Epidemiology+Paper

__Executive Summary__ Asthma and allergies are considered to be chronic diseases that affect approximately 300 million people worldwide. This paper delves into the distribution patterns and trends of asthma around the world, and also specifically researches trends and patterns within the U.S., the State of Florida, and Seminole County. Breaking down the distribution in this format allows for one to gauge the prevalence of these chronic diseases, and the necessity of intervention. The root cause of asthma is highly unknown. However, there are several risk factors that indicate a potential to develop asthma. Risk factors that will be discussed are genetics, allergies, outdoor air pollutants, occupation, age, gender, and ethnic background. Among these risk factors, genetics seems to have the greatest relation to asthma.

Since asthma can be controlled, several preventative strategies are offered in relation to many of the risk factors described. Asthma triggers, if avoided, can dramatically improve asthmatic’s quality of life. Outdoor air pollution includes ozone, found in smog, and particle pollution, found in haze, smoke, and dust. To decrease the likelihood of triggering symptoms, the importance of knowing one’s outdoor environment in order to make necessary modifications in their activities will be discussed. Indoor air pollutants include irritants such as pets, smoking, dust mites, cockroaches, and dampness. Techniques to minimize these potential indoor triggers are discussed for homes, schools, and work sites.

Based on the information discovered regarding the distribution patterns and trends, the risk factors, and the ability to prevent asthma, it was determined that public intervention is extremely important and necessary. Public interventions can come in the form of programs, which include methods of monitoring health and improving the quality and expectancy of life by providing health data reports, preventative options, and education about maintaining health. Florida’s proposed plan will be discussed, as well as the Centers for Disease Control and Prevention’s (CDC) and the American Lung Association’s (ALA) specific programs. Due to the imminent increase in the rate of asthma without prevention, these strategies will be an important factor in reducing economic costs, as well as in reducing asthma’s morbidity and mortality rates.

__Distribution Patterns and Trends__  An estimated 300 million people of all ages and ethnic backgrounds around the world have asthma.According to the World Health Organization (WHO) the occurrence of asthma has increased in all countries as the same rate as allergies.Approximately 70% of those with asthma have allergies (AAAAI.org, 2010).Due to the increase in urban areas it is projected there is a potential for an increase in the amount of asthma sufferers by100 million by the year 2025.Out of the 300 million asthma sufferers 250,000 die yearly.The rate of death is not connected to the prevalence of asthma.Instead it is related to higher rates of death in countries associated with lower access to treatment.Thus, many of these deaths are preventable and are a direct result of a lack of quality long-term treatment and delays of treatment for final attacks (WHO, 2007).

It is difficult to measure the severity of asthma through hospitalization in low and middle income countries.However, in countries where asthma management plans have been enforced hospitalization rates have dropped.Severe asthma is usually found in poor people and minorities. Economically speaking the cost of asthma is not only related to medical costs such as hospital visits and drugs but also to personal costs such as time lost from work and premature death. Promisingly, asthma management programs are proving to lead to a lower rate of death and hospitalizations (WHO, 2007). In the US an estimated 34.1 million Americans have been diagnosed with asthma. It has been reported that 3,384 people died of asthma in the US in 2005, and more than 12 million people reported having an asthma attack in the past year.Asthma cost the US a total of $19.7 billion.Out of those costs $14.7 billion are direct costs and $5 billion are indirect costs relating to a loss of productivity.One of the direct costs, prescription drugs, is responsible for $6 billion dollars alone.

In the US an estimated 34.1 million Americans have been diagnosed with asthma. It has been reported that 3,384 people died of asthma in the US in 2005, and more than 12 million people reported having an asthma attack in the past year. Asthma cost the US a total of $19.7 billion. Out of those costs $14.7 billion are direct costs and $5 billion are indirect costs relating to a loss of productivity. One of the direct costs, prescription drugs, is responsible for $6 billion dollars alone. To better gauge the prevalence of asthma and its complications in the U.S., one can research the amount of diagnoses made. It is the fourth highest chronic health condition. Within emergency department visits in 1996, asthma was the 10th most common diagnosis. In the outpatient setting, asthma was the 9th most common diagnosis. In 1995, approximately 9 million doctor office visits were attributed to asthma. Persons with asthma accounted for approximately 64 million days in bed between the years1990 and 1992. There was an increase from 19.4% in1986 to 1988 to 19.6% in 1994 to 1996 of sufferers whose activity is limited due to the severity of their asthma. This shows that asthma is significantly prevalent in the U.S. (healthy people)

