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AsthmaA Growing Epidemic

Andrew Catherine9-8487-8026

Final Project Paper

Fall 2010

BBH 440


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Asthma is a chronic lung disease characterized by episodic asthma

attacks where bronchoconstriction and inflammation causes shortness of

breath, coughing, and chest tightness (Asthma: What is It?). The severity and

triggers of the attacks vary from person to person. Some individuals may

experience minor symptoms and discomfort, but others may also have

severe airway constriction that if untreated could cause death (The Global

Initiative for Asthma). Currently there is no cure for asthma ,it is a chronic

condition, but only treatment for the symptoms of asthma attacks--bronchoconstriction being reduced via the now common asthma inhaler

(CDC Asthma).

The cause of asthma is not well understood, but evidence currently

suggests that environmental and genetic factors are causal factors (Miller

and Ho) (CDC Asthma). However, there is some understanding of what

triggers the acute asthma attacks. These triggers are different for each

person, but often include: tobacco smoke, high levels of air pollution, mold,

exercise, changing weather conditions, and stress (emotional, fatigue, etc.)

(CDC Asthma). Some link between obesity and asthma (Grant, Wagner and

KB). Asthma is also thought to possibly be related to better hygiene in

todays western culture than in the past (Ramsey and Celedon).

Reason for Selection

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I am interested in investigating asthma due to its significant impact in

the healthcare system in the future. With the growing incidence and

prevalence of asthma, better understanding the epidemiology (what

segments of the population are more likely to have asthma) behind asthma

serves to better educate me as a future healthcare professional and

community member.

I am also curious about asthma since the causal factors (environmental

and genetic) and their interactions are not well understood. The large

increase in people with asthma has lead to many hypotheses as to what is

contributing to the increase. I hope to have a slightly better understanding of

which of these hypotheses makes more sense.

Importance of Asthma

Increasing incident and prevalence rates in the US and Worldwide are

placing higher demands on the healthcare system. The disease also seems

to favor middle and lower income classes, making the monetary burden high

for those who can afford it less. In the US in 2006, people visited their doctor

for asthma over 13 million times and had 444,000 admission to the hospital

for asthma (CDC Asthma). With such large demand placed on healthcare

facilities and personnel by asthma complications, any growth in these

numbers has implications in financing this medical care (which is highly

important in todays system).

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WHO information indicates that over 300 million people today are

living with asthma and that last year alone, more than a quarter of a million

people died because of the disease (WHO Asthma). Any disease that impacts

such a large proportion of the world's population has large impacts on

society. There are several global initiatives (though with less support and

fame then global HIV/AIDS and infectious disease initiatives) to try and better

understand what causes asthma and how to reduce its incidence (WHO

Asthma) (Global surveillance, prevention, and control of chronic respiratory

diseases: a comprehensive approach) (The Global Initiative for Asthma).

Asthma also has the distinction of being the most common chronic

disease in children (Akinbami). In the past century much progress has been

made combating childhood diseases making them all but a thing of the past

in the developed world, yet asthma seems to be the new childhood

experience. While asthma when properly treated is usually only annoyance,it adds additional cost and burden to families. In the developing world where

medical care is less accessible, asthma can become a death sentence for

those who have it.

Asthma also is an important opportunity to discuss whether

environmental factors that can increase risk for asthma should be addressed

(Miller and Ho). As part of the overall global warming and air pollution

debate, this increased risk of asthma is an immediate consequence of poor

air quality that is hard to dispute. As the climate changes in the future,

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asthma may become even more of a conscious public health issue that may

help promote change in climate policy.

