONTROLLING ASTHMA
TRIGGERS
Tobacco Smoke
Pet Dander
Do not allow smoking in your home or around your children.
At home:
Choose pets based on the sensitivity of the allergic person.
Be sure no one smokes at a child's day care center.
Restrict activity of/isolate pet from sensitive persons (may not
be effective with cat allergen which may stay suspended in air for
Dust Mires
long periods).
Cover pillows and mattresses with plastic or other allergen-
Day care/schools:
impermeable material.
Keep animals in cages as much as possible; do not let them
roam.
Reduce humidity below 50% and, if dehumidifiers are used,
keep them clean according to manufacturer's instructions.
Clean cages regularly.
Soft, fabric-covered surfaces (such as carpeting and upholstered
furniture) may harbor dust mites; hard surfaces are easier to clean.
Locate animals away from ventilation system vents to avoid
circulating allergens throughout the room or building.
When vacuuming, use a high efficiency particulate air (HEPA)
filter or central vacuum system. Because vacuuming causes
Don't use warm-blooded animals, if possible.
increased levels of mite allergen in the air, have the allergic
individual wear a mask or stay away while the building is being
Mold
vacuumed.
Reduce humidity below 50% and prevent condensation.
Wash bedding in hot water.
Control moisture sources.
Cockroaches and Rodents
Repair any water leaks.
Use Integrated Pest Management (IPM):
Replace water-damaged materials.
Thoroughly clean; remove all cockroach bodies and residues.
Don't leave water standing in your home.
Keep all surfaces clean and dry.
If you use a humidifier, choose and use it wisely according to
Repair any water leaks.
manufacturer's instructions.
Keep all food away from pests, store in refrigerator or in
Outdoor Air Pollution
tightly-sealed containers.
During air pollution alerts:
Reduce/eliminate exposure to pesticides.
Stay indoors as much as possible.
Avoid strenuous physical activity.
Adapted from: National Heart, Lung, and Blood Institute,
National Asthma Education and Prevention Program.
Expert Panel Report 2: Guidelines for the Diagnosis and
Management of Asthma.
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ADDITIONAL READING
Technical
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert
Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health
pub no 97-4051. Bethesda, MD, 1997.
Mannino DM. Homa DM, Pertowski CA, et al., Surveillance for Asthma, United States, 1960-1995
MMWR 1998;47(No. SS-1):1-27.
Institute of Medicine. Indoor Allergens. Assessing and Controlling Adverse Health Effects. National
Academy Press Washington, D.C. 1993
Families
American Lung Association Family Guide to Asthma and Allergies. HOW You and Your Children Can
Breath Easier. Little, Brown and Company New York. 1997
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Asthma,
Physical Activity and School. National Institutes of Health pub no 95-3651. Bethesda, MD. 1995.
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Facts About
Controlling Your Asthma National Institutes of Health pub no 97-2339 Bethesda, MD, 1997.
National Heart, Lung, and Blood Institute. Global Initiative for Asthma. What You and Your Family Can Do
About Asthma. National Institutes of Health pub no 96-3659C Bethesda, MD. 1996
Indoor Air Pollution
EPA's Indoor Air Quality Tools for Schools. Available from:
Indoor Air Quality Information Clearinghouse: 1-800-438-4318
Indoor Air Quality Web Site: www.epa.gov/iaq/
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Centers for Disease Control and Prevention
Facsimile Transmission
Date:
10 Nov 98
To:
Devorah Adler
Phone:
FAX:
202-456-5557
From:
Star Redd
Air Pollution and Respiratory Health Branch
Division of Environmental Hazards and Health Effects
National Center for Environmental Health
Mailstop F-39
4770 Buford Highway, NE
Atlanta, GA 30341-3724
Phone: 770-488-7320
Direct: 770-488- 7581
Fax:
770-488-3507
Internet: [email protected]
Subject:
Asthma document
Pages (including cover sheet): 30
Comments:
1800 979 1252
Dan
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DRAT 13
10/9/98
Asthma in America:
Our Children at Risk
APlan for Environmenta Action
to Protect Children from Asthma
President's Task Force on Environmental Health
Risks and Safety Risks to Children
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ABOUT THE PRESIDENT'S TASK FORCE ON
ENVIRONMENTAL HEALTH RISKS AND SAFETY RISKS TO
CHILDREN
In recognition of the growing body of scientific information demonstrating that America's
children suffer disproportionately from environmental health risks and safety risks, President
Clinton issued Executive Order 13045 on April 21, 1997, directing each Federal Agency to make
it a high priority to identify, assess, and address those risks. In issuing this order, the President
also created the Task Force on Environmental Health Risks and Safety Risks to Children, co-
chaired by Donna Shalala, Secretary of the Department of Health and Human Services, and Carol
M. Browner, Administrator of the Environmental Protection Agency. The Task Force was
charged with recommending strategies for protecting children's
environmental health and safety. Two subcommittees were established
in the Executive Order to carry out this directive: a subcommittee
directed to review and foster public access to federal government
sponsored research on environmental health and safety risks to children,
and a subcommittee directed to identify priority public outreach
activities related to protecting children's environmental health and
safety.
In April 1998, the Task Force identified four priority areas for immediate attention: childhood
asthma, unintentional injuries, developmental disorders, and childhood cancer. The Task Force
created and charged the Asthma Priority Area Workgroup with reviewing current Federal efforts
to address the many facets of the issue and, most importantly, to make appropriate
recommendations for action by the Federal government. This report is the result of that effort.
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TABLE OF CONTENTS
ABOUT THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH RISKS
AND SAFETY RISKS TO CHILDREN
1
MEMBERS OF THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH
RISKS AND SAFETY RISKS TO CHILDREN
3
ASTHMA PRIORITY AREA WORKGROUP MEMBERS
5
EXECUTIVE SUMMARY
6
INTRODUCTION
8
The Growing Problem of Asthma in Children
8
What We Know About Childhood Asthma
9
Why Has Asthma Reached Epidemic Proportions in Children?
11
Scope of the Plan for Environmental Action to Protect Children
11
GOALS OF THE ACTION PLAN
12
VISION FOR THE 21ST CENTURY
13
GUIDING PRINCIPLES
14
RECOMMENDATIONS
16
RESEARCH
16
PROGRAMS TO IMPROVE PUBLIC HEALTH
19
SURVEILLANCE
23
DISPROPORTIONATE IMPACTS ON THE POOR AND MINORITIES
24
GLOSSARY
26
ADDITIONAL READING
27
TIPS FOR AVOIDING AND CONTROLLING ASTHMA TRIGGERS
28
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MEMBERS OF THE PRESIDENT'S TASK FORCE ON
ENVIRONMENTAL HEALTH RISKS AND SAFETY RISKS TO
CHILDREN
Honorable Donna E. Shalala
Honorable Rodney Slater
Co-chair
Secretary
Secretary
Department of Transportation
Department of Health and Human Services
Honorable Franklin Raines, Director
Honorable Carol M. Browner
Office of Management and Budget
Co-chair
Administrator
Honorable Karhleen McGinty, Chair
Environmental Protection Agency
Counal on Environmental Quality
Honorable Alexis Herman
Honorable Ann Brown
Secretary
Chairman
Department of Labor
Consumer Product Safety Commission
Honorable Janet Reno
Honorable Janes Yellen
Attorney General
Chair
Department of Justice
Council of Economic Advisors
Honorable Andrew Cuomo
Honorable Neal Lane Director
Secretary
Office of Science and Technology Policy
Department of Housing and Urban
Development
Honorable Gene Sperling
Assistant to the President for Economic Policy
Honorable Elizabeth A Moler
Acting Secretary
Honorable Bruce Reed
Department of Energy
Assistant to the President for Domestic Policy
Honorable Richard Riley
Secretary
Department of Education
Honorable Dan Glickman
Secretary
Department of Agriculture
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ASTHMA PRIORITY AREA WORKGROUP MEMBERS
Stephen Redd, MD (Co-chair)
Virginia Taggart. M.P.H.
National Concer for Environmental Health
National Heart, Lung, and Blood Institute
Centers for Disease Control and Prevention
Nanonal Institutes of Health
Robert Axclead (Co-chair)
Hillel Koren, PhD.
Office of Children's Health Protection
National Health and Environmental Effects Laboratory
Environmental Protection Agency
Office of Research and Development
Environmental Protection Agency
Adele C Morris
Serior Economist
Caroline Preeman
Council of Economic Advisers
Occupational Safety and Health Administration
Department of Labor
Mary White, ScD
Division of Health Studies
George Malindzak, PhD
Agency for Taxic Substances and Disease Registry
National Instruce of Environmental Health Sciences
Nanonal Institutes of Health
John Talbon
Office of Building Technologies
Lucas Neas, PhD
Department of Energy
National Health and Environmental Effects Laboratory
Office of Research and Development
Ron Ashford
Environmental Protection Agency
Department of Housing and Urban Development
Edward Chu
Warren Friedman. Ph.D, CIH
Office of Children's Health Protection
Office of Lead Hazard Control
Environmental Protection Agency
Department of Housing and Urban Development
Marilyn Wind
Tracey Mirchell
Consumer Product Safety Commission
Indoor Environments Division
Environmental Protection Agency
Stacey Karz
Office of Science Policy
Marshall Plaur, M.D.
Department of Health and Human Services
National Institute of Allergy and Infectious Discuss
National Institutes of Health
Polly Hoppin. ScD
Office of Science Policy
Jerry Phelps
Department of Health and Human Services
National Insurance of Environmental Health Sciences
National Institutes of Health
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EXECUTIVE SUMMARY
An epidemic of asthma is occurring in the United States. While the epidemic affects people of
all ages, children are particularly affected. Nearly 1 in 13 school-aged children has asthma, and
the percentage of children with asthma (i.e., prevalence rate) is rising more rapidly in preschool-
aged children than in any other age group.
There is no national system to collect data from states specifically on
asthma, although several states are developing systems to collect such
An epidemic of
aschma is
data. Although national data do not provide the resolution necessary to
identify particular geographic areas hardest hit by the asthma epidemic,
occurring in
the United
surveys undertaken in a number of large cities in the United States
States.
indicate that the prevalence and severity of asthma are greatest in the
large, urban inner cities.
Asthma is one of the leading causes of school absenteeism, accounting for over 10 million
missed school days per year. Asthma also accounts for many nights of interrupted sleep,
limitation of activity, and disruptions of family and care-giver routines. Asthma symptoms that
are not severe enough to require a visit to an emergency room or to a physician can still be severe
enough to prevent a child with asthma from living a fully active life.
In 1990, the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the
majority of the expense attributed to direct medical expenses. A 1996 analysis found the cost of
asthma to be $14 billion, indicating a rapidly increasing financial burden. These estimates,
which are not limited to the costs of childhood asthma, indicate that the direct medical costs of
asthma account for between 1% and 3% of all health care expenditures in the United States.
Asthma is a particularly important disease to consider in the context of environmental hazards to
which children are exposed. Children breathe more air, eat more food, and drink more liquid in
proportion to their body weight than do adults, and their developing respiratory, immunological,
and digestive systems may be more susceptible to environmental exposures than those of adults.
In a typical day, children may be exposed to a wide array of environmental agents at home, in day-
care centers, schools and while playing outdoors. There is substantial evidence that
environmental exposures, including viruses and allergens, play a major role in triggering asthma
symptoms. Airborne allergens include those from house dust mites, cockroaches, mold and
animal dander. In addition, exposure to environmental tobacco smoke has been shown to be a
major determinant of asthma symptoms. Elevated levels of outdoor air pollutants, particularly
ozone, are associated with increased symptoms and an increased risk of emergency department
visits for asthma, as well.