Asthma prevalence within the state of Florida has become an emerging public health concern. More than 10% of the adults in Florida report having had asthma. In the year 2002, over 25,000 hospitalizations were as a result of asthma. Those hospitalized had an average age of 37 and remained hospitalized an average of 3.6 days, resulting in approximately $11,802 of hospital charges. That same year, a total of 232 people died of asthma. In order to understand this proportion, it is helpful to note that within the U.S. in 2002, there were a total of 4,483 deaths. Children are also affected greatly. Between the years 2001 and 2002, a total of 97,386 children had asthma, which represents approximately 40 out of every 1,000 children or 4% of the children attending public schools. (DOH) In the state of Florida, both genders attribute to 10.7% of asthma sufferers. Within females, there is an 11.7% rate of asthma and within males, a 9.7% rate. According the age breakdown, those 18-24 years of age account for 11.6%, 25-34 account for 11.7%, 35-44 account for 11.2%, 45-54 account for 10.4%, 55-64 account for 11.3%, and 65 and over account for 9.1%. According to race and ethnicity, Whites account for 10.5%, Blacks for 11.9%, Hispanics for 10.7%, multi-racial 11.9%, and other races 9.3%. (CDC).

It was reported that the percentage of adults with asthma in Seminole county in 2007 was 6.3%. (florida charts) In 2007, the rate of hospitalization for asthma per 10,000 population was 8.3%. (CDC) The rate of high school students with known asthma in 2008 was16.3%. The rate for those in middle school was comparable at 16%. The age adjusted asthma 3-year death rate for Seminole county from 2006 to 2008 was 0.3%, whereas the state total was 0.8%.

__Risk Factors__

Although the cause of asthma is largely unknown, several risk factors contribute. While it is possible to develop this disease regardless of whether one has a risk factor, these risk factors are strong indicators for those with a potential to develop asthma and may aid in prevention. Those with several risk factors have a higher chance of developing asthma and should be proactive in taking steps to reduce their risk. These risks include genetics, allergies, medical conditions, occupational irritants, age, gender, and ethnic background. (aurorahealthcare.org) Asthma appears to have a strong relation to genetics. Those who have immediate blood relatives with asthma have a higher likelihood of developing the condition. If asthma does not run in one’s family, and they develop the disease, it is attributed primarily to the environment. (aurorahealthcare.org) Genetic factors play a role because they have been found to be potentially responsible for causing hypersensitivity in the airways. (scotpho.org) Studies have discovered 18 genomic regions and more than 100 genes related to allergy and asthma in 11 populations. These regions can be found on long arms of the chromosomes 2, 5, 6, 12, and 13. The newly discovered gene, ORMDL3, shows a significant link with asthma. Although it is difficult to replicate research regarding genes and asthma, the information provided through prior and current studies continue to suggest a somewhat significant correlation of genetics as a predisposition to asthma. (cmaj.ca) Allergies also play a significant role. Those that suffer with allergies, most commonly allergic rhinitis and severe food allergies, are more inclined to develop asthma. Potential allergens may include pollen, animal dander, mites, molds, dust and dust mites, certain foods, aspirin or other non-steroidal anti-inflammatory drugs, air pollution, and cigarette smoke. (aurorahealthcare.org)

Outdoor air pollution is often beyond one’s control. The two air pollutants primarily responsible for contributing to asthma attacks are ozone, found in smog, and particle pollution, found in haze, smoke, and dust. Other air pollutants include carbon monoxide, nitrogen oxides, sulfur dioxide. Carbon Monoxide includes combustion from motor vehicles and woodsmoke. Nitrogen oxides include fuel emissions from mobile sources, such as cars or trucks, and also from power plants. Sulfur dioxide is usually from industrial sources such as power plants that burn coal and oil. (doh.wa.gov/cfh).  Those who suffer from certain medical conditions have a higher predisposition to developing asthma.These include respiratory infections in childhood, low birth weight, gastroesophageal reflux disease (GERD), obesity, congestive heart failure, and pulmonary embolism. (aurorahealthcare.org) One’s choice of occupation may in fact be a risk factor for them depending upon the various irritants that may be present.Work-related asthma is the most common respiratory disease in developed countries.It is estimated that 15-25% of adults that have asthma is due to the result of their work environment.It can either be classified as allergy-induced asthma or irritant-induced asthma.Some allergens include natural rubber latex in the medical field, animal allergens in research laboratories and veterinary offices, airborne dust, gases, fumes, and vapors, acid anhydrides, mineral and inorganic dust, pyrolysis products, isocyanates, solvents, hydrocarbons, polymers, and welding exposures.Some irritants include cleaning agents, epoxy glues, and hairdressing products. (www.atsdr.cdc.gov)

Asthma does not discriminate based on age.However, those within certain age brackets are more likely to have asthma.More than 50% of asthma sufferers are children between the ages of 2 and 17. (aurorahealthcare.org) According to the hygiene hypothesis, lower levels of exposure to childhood infections increase one’s chances of being diagnosed with asthma. (scotpho.org)