Epidemiology-- Descriptive and Analytical

This graph (above) from CDC National Health Interview Surveys shows

that since 1980, the prevalence of asthma in children has grown (CDC

Asthma). The data shows trend in both children and lifetime diagnosis of

asthma. This supports the information on the CDCs website about the

growing numbers of asthma cases. There has been much debate and5
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thought over what is causing the rise in asthma cases. Increases in obesity

have been shown to be related to an increase in asthma prevalence. There is

also the idea that reduced exposure to diseases when a baby is leading to

higher asthma rates (the good hygiene hypothesis). Changes in air pollution

levels may also influence the incidence of asthma.

The 2008 BRFSS survey (above) shows that the prevalence of asthma

across the US is widespread and not particularly localized to one region.

Even areas with lower prevalence of asthma are not all that low compared to

numbers 30 years ago. Some localized variation on the city and town level

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do exist depending on which ethnic groups and income level segments of the

population live in one small particular area. The majority of US states now

have greater than 8.3% of the adult population living with asthma.

Geographically when care is less accessible, death from asthma

(asthma attacks) is higher than in countries with more widely available

health care. In China, South Africa, Mexico, and Russia the mortality rates for

asthma are higher since in these countries access to medical care is more

expensive and/or less prevalent. This map highlights the inequality that

exists with regard to health care, but is very important in chronic diseases

and ones that begin in children and persist for a lifetime.

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There exists very different incidence and prevalence rates for different

ethnic groups. Many more African Americas, Irish Americans, Puerto Ricans,

and Native Hawaiians have asthma in comparison with the rest of the US

population (Davis, Kreutzer and Lipsett) (Lara, Akinbami and Flores). This

seems to stem from the genetic link that increases the risk of having asthma

(Lara, Akinbami and Flores).

In addition to racial groups, asthma has been found to impact lower

income groups at higher rates than middle and high income groups. Some

research has associated the an increase in asthma to living with cockroaches

and other household pests (Asthma Triggers: Cockroaches and Pests). This

lower income also contributes to poorer management of the disease in

population segments that cannot afford the treatments for asthma (CDC

Asthma).

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Source: National Health Interview Survey; CDC National Center for Health Statistics

Asthma is a emerging (incidence is increasing more rapidly than in the

past) condition that usually presents in childhood. This explains why a larger

percentage of children have asthma than adults today but this trend will be

less pronounced in the future as todays children become adults.

Source: National Health Interview Survey; CDC National Center for Health Statistics

Asthma affects more boys than girls in childhood. However, by

adulthood, more women than men have asthma. There is no current9
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information on why this disparity exists and is another area where research

is needed.

Source: asthmablog.org

Evidence has shown that asthma attacks can be triggered by various

agents including mold, pets, dust, cockroaches, household chemicals,

exercise, and stress (Asthma Triggers: Cockroaches and Pests) (CDC

Asthma). Exactly why each of these trigger a response and not others is not

well understood. Part of asthma is related to an immune response to these

agents, and in particular immunoglobulin E levels (WHO Asthma).

Not all of these agents causes asthma in every person. Someone with

asthma may be triggered only by exercise or only by smoke. On the other

hand some else with asthma may be triggered by all of these and more

(West Virginia Asthma Education and Prevention Program). This variability

makes hard causal relations difficult to pin down.

The cause of asthma is not well understood, but evidence currently

suggests that environmental and genetic factors are causal factors. Some

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link is thought to exists between obesity and asthma. Asthma is also thought

to possibly be related to better hygiene in todays western culture than in

the past (Ramsey and Celedon). In particular, by spending a higher amount

of time indoors being exposed to indoor allergens children are thought to be

at higher risk, yet studies have shown that reducing this exposure has

mixed results (Ramsey and Celedon).

Early exposure to air pollution (studies have focused on traffic pollution

and living proximity) has been linked to an increased risk of infants

developing asthma (Miller and Ho). Used by environmentalists to try and

crack down on air pollution by demanding more regulation to try and stop

the increasing prevalence of asthma among other conditions.