In addition, environmental factors such as airborne allergens and environmental tobacco smoke
(i.e., secondhand smoke) may play a major role in the onset of asthma. Other pollutants may also
play a role, although the scientific data are inadequate to offer firm conclusions. Genetic
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predisposition is the strongest known risk factor for developing asthma, but the rapidly rising
number of cases of childhood asthma cannot be solely genetic because the genetic composition of
the population changes slowly. Rather, some interaction between genetic predisposition and
environmental exposures, and possibly other factors such as diet or lack of exercise are likely to
be responsible for the increase. Further work is essential to clarify how genetic susceptibility and
environmental exposures interact to cause asthma.
Reducing exposures of children with asthma to airborne allergens and pollutants will reduce the
health burden of asthma and significantly improve their quality of life. It is not yet certain, but it
is possible that reducing the exposure of infants and young children at risk of developing asthma
may prevent its onset. Environmental control methods and asthma treatments are available now
that can help children and their families control asthma and lead healthy, active lives. Yet not all
children have access to these measures. Too many children miss school, limit their physical
activity, and are seriously ill because of asthma.
The environmental action plan for asthma outlined in this report is
designed to promote concerted Federal action to protect all children
with asthma from environmental risks that worsen their disease and
to expand federal research to reveal how reducing environmental
risks might prevent children from getting asthma.
GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this initiative are
predicated on the principles that federal action must have:
A focus on efforts to eliminate the disproportionate impact of asthma in minority
populations and those living in poverty.
An emphasis on partnerships and community based programs.
A commitment to setting measurable and consistent goals for childhood asthma under
the Healthy People 2010 program.
An investment in evaluation to identify those strategies that are most effective in reducing
the burden of asthma so that they may be replicated.
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RECOMMENDATIONS FOR ACTION
RESEARCH
Strengthen and accelerate focused research into the environmental factors that cause or worsen
childhood asthma.
Strengthen and accelerate research into the environmental factors
This year 2000
that may contribute to the onset of asthma in children.
initiative is
about
Expand and accelerate research to develop and evaluate
protecting
environmental strategies that will improve the quality of life of
children from
people with aschma.
asthma
PUBLIC HEALTH PROGRAMS
Implement public health programs that foster improved use of current scientific knowledge to reduce
environmental exposures to prevent and reduce the severity of symptoms for chose with aschma.
Promote clinician and patient implementation of national guidelines for reducing
environmental risks that worsen aschma.
Expand support for state and local public health action.
Reduce children's exposure to environmental tobacco smoke and other indoor triggers in
their homes.
Establish school based asthma programs in every community that help reduce or
eliminate allergens and irritants and that promote student's self management of aschma
and full participation in school activities.
Continue TO reduce outdoor air pollution.
SURVEILLANCE
Establish a coordinated, integrated, and systematic nationwide asthma surveillance system for collecting
and analyzing health outcome and risk factor data at the state, regional and local levels.
DISPROPORTIONATE IMPACT ON THE POOR AND MINORITIES
Eliminate the disproportionate burden of asthma among different racial and ethnic groups and those
living in poverty.
Conduct research and surveillance activities to improve
understanding of the problem.
Implement activities to eliminate the disproportionate impact
of aschma in minority populations and those living in poverty.
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INTRODUCTION
The Growing Problem of Asthma in Children
Asthma is a chronic lung disease characterized by recurrent episodes of breathlessness,
wheezing, coughing, and chest tightness; these episodes are also known as exacerbations or
attacks. The severity of exacerbations can range from mild to life threatening. Both the
frequency and severity of asthma symptoms can be reduced by the use of medications and by
reducing exposure to the environmental triggers of asthma attacks.
For the past 15 years, an epidemic of asthma has occurred in the United
States. By all indications, this epidemic is continuing. Although asthma
has become a major public health problem affecting Americans of all ages,
races and ethnic groups, children have been particularly severely affected.
National survey data -- the responses of randomly selected U.S. residents
being asked whether they had symptoms of physician diagnosed asthma in the previous 12
months -- indicate that the number of children with asthma in the United States has more than
doubled in the past 15 years. In 1980, 2.3 million American children had asthma. In 1995, the
most recent year for which data are available, the number of affected children had risen to 5.5
million. Based on these trends, it is estimated that in 1998 more than 6 million children in the
United States have asthma. Prevalence rates of asthma are highest in boys and are increasing in
both boys and girls, and in all race and ethnic groups. The prevalence of asthma in children
under age 18 is 7.3%. The most rapid increase has occurred in children under 5 years old, with
rates increasing over 160% over the past 15 years.
The number of deaths attributed to asthma in children has also increased. In 1977, 84 deaths in
children 18 and younger were recorded; the number of deaths has risen to 280 in 1995, a more
than 3-fold increase. Although the death rate due to asthma has increased in all racial and ethnic
groups, minority populations experience a disproportionately higher death rate from asthma. In
1995, the death rate from asthma in African-American children, 11.5 per million, was over four
times the rate in white Americans, 2.6 per million. The higher death rates among African-
American children are especially troubling.
The number of hospitalizations and emergency room visits for asthma have increased in all
population groups. Asthma accounts for one-third of all pediatric emergency room visits and is
the fourth most common cause for physician office visits. The variation in the impact of asthma
across racial and ethnic groups is significant African American children have an annual rate of
hospitalization of 74 per 10,000, over 3 times that for whites, 21 per 10,000. In addition, African
American children are approximately 4 times more likely than white children to seek care at an
emergency room. In short, African-American children have a slightly higher risk of getting
asthma, but have a much higher risk of hospitalization or death due to the disease.
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At the present time, surveillance for asthma in children is limited to analyses of ongoing surveys
and data systems on health events such as mortality, hospitalization, and outpatient visits. Other
than for African Americans, such information is extremely limited for most ethnic groups. There
is no national system to collect data from states specifically on asthma, although several states
are developing systems to collect such data. Although national data do not provide the resolution
necessary to identify particular geographic areas hardest hit by the asthma epidemic, surveys
undertaken in a number of large cities in the United States indicate that the
prevalence and severity of asthma are greatest in the large, urban inner cities.
There is no
national system
These measures, particularly for death, hospitalization, and emergency room
to collect data
visits, give an incomplete picture of the true burden of asthma in the United
from states
States. For example, one follow-up study of children with asthma in inner
specifically on
city areas found a nearly 10 times higher likelihood of a child suffering
asthma, although
symptoms of asthma on a given day than visiting an emergency room.
several states
Asthma is one of the leading causes of school absenteeism, accounting for
are developing
over 10 million missed school days per year. Asthma also accounts for many
systems to
nights of interrupted sleep, limitation of activity, and disruptions of family
collect such
and care-giver routines. Asthma symptoms that are not severe enough to
data
require a visit to an emergency room or to a physician can still be severe
enough to prevent a child with asthma from living a fully active life.
Estimating the costs of asthma is an indirect way to measure its health burden. In 1990, the cost
of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority of the expense
attributed to direct medical expenses. A 1996 analysis found the cost of asthma to be $14 billion,
indicating a rapidly increasing financial burden. These estimates indicate that the direct medical
COSIS of asthma for all ages account for between 1% and 3% of all health care expenditures in the
United States.
What We Know About Childhood Asthma
Over the past 15 years, there have been major advances in the scientific understanding of asthma.
Asthma is now known to be a disease of airway inflammation resulting from a complex interplay
between environmental exposures and genetic and other factors. This has implications for the
medical treatment and for the environmental management of asthma.
In contrast to the limited understanding of the relationship of environmental exposures to the
onset of asthma, the environmental triggers of asthma attacks for children with asthma have
become increasingly well characterized. House dust mites, cockroaches, mold and animal dander
have been identified as the principal allergens that uigger asthma symptoms. Reducing exposure
to these allergens has been shown not only to reduce asthma symptoms and the need for
medication, but also to improve lung function. Environmental tobacco smoke (also called
secondhand smoke) is an important irritant that can trigger an asthma episode and possibly
potentiate the effects of allergens. Upper respiratory viral infections are also recognized as
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important triggers for asthma episodes.
Children with asthma have long been recognized as particularly sensitive to outdoor air pollution.
Many common air pollutants, such as ozone, sulfur dioxide, and particulate matter are respiratory
irritants and can exacerbate asthma. Air pollution also might act
synergistically with other environmental factors to worsen asthma. For
example, some evidence suggests that exposure to ozone can enhance a
Children with asthma
person's responsiveness to inhaled allergens. Whether long term exposure to
have long been
these pollutants can actually contribute to the development of asthma is not
recognized as
known, though scientists do not believe that outdoor air pollution is a major
par ticularly sensitive
contributor to the current epidemic. To date, little research has examined the
to outdoor air
role of other air pollutants in the development or exacerbation of asthma,
pollution.
although this is an issue of increasing public concern.
In addition to improved understanding of appropriate environmental management of asthma, the
medical management of asthma has changed significantly. Inhaled anti-inflammatory
medications have become the mainstay of medical management to prevent asthma episodes and
lessen chronic symptoms of asthma. In addition, improvements in monitoring techniques now
permit objective measures of lung function that are easy for patients and physicians to use in
assessing asthma severity and monitoring changes in the disease. In a disease like asthma that
varies considerably over time and where changes in lung function can occur before symptoms
develop, these objective measures are essential tools for making management decisions.
As a result of these advances, the medical and environmental management of asthma is better
defined and the knowledge exists to manage asthma better than ever before. One especially
important finding is that patient education has been documented to be cost effective. Teaching
patients and their families specific management skills improves asthma management, reduces the
use of emergency services, and improves quality of life. This is particularly important for asthma
management, since the environmental management of asthma requires knowledge of asthma
triggers and specific actions that can be undertaken to reduce exposure to these triggers. The
treatment goal for almost all individuals with asthma should be for that person to lead a life
unrestricted because of asthma.
Reducing exposure to environmental allergens and pollutants will reduce the frequency and
severity of attacks for children with asthma, reduce their need for medicine, and improve their
lung function. Children are exposed to many environmental agents that could trigger asthma
attacks. For example, 25% of children in America live in areas that regularly exceed EPA limits
for ozone. Approximately 38% of children are exposed to environmental tobacco smoke in the
home on a regular basis and exposure IO environmental tobacco smoke is so widespread that
approximately 88% of all children have some level of documented exposure. A high proportion
of children living in the inner city are exposed to high levels of cockroach antigen.
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Why Has Asthma Reached Epidemic Proportions in Children?
The causes of the increasing rate of asthma over the past 15 years and the particular role that
environmental exposures play are not known, but there are some clues. Atopy, the genetically
inherited susceptibility to become allergic, is the most important predictor of a child developing
asthma. A substantial research effort is underway to identify the genes that are responsible for
susceptibility to asthma. Because the genetic make-up of the population changes slowly, genetic
susceptibility alone cannot be responsible for the epidemic of asthma that has occurred in the
United States over the past 15 years. Further work is essential to clarify how genetic
susceptibility and environmental exposures interact to cause asthma. Factors such as the
intensity of environmental exposure and the age of the person being exposed are likely to be
important.
Exposure to allergens found indoors is a strong risk factor for developing asthma. Children are
spending increasing amounts of time indoors, thus increasing their exposure to indoor allergens.