Gender is also not a discriminating factor, as it is found in both men and women.It is more common in boys during childhood years.Adolescent and young adult females have a greater rate of asthma.This age group exhibits boys as having higher rates of remission.Boys under the age of 12 have been found to have more severe asthma than girls, as well as higher rates of hospital admissions.After the age of 20, the rate of asthma has been found to be quite equal between men and women.However, adult females have more severe asthma than males, as well as more hospitalizations.This may be attributed to the differences experienced by boys and girls during puberty. (cmaj.ca/)

Finally, one’s ethnic background may also be a risk factor for asthma.It is found to be somewhat more frequent in Blacks and Hispanics than in Whites.Although this is the case statistically, asthma may occur regardless of one’s ethnicity. (aurorahealthcare.org) Although much still remains undiscovered regarding the underlying causes of asthma, the risk factors mentioned have undergone several studies.Through these studies, they have been found to be strongly and consistently linked to asthma.  __Preventative Strategies__  Outdoor air pollution can also trigger or worsen asthma attacks.The two air pollutants primarily responsible for contributing to asthma attacks are ozone, found in smog, and particle pollution, found in haze, smoke, and dust.One can prevent or lessen the effects of pollution by determining how sensitive they are to pollution.Essentially, one should note the severity of their symptoms when they are outdoors in polluted areas.Exposure to outdoor air pollution can also make one more sensitive to indoor pollutants such as mold and dust mites.

In order to prevent outdoor air pollution as a trigger, it is beneficial to know the ozone is worse during the summer, especially afternoons and early evenings, and that particle pollution can be bad any time of the year.Particle pollution is worse when the airflow is calm.It is also bad near busy roads, during rush hour, and around factories.One should plan activities around these places and time frames.In the event they must be out, they should lower their activity level, so as to not breathe in as much pollution.It is also important to listen to one’s body.Thus, if symptoms arise during an outdoor activity, immediate cessation of that activity is advised.Finally, taking time to quickly view any available air quality forecast reports will alert one to the severity of the pollution, aiding in the decision to proceed or modify activities. ([] )  Indoor exposures are easier to control than outdoor exposures.However, outdoor air quality does have some effect on indoor quality due to the movement of air from the outside to the inside on a continuous basis.Many preventative strategies can be implemented to reduce asthma triggers from indoor pollutants.Some of these strategies include removing pets from the house or from certain areas in the house, prohibiting smoking both indoors and near entryways or air intake systems, and utilizing fragrance-free products.Although more difficult to control, eliminating the presence of dust mites and cockroaches is also an important preventative strategy.Dust mites can be somewhat controlled through good cleaning and removal of habitat, such as putting dust covers on mattresses and removing carpet and stuffed animals.As for cockroaches, cleaning is good, but they can also live in clean houses.To control these, there should be structural seals within the house, and no food or water should ever be left out.Finally, indoor dampness and mold should be controlled through sealing the home, ensuring there are no plumbing leaks, and checking the ventilation to ensure dampness is being vented out of the house.([|www.doh.wa.gov/cfh/asthma/publications/burden/env-risk-ractors.pdf])

Pollen is another common outdoor pollutant. There are three types of pollens to be aware of. These are ragweed, grass, and tree pollen. Ragweed is present from August to November. Levels peak mid-September, and are prevalent in many areas of the country. It is helpful to know counts are highest between 5 and 10 AM on dry, hot, and windy days, thus planning outdoor activities around this will keep triggers at bay. Also, windows in homes and cars should be kept closed and clothing should be dried in automatic machines, as opposed to outdoors. Like ragweed, seasons and regions also affect grass pollen levels. Grass pollen is also affected by temperature, time of day, and rain. It is imperative to keep the grass short, have another mow the lawn or wear a mask while mowing, and choose ground covers that do not produce as much pollen, such as Irish moss. Finally, tree pollen releases pollen starting in January in the Southern states and May or June in the Northern states. This type of pollen can affect one even if the trees are not located on the inhabited property, thus in order to prevent this trigger avoid going outdoors between 5 and 10 AM, keep windows closed, keep cool using air conditioners, avoid window and attic fans, and dry clothing in an automatic dryer. (www.niehs.nih.gov/health/topics/conditions/asthma/pollen.cfm)

Indoor pollutants are not just an issue at home. It is important that the community also be involved in controlling these triggers. These include controlling pollutants in places such as worksites, schools, government buildings, libraries, daycare facilities, and churches. A survey of classrooms in Washington and Idaho public schools determined many schools exhibited risk factors for poor air quality. A small number of schools had protective measures. This demonstrates the prevalence of indoor air pollutants within one’s community. Although controllable, it is out of the hands of the asthma sufferer, as the control of these pollutants is dependent upon community initiatives. (same source as above)

