Environmental Protection Agency

1. EnvironmentalProtection Agency American Association forRespiratory Care

2. Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP • A disease characterized by the following: • Airway inflammation • mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cells • Increased airway responsiveness to a variety of stimuli • Airway obstruction that is reversible (at least to a significant degree)

3. Asthma in the United States • 17.3 million Americans with Asthma • 4.8 million children < 18 with Asthma • Asthma prevalence • 5.8% of Americans • 75% increase since 1980 • 6.8% of preschool children • 160% increase since 1980

4. Asthma Prevalence National Health Interview Survey

5. Race and Prevalence Prevalence of Asthma by Race Ages 5-34 United States, 1982 - 1995 8 7 Black 6 5 4 White Prevalence (%) 3 2 Other 1 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 Year Source: National Health Interview Survey

6. Asthma Morbidity • Approximately 500,000 hospitalizations • Approximately 1.9 million ER visits • 10 million missed school days per year • Loss productivity is estimated at $1 billion per year

7. 600 500 400 300 200 100 0 82 83 84 85 86 87 88 89 90 91 92 Morbidity Hospital Discharge Rates (per 100,000 Population) for Asthma as the First Listed Diagnosis, by Race, Age and Year, Age 5-34 Years A-A (Age 5 through 14) Rate A-A (Age 15 through 34) Cauc. (Age 5 through 14) Cauc. (Age 15 through 34) Year National Hospital Discharge Survey - United States, 1982 - 1992

8. Asthma Mortality Asthma Mortality Rate Ages 5-34, United States, 1979-1995

9. Asthma Annual Mortality Rates by: Race, Ages 5-34, U.S. 1979-1995 African-American Other Caucasian

10. Costs

11. Age in Years Cost Component 0-4 5-17 > 17 Total $ (col%) $ (col%) $ (col%) $ (col%) Prescribed Medicines 48(6.1) 187(22.3) 581(16.5) 81(15.9) Ambulatory Visits 105(13.4) 235(28) 841(23.9) 1,182(23) ED Visits 52(6.5) 131(15.6) 165(4.7) 348(6.8) Admissions 586(74.1) 286(34.1) 1,926(54.8) 2,800(54.4) Total Direct Cost 792(100) 839(100) 3,514(100) 5,147 Direct Cost Estimates for Asthma Smith D et al. AJRCCM 156:787-93,1997

12. Risk Factors for Asthma • Host - Intrinsic • genetic: atopy, IgE, BHR • gender, race, pre-, perinatal • Environmental • allergens, diet, air pollution • Environmental tobacco smoke (ETS) • infections

13. Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP • A disease characterized by the following: • Airway inflammation • mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cells • Increased airway responsiveness to a variety of stimuli • Airway obstruction that is reversible (at least to a significant degree)

14. Expert Panel Report 2:Four Components of Asthma Management • Measures of Assessment and Monitoring • Control of Factors Contributing to Asthma Severity • Pharmacologic Therapy • Education for a Partnership in Asthma Care

15. What does the Indoor Environment have to do with Asthma? • All of the common asthma triggers are found indoors • Americans spend about 90% time indoors • Reducing exposure to indoor allergens and irritants can reduce asthma symptoms • Prevention is an important asthma management tool

16. Indoor Environment in the U.S. • 8 of 10 people are exposed to mites • 6 of 10 people are exposed to cat or dog dander • Clinical studies have demonstrated the prevalence of cockroaches in the inner city, schools and Southern U.S.

17. What is the Indoor Environment... • Home Environment • Bedroom • Kitchen • Bathroom • Basement • Living Area

18. Triggers Away fron the Home Environment…... • School • Workplace • Public areas • Second hand smoke

19. Allergens molds, dust mites, cockroaches, animal dander, pollens,foods Irritants secondhand smoke, strong odors, aerosols, volatile organic compounds, ozone, particulate matter Other Viral respiratory infections Changes in weather (cold air, wind, humidity) Exercise Medication Endocrine factors (menstrual period, pregnancy, thyroid disease) Common Asthma Triggers * 5 major indoor asthma triggers

20. Frequency of Positive Skin Tests % Positive Tests

21. Most Common Indoor Environmental Triggers Secondhand Smoke Dust Mites Mold Pets Cockroaches

22. Secondhand Smoke • Contains more than 4,000 substances (over 40 are carcinogenic) • Is particularly harmful to young children • Can trigger asthma attacks and cause young children to develop asthma