The environmental exposures most strongly suspected of causing asthma to develop include
environmental tobacco smoke and allergens such as house dust mites, cockroaches, mold, and
animal dander. Exposures that stimulate the immune system may also be significant, such as diet
during the prenatal period and early infancy, the pattern of respiratory infections early in life, and
even decreasing rates of exercise have all been suggested as risk factors for the development of
asthma. In the broadest sense, many environmental exposures are suspected of contributing to
the epidemic of asthma in children.
Scope of the Plan for Environmental Action to Protect Children With
Asthma
This action plan is about protecting children from asthma and the consequences of asthma. To
accomplish this goal, the environmental aspects of asthma must be considered in the context of
other aspects of asthma prevention and management, such as early access to quality medical care
and efforts to understand the disproportionate health impact of asthma among minority
populations. Childhood asthma is a multi-factorial disease, and efforts to improve its
management and to prevent it will require multi-dimensional, multi-disciplinary efforts that must
occur simultaneously. This action plan focuses on improving the environment in which children
with asthma live, learn, play and work so that they can live productive, active lives and so that
future generations of children might be spared the disease altogether.
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GOALS OFTHECHILDREN'S ENVIRONMENTAL
HEALTH ASTHMAACTION PLAN
BY THE YEAR 2005, THE NUMBER OF HOUSEH IN WHICH CHILDREN ARE REGULARLY
EXPOSED TO SECONDHAND SMOKE WILL BE REDUCED TO 15%
BY THE YEAR 2010, GUIDELINES FOR PREVENTING THE ONSET OF ASTHMA WILL BE DEVELOPED.
BYTHBYEAR 2010, THE INCREASING RATE OF ASTHMA PREVAI ENCE IN CHILDREN WILL BE
HALTED
BY THE YEAR 2010, EVERY CHILD IN AMERICA WILL HAVE PROMPT, AFFORDABLE, AND
CONVENIENT ACCESS TO THE MOST EFFECTIVE ASTHMA MANAGEMENT TECHNIQUES
AVAILABLE
BY THE YEAR 2010, ASTHMA HOSPITALIZATION RATES IN CHILDREN WILL HAVE FALLEN TO NO
MORE THAN 10 HOSPITALIZATIONS PER 10,000 PEOPLE2 (HP 2010 DRAFT)
BY THE YEAR 2010. EMERGENCY DEPARTMENT VISITS WILL BE REDUCED TO NO MORE THAN 46
PER 10,000 PEOPLE' (HP 2010 DRAFT)
BY THE YEAR 2010, NO MORE THAN 10% OF PEOPLE WITH ASTHMA WILL EXPERIENCE ACTIVITY
LIMITATIONS. (HP 2010 DRAFT)
I Baseline: 29% in 1994. Source: Biennial Radon and ETS Survey of the Conference of Radiation Control Program
Directors and EPA.
2 Baseline: Hospitalization race per 10,000 population in 1993-94: 18 for total population: 50 for children 0-4 yrs
of age and 18 for children 5-14 yrs. Source: HP2010 Draft
3 Baseline: Emergency room visits 71 per 10.000 population for total population in 1992-94; 121 for children 0-4
yrs of age and 81 for children 5-14 yrs. Source: HP2010 Draft
4 Baseline: Activity limitation for persons with aschma 22 percent for overall population in 1992-94. No children-
specific data available. Source: HP2010 Draft
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VISION FOR THE 21ST CENTURY
Every child in America will live,
learn, work, and play in
environments that do not cause or
worsen asthma.
Asthma will no longer inhibit
children from leading full and active
lives.
More cost-effective medical and
environmental asthma prevention
and management tools will enhance
the lives of children and their
families.
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GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this plan are
predicated on the principles that federal action must have:
1. A focus on efforts to better understand and eliminate the disproportionate impact of
asthma in minority populations and those living in poverty.
The health burden of asthma is not shared equally throughout the U.S. population. Although the
rising prevalence of asthma has affected all populations, poor and minority children are much
more likely than white, non-Hispanic children to visit an emergency room, to be hospitalized, or
to die from asthma. The reasons for this inequity are not known, although environmental
exposures and limited access to quality medical care may all play a role.
The focus on eliminating disparities across racial and ethnic groups has to be considered in all
efforts to prevent asthma and its health impact; however, because of the importance of this issue
the committee has included a specific recommendation in this action plan to examine,
understand, and ultimately eliminate disparities.
2. An emphasis on partnerships and community based programs.
A successful effort to reduce childhood asthma will depend in part on the level of success
achieved in enlisting all sectors of society in efforts to implement effective programs to prevent
and manage the disease. Federal agencies have already forged effective partnerships with many
health and professional organizations, corporations, and foundations to conduct training, educate
health care providers and the public, and to implement a wide range of
prevention activities at the national, state, and local levels.
The challenge for
Expanded partnerships both within government and between government
the 21" century
and the private sector are needed. With increasing knowledge about the
will be to learn to
primary causes of asthma and triggers of asthma attacks, the challenge for
integrate
the 21st century will be to learn to integrate successfully these findings into
successfully these
more effective environmental, medical and educational programs.
findings into more
Partnerships will be critical to implementing this broad vision of asthma
effective
control. In particular, community-based programs should integrate asthma
environmental,
control activities into existing systems such as schools, child care, youth
medical and
programs, workplaces, primary health, correctional facilities, and job
educational
training programs.
programs.
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3. A commitment to setting measurable and consistent goals for childhood asthma
under the Healthy People 2010 program.
Health objectives are now being developed for the year 2010 and represent a significant revision
of the goals set for the year 2000. These objectives will set the nation's health agenda for
increasing years of healthy life and reducing disparities among the entire American population.
Draft objectives currently encompass an expanded set of asthma-related objectives as well as a
series of environmental objectives addressing known asthma triggers such as indoor allergens,
secondhand smoke and outdoor air pollution.
The goals embodied in the final Healthy People 2010 document will serve as the tools to measure
progress towards control of asthma. Although some of the goals are likely to measure aspects of
asthma clinical management that will not be directly affected by this action plan, the primary
objectives of morbidity reduction and reducing exposures to environmental hazards will be
addressed.
4. Investment in evaluation of programs to identify those strategies that are most
effective in reducing the burden of asthma so that they may be replicated.
Asthma intervention programs and related activities need to be fully evaluated to determine those
techniques which are successful and should be replicated. Evaluation should be incorporated in
the planning and should include:
identification of desired health outcomes of the program:
measurement of effectiveness of the intervention activities and processes used TO
implement them:
identification of unforseen obstacles;
assessment of the cost-effectiveness of the program;
a prediction of long term sustainability of the program.
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RECOMMENDATIONS FOR ACTION
1. RESEARCH
Strengthen and accelerate focused research into the
environmental factors that cause or worsen childhood asthma.
A. EXPAND RESEARCH INTO THE ENVIRONMENTAL FACTORS THAT
CONTRIBUTE TO THE ONSET OF ASTHMA IN CHILDREN.
Though progress has been made in understanding what causes asthma, there is currently
insufficient scientific information to establish specific guidelines and recommendations for
public health practices to prevent the onset of asthma in children (i.e. primary prevention).
In order to establish primary prevention guidelines, the top priority for
research is to determine the causes of asthma in children and
particularly the role of the environment. To understand what causes
asthma, research must identify the basic cellular and molecular
mechanisms that cause airway inflammation and sensitization and, in
particular, the interaction of environmental exposures and genetic
susceptibility. In addition, clinical and epidemiologic studies are
needed to examine the relationship between environmental exposures and the onset of asthma.
Because of promising preliminary work on the relationship of indoor allergens and asthma onset,
as well as the much greater proportion of time that children spend indoors, greater emphasis on
examining the relationship of indoor exposures to the development of asthma is warranted.
Exposures to high levels of allergens in the indoor environment have been shown in some studies
to be associated with the subsequent development of asthma. However, few studies have
examined the influence of geographic location on the role of allergens. In studies evaluating the
role of indoor allergens on exacerbations of asthma, different allergens, such as those associated
with cockroaches, dust mites, and mold, have been implicated in different locations. This
suggests that different allergens can exacerbate asthma, and that different allergens may be
capable of inducing the new onset of asthma.
In one study, avoiding exposure to dust mite and food allergens early in life was found to reduce
the risk of developing asthma in the first year of life. However, this effect was not statistically
significant at 2 to 4 years of age. Whether such allergen avoidance strategies are feasible and
effective in reducing the development of asthma is not known.
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The complex interactions berween outdoor air pollutants and
Exposures to high
allergens and the development of asthma have not been adequately
levels of allergens in
evaluated. Some epidemiologic studies have suggested a relationship
the indoor
between exposure to volatile organic compounds and prevalence rates
environment have
of childhood asthma. Because adult-onset asthma is known to be
been shown in some
associated with occupational exposures to volatile organic
studies to be
compounds including formaldehyde, ethylene oxide, and isocyanates,
associated with the
further work to assess the possible etiologic role of specific pollutants
subsequent
in childhood asthma is appropriate.
development of
asthma.
KEY ACTIONS:
NIH, CDC, and EPA will conduct and fund studies to determine the causes of asthma. Such studies
should include the following:
examine the role of genetic susceptibility to specific environmental exposures in the
development of asthma;
assess the importance of early life events, such as in utero viral infections, viral
infections during infancy, specific antigen exposures and exposures to maternal
smoking on the development of asthma;
examine the effects of pollutants and allergens on immune responses in animal models
and in preclinical studies;
Identify the clinical characteristics of asthma associated with different genetic,
physiologic, immunologic and environmental factors;
examine the effectiveness of combinations of immune modulation to reduce IgE
responses to allergen and allergen avoidance as a means to reduce the risk of
developing asthma;
examine the epidemiology of asthma in different populations to identify risk factors for
the onset of asthma.
ATSDR, in partnership with state and local health departments and community groups, will investigate
childhood asthma in 5-7 communities where sources of emissions from hazardous waste facilities have
already been identified. These investigations will characterize any associations between hazardous
materials and the burden of asthma in children.
In addition to intramural and extramural grant programs, NIH, CDC, and EPA will fund medical centers to
conduct comprehensive research on environmental aspects of asthma.
The National Academy of Sciences, with support of EPA, will complete its assessment of asthma
associated with indoor pollutants These findings will be used to guide research efforts on the causes of
asthma.
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B. EXPAND AND ACCELERATE RESEARCH TO DEVELOP AND EVALUATE
ENVIRONMENTAL STRATEGIES THAT WILL IMPROVE THE QUALITY OF LIFE FOR
CHILDREN WITH ASTHMA.
It is well established that inhaled allergens and irritants and outdoor pollutants provoke asthma
symptoms. Research is needed to identify if other environmental exposures are significant.
Further, the relative importance of various exposures is not well understood. Cost effective
strategies for reducing exposures are not well developed.
Patient education strategies in certain populations have profound impacts on reducing the
frequency and severity of exacerbations and improving the quality of life for children. But many
of these programs are not responsive to the cultural, ethnic, and economic diversity of the
American population. Innovative strategies are urgently needed for reaching a wide range of
children and their families, for tailoring recommendations for reducing environmental exposures
to their needs, and for providing support to follow the recommendations.
KEY ACTIONS:
NIH and EPA will conduct studies to examine the interrelationship between indoor allergen exposures,
viral infections, ambient air pollutants, and exacerbations of asthma. This research will include
identifying and evaluating cost effective methods to reduce allergen exposures, as well as methods to
render the immune system less susceptible to environmental exposures.