One’s occupational choice may actually be triggering asthma. In cases where occupational triggers are part of the job description and duties, such as working with certain substances, fumes, vapors, or gases, one may need to modify job responsibilities. If this is not possible, asthma sufferers may have to consider removing themselves from the occupation. Work related asthma increased by 63%, from 7.9 claims per 100,000 full time equivalents to 12.9 claims per 100,000 full time equivalents from 1995 to 2002. Implementing engineering controls, utilizing personal protective equipment, and educating employers and employees on preventative strategies can prevent some work related asthma. ([|www.lni.wa.gov/safety/research/occhealth/asthma/default.asp])

__Implications for Public Health Interventions__ Recognizing the prevalence and severity of asthma, as well as the risk factors and prevention strategies is not sufficient.Programs must be put in place to create awareness and provide education to asthma sufferers or potential asthma sufferers in order to prevent and maintain health.Public health programs should have the goal of protecting health within these various communities.Programs should include methods of monitoring health and should provide services to improve the quality and expectancy of life.They should also include the creation of health data reports, and provide preventative options, as well as education about maintaining health.(health.nsw.gov)

In efforts to improve public health, Florida has taken a proactive approach by submitting a grant proposal to the CDC.If Florida gains funds, their initiative will include the implementation of a statewide program at the Florida Department of Health, as well as the creation of a coalition.In addition, a statewide strategic asthma plan will be created.The public intervention will also include education and treatment initiatives.Finally, the program seeks to establish partnerships between public and private organizations. (doh.state.fl.us/environment/programs/environm) This initiative by the state of Florida is a vital first step to creating change and efficiency within the healthcare system in regards to asthma care.If every state takes this approach, the national rate of asthma will begin to decline. According to the Agency for Healthcare Research and Quality (AHRQ), the indirect costs of asthma for the state of Florida is $601,069,835 per year and the direct costs are $794,836,947, totaling $1,396,906,782. (AHRQ, 2007) Direct costs include payments for ambulatory care, hospital outpatient services, emergency department visits, inpatient hospital stays, physician ad facility payments, and prescribed medications.Indirect costs include costs resulting from missed days of work or school, and days with limited activities at work due to symptoms.(Smith, Malone, Lawson, Okamoto, Battista, & Saunders, 1997) These figures alert one to the high costs associated with this disease.

Prior research demonstrates that, nationally, hospitalizations are responsible for over half of all of the expenditures relating to asthma.This figure takes into account that 80% of healthcare resources were used for 20% of the population.This specific portion of the population is considered the high-cost patients.These patients cost approximately $2,584 annually.Essentially, the research indicates the importance of asthma research and intervention targeting hospitalizations and high-cost patients.This will ultimately lead to the most beneficial strategy in reducing utilization of healthcare dollars, and promote cost savings. (Smith, Malone, Lawson, Okamoto, Battista, & Saunders, 1997)

There are several educational programs already in place throughout the nation.These programs also share the goal of managing, preventing, and reducing costs associated with asthma and allergies.One such program is the CDC’s National Asthma Control Program.This program funds states, cities, and school programs in order to aid in monitoring asthma, train healthcare workers, educate asthma sufferers along with their families, and create awareness and education regarding asthma to the public in general. (http://www.cdc.gov/asthma/NACP.htm) Another such program is provided by the American Lung Association (ALA).It is a free program called Better Breathers Club that provides support and education to those with respiratory problems. Various healthcare personnel in the community provide education during monthly meetings.The ALA also hosts an asthma camp for children.Children learn to manage their asthma by identifying and avoiding triggers, as well as how to use inhalers and nebulizers.They are also provided support through social and emotional counseling regarding the disease.Parents also benefit through classes that reinforce what their children have learned regarding asthma management. (www.lungusa.org/) Based on the projected rate of increase of asthma sufferers, the most likely scenario is an increase of costs if interventions are not implemented.By 2025, it is expected that the worldwide rate of asthma sufferers will increase by 100 million, bringing the grand total of asthma sufferers around the world to 400 million. (aaaai.org) The current rate of 300 million is also unacceptable.It is crucial that awareness is created regarding asthma, as many people tend to adopt the attitude or assumption that it is not a critical disease.On the contrary, asthma has a large influence on morbidity, economic cost, and mortality.This reinforces the importance of public interventions with the goal of lowering the incidence of asthma.Although the implementation of public programs may be costly in the beginning, the goal of these programs is to reduce the state costs for the treatment of asthma sufferers.Costs will surely remain the same or increase without public intervention.

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