23. Avoiding Secondhand Smoke Choose not to smoke in your home or car and do not allow others to do so either

24. Tobacco Smoke • Secondhand smoke is classified by the EPA as a known cause of lung cancer • Is a serious asthma trigger • EPA estimates that between 200,000 - 1,000,000 asthmatic children are affected

25. Smoking Interventions • Stop smoking • Smoke outside • Enforce smoking bans on school property • Enroll in a smoking cessation program • Get help from physician • Take the Smoke-Free Pledge

26. It’s Okay to Let People Know Smoking Around People with Asthma Is Not Cool

27. Remember Other Sources of Secondhand Smoke

28. Dust Mites • Found in most homes • Live in soft bedding • Feed on skin flakes • Mites and mite droppings can be asthma triggers • Can cause children to develop asthma

29. Dust Mites • Evidence suggests that avoidance can effectively reduce allergic symptoms • Dust mites feed on skin scales and organic materials found in homes • Need RH of 55% or more

30. NCICAS - Hospitalization, Allergy, Exposure Dust Mites p = 0.88 Rosenstreich et al. NEJM 1997; 336: 1556

31. Avoiding Dust Mite Triggers • Wash sheets and blankets once a week in hot water • Cover mattresses and pillows in dust-proof (allergen-impermeable) zippered covers

32. Avoiding Dust Mite Triggers • Choose washable stuffed toys, wash them often in hot water, and dry thoroughly -- keep stuffed toys off beds • Freezing soft toys and small items

33. Avoiding Dust Mite Triggers • Vacuum often (when asthmatic is not present) • Maintain low indoor humidity, ideally between 30-50%  • Replace carpets, draperies, and upholstery

34. Pets • Skin flakes, urine, and saliva of warm blooded animals can be asthma triggers • Triggers can remain in the home for several months after a pet is removed, even with cleaning

35. Warm Blooded Animals Includes…. • Dogs • Cats • Birds • Cows • Horses • Rodents

36. Pet Interventions • Consider keeping pets outdoors or even finding a new home for your pets, if necessary • Wash weekly

37. Pet Interventions • Keep out of bedroom • Restrict to one area

38. Pet Interventions • Remove carpeting • Vacuum carpeting • Use high-efficiency air cleaners

39. Avoiding Pet Triggers • Keep pets away from fabric-covered furniture, carpets, and stuffed toys • If you remove an animal from the home, clean the home thoroughly

40. Molds • Molds grow on damp materials • Found in basements, bathrooms, kitchens, outdoors

41. Molds • Can be found almost anywhere and can grow on virtually any damp substance • Key to mold control is moisture control • Clean up the mold and get rid of excess water or moisture • Reducing moisture also helps reduce other triggers, such as dust mites and cockroaches

42. Mold Intervention • Use dehumidifiers • Provide adequate ventilation • Use exhaust fans when cooking • No carpeting over cement flooring

43. Mold Intervention • Vent showers • Do allow standing water • Frequent inspections for mold

44. Avoiding Mold Triggers • Wash mold off hard surfaces and dry completely • Absorbent materials (ceiling tiles and carpet) may need to be replaced • Fix leaky plumbing or other sources of water • Keep drip pans in your air conditioner, refrigerator, and dehumidifier clean and dry • Use exhaust fans or open windows in kitchens and bathrooms when showering, cooking, or using the dishwasher • Vent clothes dryers to the outside • Maintain low indoor humidity (between 30-50% relative humidity)

45. Cockroaches • Require a water/food source • Over 3500 different species • An inner city problem (85% of homes with children) • Inner city schools also a concern (Baltimore 69% of dust samples) • Become airborne (similar to dust mites)

46. Cockroaches • Droppings or body parts of cockroaches can be asthma triggers • Cockroaches likely contribute significantly to asthma problems in inner city area • Free your home of places for pests to hide and sources of food and water

47. NCICAS - Asthma Morbidity - ED Visits Cockroach p < 0.001 Rosenstreich et al. NEJM 1997; 336: 1556

48. NCICAS - Hospitalization, Allergy, Exposure Cockroach p = 0.001 Rosenstreich et al. NEJM 1997; 336: 1556

49. Relations Among Skin Test and Morbidity • Children with sensitization and high exposure to cockroach have: • More symptomatic days • More nights of lost sleep • More school days missed • More days of caregiver change in plans

50. Cockroach Intervention • Education that emphasizes: • Do not leave food or garbage out • Place trash outside • Store food in airtight containers • Clean all food crumbs or spilled liquids right away • Washing dishes daily • Seal off ports of entry • Remove standing water