NIH, CDC and EPA will conduct studies to improve and evaluate interventions designed to teach
families and patients how to minimize exposure to environmental asthma triggers.
CDC and NIH will work with state and local health departments to develop and evaluate the cost-
effectiveness of model public health intervention programs.
NIH and HUD will complete the first National Allergen Survey to provide estimates of allergen exposure
for the U.S. population; this survey will provide much needed information about the apparent regional
differences in allergen exposures.
NIH, with support from EPA for particulate air monitoring, will continue to fund the National Cooperative
Inner-City Asthma Study (NCICAS), 1996-2000, which will determine the capacity of interventions to
reduce asthma morbidity among inner city children.
EPA, NIH, and CDC will fund and conduct research in collaboration with the private sector to identify
home construction, maintenance and occupancy practices that will reduce children's exposure to
environmental agents that trigger asthma episodes.
As part of its program on energy efficient buildings, DOE will study the relative effectiveness of energy
conservation strategies and technologies on reducing exposures to allergens.
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2. PROGRAMS TO IMPROVE PUBLIC HEALTH
Implement public health programs that improve use of scientific
knowledge to prevent and reduce the severity of asthma
symptoms by reducing environmental exposures.
Despite uncertainty about the causes of the increase in asthma prevalence rates, much can and
should be done to prevent severe illness and death from asthma and improve the quality of life of
persons with asthma. Experts convened by the National Asthma Education and Prevention
Program (NAEPP) coordinated by the National Institutes of Health (NIH) have reviewed the
scientific literature and produced guidelines for managing asthma. These include specific
recommendations for controlling environmental factors that contribute to asthma severity.
While there is consensus that NAEPP guidelines define the best diagnosis and management
practices for asthma, dissemination of the guidelines must be expanded and adoption improved.
Many clinicians do not include advice about environmental control in
their patient education. Among families who do receive
recommendations, adherence is generally low. Asthma is highly
variable, and families need help establishing priorities for
environmental control measures that will be suitable for their
individual child's asthma and their family circumstances. Effective
public health programs can provide this education and support.
For children without access to quality health care, appropriate instruction on the environmental
triggers of asthma is impossible or severely limited. Emergency rooms or urgent care facilities
may serve as the only source of primary care for such children. These settings should be
recruited to provide the kind of education and links to chronic disease management services that
are essential to reducing the severity and frequency of asthma attacks.
A. PROMOTE CLINICIAN AND PATIENT IMPLEMENTATION OF NATIONAL
GUIDELINES FOR REDUCING ENVIRONMENTAL RISKS THAT WORSEN ASTHMA.
KEY ACTIONS:
NIH will use appropriate existing partnerships and innovative mechanisms to ensure wider use of the
most up-to-date Guidelines for the Diagnosis and Management of Asthma published and periodically
updated by the NAEPP/NIH. These guidelines offer specific advice on the environmental management
of asthma.
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Encourage and assist health care practitioners, including doctors, nurses, and personnel in emergency
rooms and urgent care facilities, to provide high quality patient education on reducing exposure to
pollutants that trigger asthma.
NIH, CDC, and EPA will establish partnerships with managed care organizations to integrate strong
messages about management of asthma into existing health education programs, emphasizing the
environmental management of asthma.
HCFA will investigate ways to improve the management of asthma, following the NAEPP guidelines, in
care provided to Medicaid beneficiaries under 18 years old in the Managed Care Program.
ATSDR will expand to ten the number of pediatric environmental health specialty units across the
country. These specialty units will develop environmental medicine materials, health education
activities, and risk communication strategies on issues related to asthma and the environment well as
other environmental health hazards to children: these educational activities will target both primary care
providers and persons potentially exposed to harmful pollutants. In addition, these specialty units will
provide consultation services to primary care as well as clinical diagnostic services to patients upon
referral.
B. EXPAND SUPPORT FOR STATE AND LOCAL PUBLIC HEALTH ACTION.
Recent advances in the treatment of asthma and in identifying the environmental triggers of
asthma attacks make it possible to control and prevent symptoms at a level unheard of just ten
years ago. But these gains have not been realized by many of our children. Public health
agencies have a critical role in helping to reduce environmental factors affecting asthma and the
human and financial toll of the disease. These programs should include the following
components:
(1) Education and training
(2) Asthma surveillance
(3) Coalitions for prevention
KEY ACTION:
CDC, in collaboration with NIH, will provide grants to 12 state health departments in FY 2000 to ensure
that effective asthma education, prevention, and public health outreach activities in local communities
are developed and sustained.
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C. REDUCE CHILDREN'S EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE
AND OTHER INDOOR TRIGGERS IN THEIR HOMES.
Secondhand tobacco smoke and indoor allergens are major
contributors to the incidence of wheezing in young children and play
a significant role in the number and severity of asthma attacks.
Reducing smoking in homes with young children will improve the
health status of the estimated 2 million children with asthma who are
exposed to secondhand smoke. In addition, exposure to allergens
such as cockroach, house dust mite, mold, and animal dander causes
many attacks of asthma that are preventable.
KEY ACTIONS:
EPA, CDC, and NIH will conduct a national public information campaign to reduce children's exposure to
environmental tobacco smoke.
EPA, HUD. and CDC will work within existing public health programs that visit homes to increase the
avenues through which parents and children receive key messages about asthma prevention and
management. For example, partnerships with the extensive lead paint home
intervention network, the AmeriCorps volunteers program, VISTA volunteer
Exposure to
program, U.S. Department of Agriculture Extension Service, and the "Welfare to
secondhand smoke
Work" program could all be used to bring asthma prevention messages (e.g.,
smoking and controlling allergens through techniques such as Integrated Pest
and allergens such as
Management) directly into millions of homes in a cost-effective manner.
cockroach, house
dust mite, mold, and
EPA and DHHS, under the coordination of the National Asthma Education and
animal dander causes
Prevention Program and in close cooperation with the private sector, will undertake
many attacks of
a national asthma awareness campaign, targeted at parents and emphasizing
asthma that are
avoidable asthma triggers such as environmental tobacco smoke, indoor allergens,
preventable.
and outdoor air pollution episodes as well as early diagnosis and effective
management.
HUD will collaborate with health departments with authority over low-income housing, home health
educators, and building operators to implement appropriate guidance on building operation and
maintenance practices, including ventilation, moisture control and integrated pest management
techniques.
EPA will develop innovative means to disseminate information to persons and families with asthma on
the health impact of ambient air pollutants, particularly ozone and particulate matter.
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D. ESTABLISH SCHOOL BASED ASTHMA PROGRAMS IN EVERY COMMUNITY.
The educational system is a critical component of effective efforts to reduce illness due to asthma
in children. Programs need to be implemented at the local school level to assure a healthy
physical environment at the school and to promote improved self-management of asthma through
education.
KEY ACTIONS:
Develop and expand partnerships between EPA, NIH, CDC, the Department of Education, and non-
governmental public and private organizations to implement programs to assure that the school
environment is safe for children with asthma. Such efforts should include expanding programs such as
the Indoor Air Quality Tools for Schools Program.
EPA and NIH will collaborate with private and voluntary organizations to expand their successful school-
based asthma management programs.
E. CONTINUE TO REDUCE OUTDOOR AIR POLLUTION
The U.S. EPA set national ambient air quality standards (NAAQS) for six air pollutants in 1971,
in part based on evidence of associations between air pollutants such as ozone, particulate matter,
and sulfur dioxide and asthma. Since that time substantial new epidemiological evidence has
been published supporting the association berween levels of ozone and
particulate matter and increased hospitalization for respiratory causes,
such as childhood asthma. In 1997, NAAQS for both ozone and
particulate matter were strengthened to improve the protection afforded
by these standards and to help reduce the risk of ambient exposures
that aggravate asthma in children
Federal, State, local, and private sector efforts to implement the original NAAQS resulted in
substantial improvements in air quality, yet notable problems remain. Following the 1990 Clean
Air Act Amendments, efforts were expanded to improve nationwide air quality and reduce
related health effects. In conjunction with the strengthening of the ozone and particulate matter
NAAQS, EPA has taken steps to integrate implementation measures for these pollutants and to
improve the effectiveness of control programs. EPA has also taken steps to inform the public
about air pollution that may affect children.
KEY ACTIONS:
EPA has proposed that twenty-two States revise their implementations programs in order to provide
widespread regional reductions in ozone and related pollutants
Revisions will be made to strengthen the Pollutant Standards Index (PSI) to help make the public more
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aware of days when air pollution levels could affect health and to alen individuals to steps which could be
taken to mitigate health effects associated with exposure to air pollution.
The Environmental Monitoring for Public Access and Community Tracking (EMPACT) program will
increase the availability of real time ozone data over the Internet and through local TV weather
broadcasts.
3. SURVEILLANCE
Establish a coordinated nationwide asthma surveillance system for
collecting and analyzing health outcome and risk factor data at the
state, regional and local levels.
Current national surveillance permits tracking of asthma prevalence, asthma physician office
visits, asthma emergency room visits, asthma hospitalizations and asthma mortality at a national
level and in four geographic regions (i.e., Northeast, Midwest, South, and West) through surveys
conducted by the National Center for Health Statistics. Surveillance information on asthma, with
the exception of mortality data, are not available at the state or local level. This information is
needed to identify high risk populations and environmental risk factors of relevance to particular
communities and to design and implement interventions that will be most suitable for, and
therefore most likely to succeed, in that community. State and local health agencies also need
this information to evaluate the impact of local sources of air pollution on childhood asthma in
specific communities. A significantly enhanced and expanded surveillance program will be
essential to study issues related to race and gender differences in asthma morbidity and mortality
among children, identify gaps in providing comprehensive care, and monitor trends in asthma
morbidity and mortality at the community level.
KEY ACTIONS:
CDC, in collaboration with NIH, will work with state and local health departments to build a national
asthma surveillance system The first priority in this work will be to develop the state and local
infrastructure that will be needed to collect, analyze, and interpret data at the local level. The
surveillance system will consist of the following components:
Annual surveys of states and major metropolitan areas using standard instruments and methods
to define the prevalence of asthma, to charactenze the severity of asthma and the quality of life
for persons with asthma, and to assess the quality of asthma management
Systematic, periodic examinations of existing mortality and morbidity data at state/city or county
level to determine deaths, hospitalizations, and emergency room visits for asthma.
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Expanded capability to integrate analysis of ambient air monitoring data with asthma morbidity
and mortality data.
Modify existing data collection systems as needed, to ensure the ability to measure progress
toward the Healthy People 2010 goals, now under development.
Follow-up studies of geographic and population groups with elevated asthma prevalence rates
and elevated rates of morbidity.
4. DISPROPORTIONATE IMPACTS ON THE POOR AND
MINORITIES
Identify the reasons for and eliminate the disproportionate burden of
asthma among different racial and ethnic groups and those living in
poverty.
Poor and minority children are disproportionately affected by asthma,
which has reached epidemic proportions in many American inner cities.
Peor and minority
Prevalence rates vary only by a few percentage points among different
children are
race and ethnic groups, yet emergency room use, hospitalization, and
disproportionately
mortality rates vary 3- to 4-fold. Understanding the factors that
affected by asthma,
contribute to the disproportionate impact of asthma on minority and
which has reached
lower income populations is the critical first step to reducing and
epidemic
eventually eliminating the disparities between rich and poor, minority
proportions in many
and non-minority children. Such factors may include differing intensities
American inner
of environmental exposures, such as exposure to cockroach antigen and
cities.
access to and quality of care, among others.
