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April 6 -8, 2004
Asthma in California: Challenges in Assessment and Intervention
Shanghai-California Environmental Health Conference
Richard Kreutzer, M.D.California – China Environmental
Health Training Program
April 6 -8, 2004
Lifetime Asthma Prevalence by Period (Survey Year)
0
2
4
6
8
10
12
14
16
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Period (survey year)
% li
feti
me
asth
ma
Asthma in California
Asthma in California-Lifetime Prevalence
April 6 -8, 2004
Age by Cohort
0
5
10
15
20
25
<1910 1910-19 1920-29 1930-39 1940-49 1950-59 1960-69 1970-79 1980+
birth cohort (year born)
% li
feti
me
asth
ma 18-24
25-34
35-44
45-54
55-64
65-74
75+
Asthma in California-Cohort Analysis
April 6 -8, 2004
Definition of Asthma
• A chronic inflammatory disorder of the airway
• Infiltration of mast cells, eosinophils and lymphocytes
• Recurrent episodes of wheezing, coughing and shortness of breath
• Widespread, variable and often reversible airflow limitation
• Airway hyperresponsivenessSlide 1
April 6 -8, 2004
Magnitude of the Problem
• 150 million asthmatics world wide
• Prevalence increasing in most countries (20 to 50% every 10 years)
• Significant cause of school/work absence
• Health care expenditures very high
• 1 million unnecessary deaths each decade
Slide 3
April 6 -8, 2004
Cost of Illness
• Hospital Stay
• Intensive Care
• Emergency Department
• Primary Care
• Medications
Direct Medical Care
• Social Security
• Lost work output
• Lost school days
• Impact on individual/family/society
Indirect Costs
Slide 5
April 6 -8, 2004
What is the cause of asthma?
April 6 -8, 2004
Mechanisms Underlying the Definition of Asthma
Risk Factors(for development of asthma)
AirwayHyperresponsiveness
Airflow Limitation
SymptomsRisk Factors
(for exacerbation)
Slide 2
April 6 -8, 2004
Risk Factors for Asthma
• Asthma occurs in families
• Atopy: The strongest identifiable risk factor for the development of asthma
• Allergen and chemical sensitizer exposures
• Contributing factors may increase susceptibility to development of asthma in predisposed individuals
Slide 6
April 6 -8, 2004
Risk Factors that Lead to Asthma Development
• Atopy• Family history
Predisposing Factors
• Indoor Allergens– Domestic Mites and cockroach– Animal Allergens– Tobacco smoke– Fungi
• Outdoor Pollution/Allergens– Ozone– Pollens
• Occupational Sensitizers
Causal Factors
• Respiratory Infections
• Small Size at Birth
• Diet
• Exercise
• Cold air
• Air Pollution/allergens– Outdoor Pollutants– Indoor Pollutants
• Smoking– Passive Smoking– Active Smoking
Contributing Factors
Slide 7
April 6 -8, 2004
Factors Influencing the Rise in Asthma
Lifestyle Changes
Immune System Changes
Slide 8
April 6 -8, 2004
Role of “Western” Lifestyle
• Increase in indoor furnishings
• Humidity and indoor temperature
• Decreased ventilation
• Increased time indoors
• Reduction in physical activity can result in allergic sensitization and “priming” for asthma development
• Hygiene hypothesis
Slide 10
April 6 -8, 2004
Factors Influencing Atopy
Slide 9
April 6 -8, 2004
Immune System Balance in Asthma Development
Slide 11
April 6 -8, 2004
Influences on the Developing Immune Response
Inheritance of a genetic susceptibility to atopy
Effect of the in utero environment created by the mother (diet, allergen exposure, etc.)
Maternally directed development of the fetal immune response to common environmental antigens
Actions of early infections, gut microbial flora colonization and allergen exposures of the infant on the developing immune
response after birth
Development of a normal or allergic immune response (and symptoms) to common environmental antigens
1st trimester of pregnancy
2nd and 3rd trimester of pregnancy
Birth
1st year of life
British Medical Bulletin 2000;56(No.4) Slide 12
April 6 -8, 2004 Slide 13
April 6 -8, 2004 Slide 14
April 6 -8, 2004
Asthma Management Issues
• Disease management model versus addressing the ecology of the disease
• Clinical approach versus a population-based approach
• What are the places in the community where changes can influence the course of asthma?
April 6 -8, 2004
Management by Management by PatientPatient
Management by Management by PatientPatient
Family InvolvementFamily InvolvementFamily InvolvementFamily Involvement
Clinical ExpertiseClinical ExpertiseClinical ExpertiseClinical Expertise
Work/School SupportWork/School SupportWork/School SupportWork/School Support
Community Awareness, Support & ActionCommunity Awareness, Support & ActionCommunity Awareness, Support & ActionCommunity Awareness, Support & Action
Community-Wide Environmental Control MeasuresCommunity-Wide Environmental Control MeasuresCommunity-Wide Environmental Control MeasuresCommunity-Wide Environmental Control Measures
Conducive PoliciesConducive PoliciesConducive PoliciesConducive PoliciesNoreen Clark
April 6 -8, 2004
PlacePlacePlacePlace
LocationLocationLocationLocation
PurposePurposePurposePurpose
Physical InfrastructurePhysical InfrastructurePhysical InfrastructurePhysical Infrastructure
Policies/PracticesPolicies/PracticesPolicies/PracticesPolicies/Practices
Multiplicity of UsersMultiplicity of UsersMultiplicity of UsersMultiplicity of Users
Governance and Governance and EnforcementEnforcement
Governance and Governance and EnforcementEnforcement
16
April 6 -8, 2004
April 6 -8, 2004
April 6 -8, 2004
Social Environment Stressors
Physical Environment Stressors
Health Outcomes
Intervening Factors
Amy Schulz, et.al.
Stress Process Model
April 6 -8, 2004
Potential Places for Intervention
• Clinics and health care institutions
• Home
• Preschool
• School
• Workplace
• Community- e.g. energy, agriculture, transportation, planning and zoning
April 6 -8, 2004
Strategic Plan for Asthma in California
April 6 -8, 2004
Strategic Plan for Asthma in California – Five Goals
• Research, epidemiology, and evaluation
• Public education
• Treatment and management
• Secondary prevention
• Policy
April 6 -8, 2004
Overcoming barriers:Integration across organizations
April 6 -8, 2004
To conclude:
• Integration is a powerful tool to extend current resources and develop new ones.
• Integration doesn’t come easily but there are effective strategies to help get there.
• Paths to integration will vary by community and must fit the local landscape.
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