A. CONDUCT RESEARCH AND SURVEILLANCE ACTIVITIES TO IMPROVE
UNDERSTANDING OF THE PROBLEM
CDC, NIH and ATSDR WIll conduct research and collect surveillance data to better define factors
contributing to asthma morbidity and asthma prevalence in minority and lower socioeconomic
populations. Such data will
Separate roles of geography and environmental factors from ethnicity and socio-cultural
variables in assessing their contribution to asthma prevalence.
Examine the differences in asthma prevalence in Hispanics of different origins in order to
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provide some clues on risk factors contributing to higher rates of asthma.
Examine the influence of poverty versus racial and ethnic group on use of emergency room
services and hospitalization rates.
B. IMPLEMENT PROGRAMS TO ELIMINATE THE DISPROPORTIONATE IMPACT
OF ASTHMA IN MINORITY POPULATIONS AND THOSE LIVING IN POVERTY.
KEY ACTIONS:
NIH, EPA, and CDC will implement public health interventions directed specifically to relieve the impact
of asthma on vulnerable populations, particularly targeting the environmental exposures of vulnerable
populations
Ensure a substantial and appropriate focus of public health asthma initiatives on
vulnerable populations.
Make culturally and linguistically appropriate information on asthma widely available.
Expand the availability of services, particularly emphasizing the need to modify the
environment to reduce exposure to known asthma triggers, to the under-served in lower
socioeconomic communities.
EPA will collaborate with state environmental protection programs to establish targeted compliance
monitoring and enforcement efforts in communities with higher than average childhood asthma morbidity
and mortality rates.
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GLOSSARY
Acute: Brief (days to weeks).
Allergen: A chemical or biological substance (e.g. pollen, animal dander, or house dust mite proteins)
that causes an allergic reaction, characterized by hypersensitivity.
Asthma: A chronic lung disease with chronic inflammation of the airways and recurring exacerbations of
airflow limitation that result in wheezing, cough, chest tightness, and difficulty breathing.
Atopy: The genetically inherited susceptibility to become allergic.
Chronic: Remains for several years, possibly a lifetime.
Exacerbate: To aggravate or make asthma worse.
Genome: The inherited genetic composition of an organism.
Incidence: The number of individuals that develop an abnormality within a given time (usually a year)
expressed as a percentage of the population.
Irritant: Risk factor or trigger that may cause increased symptoms and/or airflow limitation via a neural
pathway.
Primary Prevention: Interventions designed to prevent the development of asthma.
Prevalence: The percentage of the population with a disease. disorder. or abnormality.
Secondary Prevention: Interventions designed to prevent the worsening of asthma among individuals
who already have the disease.
Surveillance: The ongoing collection, analysis, interpretation, and dissemination of health outcome
data used to plan and evaluate public health programs.
Trigger: An exposure that causes symptoms or exacerbations of asthma.
26
2607778
UNITED STATES
ENVIRONMENTAL PROTECTION
AGENCY
67557
OFFICE OF THE ADMINISTRATOR
401 M St., SW
Washington, DC 20460
TO: DEVORA ADLER
FROM: DOVG TSAO
COMMENTS:
NUMBER OF PAGES TO FOLLOW:
DATE:
David
TIME:
Jacobs
75517855
FAX NUMBER: (202)260-4852
TELEPHONE NUMBER: (202)260-4724
5649315
2601145
Bob
Agelied
Pay 2600m
2604103
ABOUT THE PRESIDENT'S TASK FORCE ON
ENVIRONMENTAL HEALTH RISKS AND SAFETY RISKS TO
CHILDREN
In recognition of the growing body of scientific information demonstrating that America's
children suffer disproportionately from environmental health risks and safety risks, President
Clinton issued Executive Order 13045 on April 21, 1997, directing each Federal Agency to make
it a high priority to identify, assess, and address those risks. In issuing this order, the President
also created the Task Force on Environmental Health Risks and Safety Risks to Children, CO-
chaired by Donna Shalala, Secretary of the Department of Health and Human Services, and Carol
M. Browner, Administrator of the Environmental Protection Agency. The Task Force was
charged with recommending strategies for protecting children's
environmental health and safety. Two subcommittees were established
in the Executive Order to carry out this directive: a subcommittee
directed to review and foster public access to federal government
sponsored research on environmental health and safety risks to children,
and a subcommittee directed to identify priority public outreach
activities related to protecting children's environmental health and
safety.
In April 1998, the Task Force identified four priority areas for immediate attention: childhood
asthma, unintentional injuries, developmental disorders, and childhood cancer. The Task Force
created and charged the Asthma Priority Area Workgroup with reviewing current Federal efforts
to address the many facets of the issue and, most importantly, to make appropriate
recommendations for action by the Federal government. This report is the result of that effort.
TABLE OF CONTENTS
ABOUT THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH RISKS
AND SAFETY RISKS TO CHILDREN
1
MEMBERS OF THE PRESIDENT'S TASK FORCE ON ENVIRONMENTAL HEALTH
RISKS AND SAFETY RISKS TO CHILDREN
3
ASTHMA PRIORITY AREA WORKGROUP MEMBERS
5
EXECUTIVE SUMMARY
6
INTRODUCTION
8
The Growing Problem of Asthma in Children
8
What We Know About Childhood Asthma
9
Why Has Asthma Reached Epidemic Proportions in Children?
11
Scope of the Plan for Environmental Action to Protect Children
11
GOALS OF THE ACTION PLAN
12
VISION FOR THE 21ˢᵗ CENTURY
13
GUIDING PRINCIPLES
14
RECOMMENDATIONS
16
RESEARCH
16
PROGRAMS TO IMPROVE PUBLIC HEALTH
19
SURVEILLANCE
23
DISPROPORTIONATE IMPACTS ON THE POOR AND MINORITIES
24
GLOSSARY
26
ADDITIONAL READING
27
TIPS FOR AVOIDING AND CONTROLLING ASTHMA TRIGGERS
28
2
EXECUTIVE SUMMARY
An epidemic of asthma is occurring in the United States. While the epidemic affects people of
all ages, children are particularly affected. Nearly 1 in 13 school-aged children has asthma, and
the percentage of children with asthma (i.e., prevalence rate) is rising more rapidly in preschool-
aged children than in any other age group.
There is no national system to collect data from states specifically on
asthma, although several states are developing systems to collect such
An epidemic of
asthma is
data. Although national data do not provide the resolution necessary to
identify particular geographic areas hardest hit by the asthma epidemic,
occurring in
the United
surveys undertaken in a number of large cities in the United States
States.
indicate that the prevalence and severity of asthma are greatest in the
large, urban inner cities.
Asthma is one of the leading causes of school absenteeism, accounting for over 10 million
missed school days per year. Asthma also accounts for many nights of interrupted sleep,
limitation of activity, and disruptions of family and care-giver routines. Asthma symptoms that
are not severe enough to require a visit to an emergency room or to a physician can still be severe
enough to prevent a child with asthma from living a fully active life.
In 1990, the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the
majority of the expense attributed to direct medical expenses. A 1996 analysis found the cost of
asthma to be $14 billion, indicating a rapidly increasing financial burden. These estimates,
which are not limited to the costs of childhood asthma, indicate that the direct medical costs of
asthma account for between 1% and 3% of all health care expenditures in the United States.
Asthma is a particularly important disease to consider in the context of environmental hazards to
which children are exposed. Children breathe more air, eat more food, and drink more liquid in
proportion to their body weight than do adults, and their developing respiratory, immunological,
and digestive systems may be more susceptible to environmental exposures than those of adults.
In a typical day, children may be exposed to a wide array of environmental agents at home, in day
care centers, schools and while playing outdoors. There is substantial evidence that
environmental exposures, including viruses and allergens, play a major role in triggering asthma
symptoms. Airborne allergens include those from house dust mites, cockroaches, mold and
animal dander. In addition, exposure to environmental tobacco smoke has been shown to be a
major determinant of asthma symptoms. Elevated levels of outdoor air pollutants, particularly
ozone, are associated with increased symptoms and an increased risk of emergency department
visits for asthma, as well.
In addition, environmental factors such as airborne allergens and environmental tobacco smoke
(i.e., secondhand smoke) may play a major role in the onset of asthma. Other pollutants may also
play a role, although the scientific data are inadequate to offer firm conclusions. Genetic
5
predisposition is the strongest known risk factor for developing asthma, but the rapidly rising
number of cases of childhood asthma cannot be solely genetic because the genetic composition of
the population changes slowly. Rather, some interaction between genetic predisposition and
environmental exposures, and possibly other factors such as diet or lack of exercise are likely to
be responsible for the increase. Further work is essential to clarify how genetic susceptibility and
environmental exposures interact to cause asthma.
Reducing exposures of children with asthma to airbome allergens and pollutants will reduce the
health burden of asthma and significantly improve their quality of life. It is not yet certain, but it
is possible that reducing the exposure of infants and young children at risk of developing asthma
may prevent its onset. Environmental control methods and asthma treatments are available now
that can help children and their families control asthma and lead healthy, active lives. Yet not all
children have access to these measures. Too many children miss school, limit their physical
activity, and are seriously ill because of asthma.
The environmental action plan for asthma outlined in this report is
designed to promote concerted Federal action to protect all children
with asthma from environmental risks that worsen their disease and
to expand federal research to reveal how reducing environmental
risks might prevent children from getting asthma.
GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this initiative are
predicated on the principles that federal action must have:
A focus on efforts to eliminate the disproportionate impact of asthma in minority
populations and those living in poverty.
An emphasis on partnerships and community based programs.
A commitment to setting measurable and consistent goals for childhood asthma under
the Healthy People 2010 program.
An investment in evaluation to identify those strategies that are most effective in reducing
the burden of asthma so that they may be replicated.
6
RECOMMENDATIONS FOR ACTION
RESEARCH
Strengthen and accelerate focused research into the environmental factors that cause or worsen
childhood asthma.
Strengthen and accelerate research into the environmental factors
This year 2000
that may contribute to the onset of asthma in children.
initiative is
about
Expand and accelerate research to develop and evaluate
protecting
environmental strategies that will improve the quality of life of
children from
people with asthma.
asthma
PUBLIC HEALTH PROGRAMS
Implement public health programs that foster improved use of current scientific knowledge to reduce
environmental exposures to prevent and reduce the severity of symptoms for those with asthma.
Promote clinician and patient implementation of national guidelines for reducing
environmental risks that worsen asthma.
Expand support for state and local public health action.
Reduce children's exposure to environmental tobacco smoke and other indoor triggers in
their homes.
Establish school based asthma programs in every community that help reduce or
eliminate allergens and irritants and that promote student's self management of asthma
and full participation in school activities.
Continue to reduce outdoor air pollution.
SURVEILLANCE
Establish a coordinated, integrated, and systematic nationwide asthma surveillance system for collecting
and analyzing health outcome and risk factor data at the state, regional and local levels.
DISPROPORTIONATE IMPACT ON THE POOR AND MINORITIES
Eliminate the disproportionate burden of asthma among different racial and ethnic groups and those
living in poverty.
Conduct research and surveillance activities to improve
understanding of the problem.
Implement activities to eliminate the disproportionate impact
of asthma in minority populations and those living in poverty.
7
INTRODUCTION
The Growing Problem of Asthma in Children
Asthma is a chronic lung disease characterized by recurrent episodes of breathlessness,
wheezing, coughing, and chest tightness; these episodes are also known as exacerbations or
attacks. The severity of exacerbations can range from mild to life threatening. Both the
frequency and severity of asthma symptoms can be reduced by the use of medications and by
reducing exposure to the environmental triggers of asthma attacks.
For the past 15 years, an epidemic of asthma has occurred in the United
States. By all indications, this epidemic is continuing. Although asthma
has become a major public health problem affecting Americans of all ages,
races and ethnic groups, children have been particularly severely affected.
National survey data -- the responses of randomly selected U.S. residents
being asked whether they had symptoms of physician diagnosed asthma in the previous 12
months -- indicate that the number of children with asthma in the United States has more than
doubled in the past 15 years. In 1980, 2.3 million American children had asthma In 1995, the
most recent year for which data are available, the number of affected children had risen to 5.5
million. Based on these trends, it is estimated that in 1998 more than 6 million children in the
United States have asthma. Prevalence rates of asthma are highest in boys and are increasing in
both boys and girls, and in all race and ethnic groups. The prevalence of asthma in children
under age 18 is 7.3%. The most rapid increase has occurred in children under 5 years old, with
rates increasing over 160% over the past 15 years.
The number of deaths attributed to asthma in children has also increased. In 1977, 84 deaths in
children 18 and younger were recorded; the number of deaths has risen to 280 in 1995, a more
than 3-fold increase. Although the death rate due to asthma has increased in all racial and ethnic
groups, minority populations experience a disproportionately higher death rate from asthma. In
1995, the death rate from asthma in African-American children, 11.5 per million, was over four
times the rate in white Americans, 2.6 per million. The higher death rates among African-
American children are especially troubling.
The number of hospitalizations and emergency room visits for asthma have increased in all
population groups. Asthma accounts for one-third of all pediatric emergency room visits and is
the fourth most common cause for physician office visits. The variation in the impact of asthma
across racial and ethnic groups is significant. African American children have an annual rate of
hospitalization of 74 per 10,000, over 3 times that for whites, 21 per 10,000. In addition, African
American children are approximately 4 times more likely than white children to seek care at an
emergency room. In short, African-American children have a slightly higher risk of getting
asthma, but have a much higher risk of hospitalization or death due to the disease.
8
At the present time, surveillance for asthma in children is limited to analyses of ongoing surveys
and data systems on health events such as mortality, hospitalization, and outpatient visits. Other
than for African Americans, such information is extremely limited for most ethnic groups. There
is no national system to collect data from states specifically on asthma, although several states
are developing systems to collect such data. Although national data do not provide the resolution
necessary to identify particular geographic areas hardest hit by the asthma epidemic, surveys
undertaken in a number of large cities in the United States indicate that the
prevalence and severity of asthma are greatest in the large, urban inner cities.
There is no
national system
These measures, particularly for death, hospitalization, and emergency room
to collect data
visits, give an incomplete picture of the true burden of asthma in the United
from states
States. For example, one follow-up study of children with asthma in inner
specifically on
city areas found a nearly 10 times higher likelihood of a child suffering
asthma, although
symptoms of asthma on a given day than visiting an emergency room.
several states
Asthma is one of the leading causes of school absenteeism, accounting for
are developing
over 10 million missed school days per year. Asthma also accounts for many
systems to
nights of interrupted sleep, limitation of activity, and disruptions of family
collect such
and care-giver routines. Asthma symptoms that are not severe enough to
data.
require a visit to an emergency room or to a physician can still be severe
enough to prevent a child with asthma from living a fully active life.
Estimating the costs of asthma is an indirect way to measure its health burden. In 1990, the cost
of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority of the expense
attributed to direct medical expenses. A 1996 analysis found the cost of asthma to be $14 billion,
indicating a rapidly increasing financial burden. These estimates indicate that the direct medical
costs of asthma for all ages account for between 1% and 3% of all health care expenditures in the
United States.
What We Know About Childhood Asthma
Over the past 15 years, there have been major advances in the scientific understanding of asthma.
Asthma is now known to be a disease of airway inflammation resulting from a complex interplay
between environmental exposures and genetic and other factors. This has implications for the
medical treatment and for the environmental management of asthma.
In contrast to the limited understanding of the relationship of environmental exposures to the
onset of asthma, the environmental triggers of asthma attacks for children with asthma have
become increasingly well characterized. House dust mites, cockroaches, mold and animal dander
have been identified as the principal allergens that trigger asthma symptoms. Reducing exposure
to these allergens has been shown not only to reduce asthma symptoms and the need for
medication, but also to improve lung function. Environmental tobacco smoke (also called
secondhand smoke) is an important irritant that can trigger an asthma episode and possibly
potentiate the effects of allergens. Upper respiratory viral infections are also recognized as
9
important triggers for asthma episodes.
Children with asthma have long been recognized as particularly sensitive to outdoor air pollution.
Many common air pollutants, such as ozone, sulfur dioxide, and particulate matter are respiratory
irritants and can exacerbate asthma. Air pollution also might act
synergistically with other environmental factors to worsen asthma. For
Children with asthma
example, some evidence suggests that exposure to ozone can enhance a
person's responsiveness to inhaled allergens. Whether long term exposure to
have long been
these pollutants can actually contribute to the development of asthma is not
recognized as
known, though scientists do not believe that outdoor air pollution is a major
particularly sensitive
to outdoor air
contributor to the current epidemic. To date, little research has examined the
role of other air pollutants in the development or exacerbation of asthma,
pollution.
although this is an issue of increasing public concern.
In addition to improved understanding of appropriate environmental management of asthma, the
medical management of asthma has changed significantly. Inhaled anti-inflammatory
medications have become the mainstay of medical management to prevent asthma episodes and
lessen chronic symptoms of asthma. In addition, improvements in monitoring techniques now
permit objective measures of lung function that are easy for patients and physicians to use in
assessing asthma severity and monitoring changes in the disease. In a disease like asthma that
varies considerably over time and where changes in lung function can occur before symptoms
develop, these objective measures are essential tools for making management decisions.
As a result of these advances, the medical and environmental management of asthma is better
defined and the knowledge exists to manage asthma better than ever before. One especially
important finding is that patient education has been documented to be cost effective. Teaching
patients and their families specific management skills improves asthma management, reduces the
use of emergency services, and improves quality of life. This is particularly important for asthma
management, since the environmental management of asthma requires knowledge of asthma
triggers and specific actions that can be undertaken to reduce exposure to these triggers. The
treatment goal for almost all individuals with asthma should be for that person to lead a life
unrestricted because of asthma.
Reducing exposure to environmental allergens and pollutants will reduce the frequency and
severity of attacks for children with asthma, reduce their need for medicine, and improve their
lung function. Children are exposed to many environmental agents that could trigger asthma
attacks. For example, 25% of children in America live in areas that regularly exceed EPA limits
for ozone. Approximately 38% of children are exposed to environmental tobacco smoke in the
home on a regular basis and exposure to environmental tobacco smoke is so widespread that
approximately 88% of all children have some level of documented exposure. A high proportion
of children living in the inner city are exposed to high levels of cockroach antigen
10
Why Has Asthma Reached Epidemic Proportions in Children?
The causes of the increasing rate of asthma over the past 15 years and the particular role that
environmental exposures play are not known, but there are some clues. Atopy, the genetically
inherited susceptibility to become allergic, is the most important predictor of a child developing
asthma. A substantial research effort is underway to identify the genes that are responsible for
susceptibility to asthma. Because the genetic make-up of the population changes slowly, genetic
susceptibility alone cannot be responsible for the epidemic of asthma that has occurred in the
United States over the past 15 years. Further work is essential to clarify how genetic
susceptibility and environmental exposures interact to cause asthma. Factors such as the
intensity of environmental exposure and the age of the person being exposed are likely to be
important.
Exposure to allergens found indoors is a strong risk factor for developing asthma. Children are
spending increasing amounts of time indoors, thus increasing their exposure to indoor allergens.
The environmental exposures most strongly suspected of causing asthma to develop include
environmental tobacco smoke and allergens such as house dust mites, cockroaches, mold, and
animal dander. Exposures that stimulate the immune system may also be significant, such as diet
during the prenatal period and early infancy, the pattern of respiratory infections early in life, and
even decreasing rates of exercise have all been suggested as risk factors for the development of
asthma. In the broadest sense, many environmental exposures are suspected of contributing to
the epidemic of asthma in children.
Scope of the Plan for Environmental Action to Protect Children With
Asthma
This action plan is about protecting children from asthma and the consequences of asthma. To
accomplish this goal, the environmental aspects of asthma must be considered in the context of
other aspects of asthma prevention and management, such as early access to quality medical care
and efforts to understand the disproportionate health impact of asthma among minority
populations. Childhood asthma is a multi-factorial disease, and efforts to improve its
management and to prevent it will require multi-dimensional, multi-disciplinary efforts that must
occur simultaneously. This action plan focuses on improving the environment in which children
with asthma live, learn, play and work so that they can live productive, active lives and so that
future generations of children might be spared the disease altogether.
II
GOALS OF THE CHILDREN'S ENVIRONMENTAL
HEALTH ASTHMA ACTION PLAN
BY THE YEAR 2005, THE NUMBER OF HOUSEHOLDS IN WHICH
CHILDREN ARE REGULARLY EXPOSED TO SECONDHAND SMOKE
WILL BE REDUCED TO 15%.
BY THE YEAR 2010, ASTHMA HOSPITALIZATION RATES IN CHILDREN
WILL HAVE FALLEN TO NO MORE THAN 10 HOSPITALIZATIONS PER
10,000 PEOPLE.2 (HP 2010 DRAFT)
BY THE YEAR 2010, EMERGENCY DEPARTMENT VISITS WILL BE
REDUCED TO NO MORE THAN 46 PER 10,000 PEOPLE.³ (HP 2010
DRAFT)
BY THE YEAR 2010, NO MORE THAN 10% OF PEOPLE WITH ASTHMA
WILL EXPERIENCE ACTIVITY LIMITATIONS.⁴ (HP 2010 DRAFT)
I Baseline: 29% in 1994, Source: Biennial Radon and ETS Survey of the Conference of Radiation Control Program
Directors and EPA.
2 Baseline: Hospitalization rate per 10,000 population in 1993-94: 18 for total population; 50 for children 0-4 yrs
of age and 18 for children 5-14 yrs. Source: HP2010 Draft
3 Baseline: Emergency room visits 71 per 10,000 population for total population in 1992-94; 121 for children 0-4
yrs of age and 81 for children 5-14 yrs. Source: HP2010 Draft
4 Baseline: Activity limitation for persons with asthma 22 percent for overall population in 1992-94. No children-
specific data available. Source: HP2010 Draft
12
VISION FOR THE 21st CENTURY
Every child in America will live,
learn, work, and play in
environments that do not cause or
worsen asthma.
Asthma will no longer inhibit
children from leading full and active
lives.
More cost-effective medical and
environmental asthma prevention
and management tools will enhance
the lives of children and their
families.
13
GUIDING PRINCIPLES
Federal agency actions can provide leadership and direction in reducing environmental risks to
protect children from asthma. Recommendations for action put forward in this plan are
predicated on the principles that federal action must have:
1. A focus on efforts to better understand and eliminate the disproportionate impact of
asthma in minority populations and those living in poverty.
The health burden of asthma is not shared equally throughout the U.S. population Although the
rising prevalence of asthma has affected all populations, poor and minority children are much
more likely than white, non-Hispanic children to visit an emergency room, to be hospitalized, or
to die from asthma. The reasons for this inequity are not known, although environmental
exposures and limited access to quality medical care may all play a role.
The focus on eliminating disparities across racial and ethnic groups has to be considered in all
efforts to prevent asthma and its health impact; however, because of the importance of this issue
the committee has included a specific recommendation in this action plan to examine,
understand, and ultimately eliminate disparities.
2. An emphasis on partnerships and community based programs.
A successful effort to reduce childhood asthma will depend in part on the level of success
achieved in enlisting all sectors of society in efforts to implement effective programs to prevent
and manage the disease. Federal agencies have already forged effective partnerships with many
health and professional organizations, corporations, and foundations to conduct training, educate
health care providers and the public, and to implement a wide range of
prevention activities at the national, state, and local levels.
The challenge for
Expanded partnerships both within government and between government
the 21" century
and the private sector are needed. With increasing knowledge about the
will be to learn to
primary causes of asthma and triggers of asthma attacks, the challenge for
integrate
the 21st century will be to learn to integrate successfully these findings into
successfully these
more effective environmental, medical and educational programs.
findings into more
Partnerships will be critical to implementing this broad vision of asthma
effective
control. In particular, community-based programs should integrate asthma
environmental,
control activities into existing systems such as schools, child care, youth
medical and
programs, workplaces, primary health, correctional facilities, and job
educational
training programs.
programs.
14
3. A commitment to setting measurable and consistent goals for childhood asthma
under the Healthy People 2010 program.
Health objectives are now being developed for the year 2010 and represent a significant revision
of the goals set for the year 2000. These objectives will set the nation's health agenda for
increasing years of healthy life and reducing disparities among the entire American population.
Draft objectives currently encompass an expanded set of asthma-related objectives as well as a
series of environmental objectives addressing known asthma triggers such as indoor allergens,
secondhand smoke and outdoor air pollution.
The goals embodied in the final Healthy People 2010 document will serve as the tools to measure
progress towards control of asthma. Although some of the goals are likely to measure aspects of
asthma clinical management that will not be directly affected by this action plan, the primary
objectives of morbidity reduction and reducing exposures to environmental hazards will be
addressed.
4. Investment in evaluation of programs to identify those strategies that are most
effective in reducing the burden of asthma so that they may be replicated.
Asthma intervention programs and related activities need to be fully evaluated to determine those
techniques which are successful and should be replicated. Evaluation should be incorporated in
the planning and should include:
identification of desired health outcomes of the program:
measurement of effectiveness of the intervention activities and processes used to
implement them:
identification of unforseen obstacles;
assessment of the cost-effectiveness of the program;
a prediction of long term sustainability of the program.
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RECOMMENDATIONS FOR ACTION
I. RESEARCH
Strengthen and accelerate focused research into the
environmental factors that cause or worsen childhood asthma.
A. EXPAND RESEARCH INTO THE ENVIRONMENTAL FACTORS THAT
CONTRIBUTE TO THE ONSET OF ASTHMA IN CHILDREN.
Though progress has been made in understanding what causes asthma, there is currently
insufficient scientific information to establish specific guidelines and recommendations for
public health practices to prevent the onset of asthma in children (i.e. primary prevention).
In order to establish primary prevention guidelines, the top priority for
research is to determine the causes of asthma in children and
particularly the role of the environment. To understand what causes
asthma, research must identify the basic cellular and molecular
mechanisms that cause airway inflammation and sensitization and, in
particular, the interaction of environmental exposures and genetic
susceptibility. In addition, clinical and epidemiologic studies are
needed to examine the relationship between environmental exposures and the onset of asthma.
Because of promising preliminary work on the relationship of indoor allergens and asthma onset,
as well as the much greater proportion of time that children spend indoors, greater emphasis on
examining the relationship of indoor exposures to the development of asthma is warranted.
Exposures to high levels of allergens in the indoor environment have been shown in some studies
to be associated with the subsequent development of asthma However, few studies have
examined the influence of geographic location on the role of allergens. In studies evaluating the
role of indoor allergens on exacerbations of asthma, different allergens, such as those associated
with cockroaches, dust mites, and mold, have been implicated in different locations. This
suggests that different allergens can exacerbate asthma, and that different allergens may be
capable of inducing the new onset of asthma.
In one study, avoiding exposure to dust mite and food allergens early in life was found to reduce
the risk of developing asthma in the first year of life. However, this effect was not statistically
significant at 2 to 4 years of age. Whether such allergen avoidance strategies are feasible and
effective in reducing the development of asthma is not known.
16
The complex interactions between outdoor air pollutants and
allergens and the development of asthma have not been adequately
Exposures to high
levels of allergens in
evaluated. Some epidemiologic studies have suggested a relationship
the indoor
between exposure to volatile organic compounds and prevalence rates
environment have
of childhood asthma. Because adult-onset asthma is known to be
been shown in some
associated with occupational exposures to volatile organic
studies to be
compounds including formaldehyde, ethylene oxide, and isocyanates,
associated with the
further work to assess the possible etiologic role of specific pollutants
subsequent
in childhood asthma is appropriate.
development of
KEY ACTIONS:
CENTERZ
asthma.
NIH, CDC, and EPA will conduct and fund studies to determine the causes of asthma. Such studies
should include the following:
examine the role of genetic susceptibility to specific environmental exposures in the
development of asthma;
assess the importance of early life events, such as in utero viral infections, viral
infections during infancy, specific antigen exposures and exposures to maternal
smoking on the development of asthma;
examine the effects of pollutants and allergens on immune responses in animal models
and in preclinical studies;
Identify the clinical characteristics of asthma associated with different genetic,
physiologic, immunologic and environmental factors;
examine the effectiveness of combinations of immune modulation to reduce IgE
responses to allergen and allergen avoidance as a means to reduce the risk of
developing asthma;
examine the epidemiology of asthma in different populations to identify risk factors for
the onset of asthma.
ATSDR, in partnership with state and local health departments and community groups, will investigate
childhood asthma in 5-7 communities where sources of emissions from hazardous waste facilities have
already been identified. These investigations will characterize any associations between hazardous
materials and the burden of asthma in children.
In addition to intramural and extramural grant programs, NIH, CDC, and EPA will fund medical centers to
conduct comprehensive research on environmental aspects of asthma.
The National Academy of Sciences, with support of EPA, will complete its assessment of asthma
associated with indoor pollutants. These findings will be used to guide research efforts on the causes of
asthma.
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B. EXPAND AND ACCELERATE RESEARCH TO DEVELOP AND EVALUATE
ENVIRONMENTAL STRATEGIES THAT WILL IMPROVE THE QUALITY OF LIFE FOR
CHILDREN WITH ASTHMA.
It is well established that inhaled allergens and irritants and outdoor pollutants provoke asthma
symptoms. Research is needed to identify if other environmental exposures are significant.
Further, the relative importance of various exposures is not well understood. Cost effective
strategies for reducing exposures are not well developed.
Patient education strategies in certain populations have profound impacts on reducing the
frequency and severity of exacerbations and improving the quality of life for children But many
of these programs are not responsive to the cultural, ethnic, and economic diversity of the
American population. Innovative strategies are urgently needed for reaching a wide range of
children and their families, for tailoring recommendations for reducing environmental exposures
to their needs, and for providing support to follow the recommendations.
KEY ACTIONS:
NIH and EPA will conduct studies to examine the interrelationship between indoor allergen exposures,
viral infections, ambient air pollutants, and exacerbations of asthma. This research will include
identifying and evaluating cost effective methods to reduce allergen exposures, as well as methods to
render the immune system less susceptible to environmental exposures.
NIH, CDC and EPA will conduct studies to improve and evaluate interventions designed to teach
families and patients how to minimize exposure to environmental asthma triggers.
CDC and NIH will work with state and local health departments to develop and evaluate the cost-
effectiveness of model public health intervention programs.
NIH and HUD will complete the first National Allergen Survey to provide estimates of allergen exposure
for the U.S. population; this survey will provide much needed information about the apparent regional
differences in allergen exposures.
NIH, with support from EPA for particulate air monitoring, will continue to fund the National Cooperative
Inner-City Asthma Study (NCICAS), 1996-2000, which will determine the capacity of interventions to
reduce asthma morbidity among inner city children.
CENTISMS
EPA, NIH, and CDC will fund and conduct research in collaboration with the private sector to identify
home construction, maintenance and occupancy practices that will reduce children's exposure to
environmental agents that trigger asthma episodes.
As part of its program on energy efficient buildings, DOE will study the relative effectiveness of energy
conservation strategies and technologies on reducing exposures to allergens.
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2. PROGRAMS TO IMPROVE PUBLIC HEALTH
Implement public health programs that improve use of scientific
knowledge to prevent and reduce the severity of asthma
symptoms by reducing environmental exposures.
Despite uncertainty about the causes of the increase in asthma prevalence rates, much can and
should be done to prevent severe illness and death from asthma and improve the quality of life of
persons with asthma. Experts convened by the National Asthma Education and Prevention
Program (NAEPP) coordinated by the National Institutes of Health (NIH) have reviewed the
scientific literature and produced guidelines for managing asthma. These include specific
recommendations for controlling environmental factors that contribute to asthma severity.
While there is consensus that NAEPP guidelines define the best diagnosis and management
practices for asthma, dissemination of the guidelines must be expanded and adoption improved.
Many clinicians do not include advice about environmental control in
their patient education. Among families who do receive
recommendations, adherence is generally low. Asthma is highly
variable, and families need help establishing priorities for
environmental control measures that will be suitable for their
individual child's asthma and their family circumstances. Effective
public health programs can provide this education and support.
For children without access to quality health care, appropriate instruction on the environmental
triggers of asthma is impossible or severely limited. Emergency rooms or urgent care facilities
may serve as the only source of primary care for such children. These settings should be
recruited to provide the kind of education and links to chronic disease management services that
are essential to reducing the severity and frequency of asthma attacks.
A. PROMOTE CLINICIAN AND PATIENT IMPLEMENTATION OF NATIONAL
GUIDELINES FOR REDUCING ENVIRONMENTAL RISKS THAT WORSEN ASTHMA.
KEY ACTIONS:
NIH will use appropriate existing partnerships and innovative mechanisms to ensure wider use of the
most up-to-date Guidelines for the Diagnosis and Management of Asthma published and periodically
updated by the NAEPP/NIH. These guidelines offer specific advice on the environmental management
of asthma.
19
Encourage and assist health care practitioners, including doctors, nurses, and personnel in emergency
rooms and urgent care facilities, to provide high quality patient education on reducing exposure to
pollutants that trigger asthma.
NIH, CDC, and EPA will establish partnerships with managed care organizations to integrate strong
messages about management of asthma into existing health education programs, emphasizing the
environmental management of asthma.
HCFA will investigate ways to improve the management of asthma, following the NAEPP guidelines, in
care provided to Medicaid beneficiaries under 18 years old in the Managed Care Program.
ATSDR will expand to ten the number of pediatric environmental health specialty units across the
country. These specialty units will develop environmental medicine materials, health education
activities, and risk communication strategies on issues related to asthma and the environment well as
other environmental health hazards to children; these educational activities will target both primary care
providers and persons potentially exposed to harmful pollutants. In addition, these specialty units will
provide consultation services to primary care as well as clinical diagnostic services to patients upon
referral.
B. EXPAND SUPPORT FOR STATE AND LOCAL PUBLIC HEALTH ACTION.
Recent advances in the treatment of asthma and in identifying the environmental triggers of
asthma attacks make it possible to control and prevent symptoms at a level unheard of just ten
years ago. But these gains have not been realized by many of our children. Public health
agencies have a critical role in helping to reduce environmental factors affecting asthma and the
human and financial toll of the disease. These programs should include the following
components:
(1) Education and training
(2) Asthma surveillance
(3) Coalitions for prevention
KEY ACTION:
CDC, in collaboration with NIH, will provide grants to 12 state health departments in FY 2000 to ensure
that effective asthma education, prevention, and public health outreach activities in local communities
are developed and sustained.
20
C. REDUCE CHILDREN'S EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE
AND OTHER INDOOR TRIGGERS IN THEIR HOMES.
Secondhand tobacco smoke and indoor allergens are major
contributors to the incidence of wheezing in young children and play
a significant role in the number and severity of asthma attacks.
Reducing smoking in homes with young children will improve the
health status of the estimated 2 million children with asthma who are
exposed to secondhand smoke. In addition, exposure to allergens
such as cockroach, house dust mite, mold, and animal dander causes
many attacks of asthma that are preventable.
KEY ACTIONS:
EPA, CDC, and NIH will conduct a national public information campaign to reduce children's exposure to
environmental tobacco smoke.
EPA, HUD, and CDC will work within existing public health programs that visit homes to increase the
avenues through which parents and children receive key messages about asthma prevention and
management. For example, partnerships with the extensive lead paint home
intervention network, the AmeriCorps volunteers program, VISTA volunteer
Exposure to
program, U.S. Department of Agriculture Extension Service, and the "Welfare to
secondhand smoke
Work" program could all be used to bring asthma prevention messages (e.g.,
smoking and controlling allergens through techniques such as Integrated Pest
and allergens such as
Management) directly into millions of homes in a cost-effective manner.
cockroach, house
dust mite, mold, and
EPA and DHHS, under the coordination of the National Asthma Education and
animal dander causes
Prevention Program and in close cooperation with the private sector, will undertake
many attacks of
a national asthma awareness campaign, targeted at parents and emphasizing
asthma that are
avoidable asthma triggers such as environmental tobacco smoke, indoor allergens,
preventable.
and outdoor air pollution episodes as well as early diagnosis and effective
management.
HUD will collaborate with health departments with authority over low-income housing, home health
educators, and building operators to implement appropriate guidance on building operation and
maintenance practices, including ventilation, moisture control and integrated pest management
techniques.
EPA will develop innovative means to disseminate information to persons and families with asthma on
the health impact of ambient air pollutants, particularly ozone and particulate matter.
21
D. ESTABLISH SCHOOL BASED ASTHMA PROGRAMS IN EVERY COMMUNITY.
The educational system is a critical component of effective efforts to reduce illness due to asthma
in children. Programs need to be implemented at the local school level to assure a healthy
physical environment at the school and to promote improved self-management of asthma through
education.
KEY ACTIONS:
Develop and expand partnerships between EPA, NIH, CDC, the Department of Education, and non-
governmental public and private organizations to implement programs to assure that the school
environment is safe for children with asthma. Such efforts should include expanding programs such as
the Indoor Air Quality Tools for Schools Program.
EPA and NIH will collaborate with private and voluntary organizations to expand their successful school-
based asthma management programs.
E. CONTINUE TO REDUCE OUTDOOR AIR POLLUTION
The U.S. EPA set national ambient air quality standards (NAAQS) for six air pollutants in 1971,
in part based on evidence of associations between air pollutants such as ozone, particulate matter,
and sulfur dioxide and asthma Since that time substantial new epidemiological evidence has
been published supporting the association between levels of ozone and
particulate matter and increased hospitalization for respiratory causes,
such as childhood asthma. In 1997, NAAQS for both ozone and
particulate matter were strengthened to improve the protection afforded
by these standards and to help reduce the risk of ambient exposures
that aggravate asthma in children.
Federal, State, local, and private sector efforts to implement the original NAAQS resulted in
substantial improvements in air quality, yet notable problems remain. Following the 1990 Clean
Air Act Amendments, efforts were expanded to improve nationwide air quality and reduce
related health effects. In conjunction with the strengthening of the ozone and particulate matter
NAAQS, EPA has taken steps to integrate implementation measures for these pollutants and to
improve the effectiveness of control programs. EPA has also taken steps to inform the public
about air pollution that may affect children.
KEY ACTIONS:
EPA has proposed that twenty-two States revise their implementations programs in order to provide
widespread regional reductions in ozone and related pollutants.
Revisions will be made to strengthen the Pollutant Standards Index (PSI) to help make the public more
22
aware of days when air pollution levels could affect health and to alert individuals to steps which could be
taken to mitigate health effects associated with exposure to air pollution.
The Environmental Monitoring for Public Access and Community Tracking (EMPACT) program will
increase the availability of real time ozone data over the Internet and through local TV weather
broadcasts.
3. SURVEILLANCE
Establish a coordinated nationwide asthma surveillance system for
collecting and analyzing health outcome and risk factor data at the
state, regional and local levels.
Current national surveillance permits tracking of asthma prevalence, asthma physician office
visits, asthma emergency room visits, asthma hospitalizations and asthma mortality at a national
level and in four geographic regions (i.e., Northeast, Midwest, South, and West) through surveys
conducted by the National Center for Health Statistics. Surveillance information on asthma, with
the exception of mortality data, are not available at the state or local level. This information is
needed to identify high risk populations and environmental risk factors of relevance to particular
communities and to design and implement interventions that will be most suitable for, and
therefore most likely to succeed, in that community. State and local health agencies also need
this information to evaluate the impact of local sources of air pollution on childhood asthma in
specific communities. A significantly enhanced and expanded surveillance program will be
essential to study issues related to race and gender differences in asthma morbidity and mortality
among children, identify gaps in providing comprehensive care, and monitor trends in asthma
morbidity and mortality at the community level.
KEY ACTIONS:
CDC, in collaboration with NIH, will work with state and local health departments to build a national
asthma surveillance system. The first priority in this work will be to develop the state and local
infrastructure that will be needed to collect, analyze, and interpret data at the local level. The
surveillance system will consist of the following components:
Annual surveys of states and major metropolitan areas using standard instruments and methods
to define the prevalence of asthma, to characterize the severity of asthma and the quality of life
for persons with asthma, and to assess the quality of asthma management
Systematic, periodic examinations of existing mortality and morbidity data at state/city or county
level to determine: deaths, hospitalizations, and emergency room visits for asthma.
23
Expanded capability to integrate analysis of ambient air monitoring data with asthma morbidity
and mortality data.
Modify existing data collection systems as needed, to ensure the ability to measure progress
toward the Healthy People 2010 goals, now under development
Follow-up studies of geographic and population groups with elevated asthma prevalence rates
and elevated rates of morbidity.
4. DISPROPORTIONATE IMPACTS ON THE POOR AND
MINORITIES
Identify the reasons for and eliminate the disproportionate burden of
asthma among different racial and ethnic groups and those living in
poverty.
Poor and minority children are disproportionately affected by asthma,
which has reached epidemic proportions in many American inner cities.
Poor and minority
Prevalence rates vary only by a few percentage points among different
children are
race and ethnic groups, yet emergency room use, hospitalization, and
dispropor tionately
mortality rates vary 3- to 4-fold. Understanding the factors that
affected by asthma,
contribute to the disproportionate impact of asthma on minority and
which has reached
lower income populations is the critical first step to reducing and
epidemic
eventually eliminating the disparities between rich and poor, minority
proportions in many
and non-minority children. Such factors may include differing intensities
American inner
of environmental exposures, such as exposure to cockroach antigen and
cities
access to and quality of care, among others.
A. CONDUCT RESEARCH AND SURVEILLANCE ACTIVITIES TO IMPROVE
UNDERSTANDING OF THE PROBLEM
CDC, NIH and ATSDR will conduct research and collect surveillance data to better define factors
contributing to asthma morbidity and asthma prevalence in minority and lower socioeconomic
populations. Such data will:
Separate roles of geography and environmental factors from ethnicity and socio-cultural
variables in assessing their contribution to asthma prevalence.
Examine the differences in asthma prevalence in Hispanics of different origins in order to
24
provide some clues on risk factors contributing to higher rates of asthma.
Examine the influence of poverty versus racial and ethnic group on use of emergency room
services and hospitalization rates.
B. IMPLEMENT PROGRAMS TO ELIMINATE THE DISPROPORTIONATE IMPACT
OF ASTHMA IN MINORITY POPULATIONS AND THOSE LIVING IN POVERTY.
KEY ACTIONS:
NIH, EPA, and CDC will implement public health interventions directed specifically to relieve the impact
of asthma on vulnerable populations, particularly targeting the environmental exposures of vulnerable
populations
Ensure a substantial and appropriate focus of public health asthma initiatives on
vulnerable populations.
Make culturally and linguistically appropriate information on asthma widely available.
Expand the availability of services, particularly emphasizing the need to modify the
environment to reduce exposure to known asthma triggers, to the under-served in lower
socioeconomic communities.
EPA will collaborate with state environmental protection programs to establish targeted compliance
monitoring and enforcement efforts in communities with higher than average childhood asthma morbidity
and mortality rates.
25
GLOSSARY
Acute: Brief (days to weeks).
Allergen: A chemical or biological substance (e.g. pollen, animal dander, or house dust mite proteins)
that causes an allergic reaction, characterized by hypersensitivity.
Asthma: A chronic lung disease with chronic inflammation of the airways and recurring exacerbations of
airflow limitation that result in wheezing, cough, chest tightness, and difficulty breathing.
Atopy: The genetically inherited susceptibility to become allergic.
Chronic: Remains for several years, possibly a lifetime.
Exacerbate: To aggravate or make asthma worse.
Genome: The inherited genetic composition of an organism.
Incidence: The number of individuals that develop an abnormality within a given time (usually a year)
expressed as a percentage of the population.
Irritant: Risk factor or trigger that may cause increased symptoms and/or airflow limitation via a neural
pathway.
Primary Prevention: Interventions designed to prevent the development of asthma.
Prevalence: The percentage of the population with a disease, disorder, or abnormality.
Secondary Prevention: Interventions designed to prevent the worsening of asthma among individuals
who already have the disease.
Surveillance: The ongoing collection, analysis, interpretation, and dissemination of health outcome
data used to plan and evaluate public health programs.
Trigger: An exposure that causes symptoms or exacerbations of asthma.
26
ADDITIONAL READING
Technical
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert
Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health
pub no 97-4051. Bethesda, MD, 1997.
Mannino DM, Homa DM, Pertowski CA, et al., Surveillance for Asthma, United States, 1960-1995.
MMWR 1998;47 (No. SS-1):1-27.
Institute of Medicine. Indoor Allergens. Assessing and Controlling Adverse Health Effects. National
Academy Press. Washington, D.C. 1993
Families
American Lung Association. Family Guide to Asthma and Allergies. How You and Your Children Can
Breath Easier. Little, Brown and Company. New York. 1997
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Asthma,
Physical Activity and School. National Institutes of Health pub no 95-3651. Bethesda, MD, 1995.
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Facts About
Controlling Your Asthma. National Institutes of Health pub no 97-2339. Bethesda, MD, 1997.
National Heart, Lung, and Blood Institute. Global Initiative for Asthma. What You and Your Family Can Do
About Asthma. National Institutes of Health pub no 96-3659C. Bethesda, MD, 1996.
Indoor Air Pollution
EPA's Indoor Air Quality Tools for Schools. Available from:
Indoor Air Quality Information Clearinghouse: 1-800-438-4318
Indoor Air Quality Web Site: www.epa.gov/iaq/
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