Prevention

Asthma itself has no known primary prevention strategies. There can

be screening (secondary prevention) from the disease via spirometry and

lung function tests although these may always determine every case. For

long term management of severe asthma, a patient may be given steroids

(or a steroid inhaler) for daily use to prevent (or reduce the risk) of

inflammation and constriction in the lungs.

Asthma attacks do have primary and tertiary prevention activities.

Often a patient can determine what triggers these attacks and then try to

avoid these triggers (if practical). Examples of triggers include: Smoke,

Pollution, Mold, Exercise, Stress, and Weather Conditions. Additionally,11


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tertiary prevention of asthma attacks includes the use of fast acting inhalers

for acute events. These short acting inhalers used intermittently with asthma

attacks have become common.

Treatment

Asthma has no cure at this point and time. Treatments currently exist

for asthma attacks. Here a person may be given a fast acting inhaler to use

when they experience asthma (shortness of breath, chest tightness). These

inhalers quickly dilate the airway passages in the lungs to increase air

movement. In more severe patients, they may be given a steroid/long term

inhaler that they should take usually daily to help prevent constriction and

inflammation in their lungs.

One of the most important treatments is identifying the triggers for a

persons asthma attacks. Everyone has slightly different triggers and by

identifying these, a person may try and avoid exposure to them. This is a

very effective method but may not always be practical. If a person's triggers

are poor air quality and they lack the mean of moving to a place with less

pollution, more disease management with medications is necessary.

Issues and Controversies

Researchers from the University of Maryland School of Medicine have

found \that lungs have sporadic taste receptors (Melnick). These taste

receptors act differently from those in the tongue and react only to bitter

tastes. When tasting or sensing a bitter taste they dilate the lung airway12


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passages. This interesting fact could be used as a possible treatment for

bronchoconstriction.

Tufts University epidemiologists have conducted several surveys over

the past decade and have found that the risk for US children is not the same

as the risks for children from developing countries (Tufts University Scientists

explain prevalence of asthma in US children). In the US if children are of

lower social economic status and are more exposed to household pests they

are at greater risk for asthma. This indicates that the country or area that

you grow up in has a significant effect on whether a person will develop

asthma or not.

Summary and Conclusion

Asthma is a growing US and global health issue that has large impacts

on the healthcare system. As the largest chronic disease among children

asthma stands to affect a larger and larger segment of the next generation.

Differences in asthma related death and illness exist due to healthcare

access across the world; closing the access gaps will help with the managing

of not only asthma, but other chronic diseases sparing many of pain,

suffering, and even death.

Asthma is also a contributing factor to the financing issues in

healthcare. A higher prevalence of chronic diseases such as asthma are

leading to higher costs. The strain placed on doctors, hospitals, and families

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to provide care is stressed more by trying to find ways to pay for treatment

and management.

Variations in asthma among women, children, and African Americans is

higher than other similar groups (gender, age, race) (CDC Asthma). There

are also statistics that show that asthma is more common in the lower

socioeconomic segment of the population (CDC Asthma).

More research needs to be done to find out what is behind the

increases in asthma prevalence. Also better and cheaper treatments (a cure

would be ideal) need to be found that will improve asthma management and

increase access for the affected population.

What I Learned

These series of project has expanded my knowledge on each of the

topics (AIDS, TB, and Asthma) beyond what I knew before both in terms of

the disease and the epidemiology. This series of projects was a great

compliment to the in class lectures. The epidemiology of HIV/AIDS taught me

that the incidence and prevalence of HIV is changing in different racial

groups much more radically than I thought. The projects also let me explore

a topic that I wanted to know more about and analyze that disease. I had

known that Asthma was more prevalent today then in the past, but I did not

know the extent to which this condition is growing and the costs and issues it

presents in the developed world and the developing world.

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I also found that these projects made me more familiar with online

research resources available through the library. This proficiency will serve

me well in the future on other projects and in medicine.

BibliographyAkinbami, Lara J. "The State of Childhood Asthma, United States, 1980-2005."Advanced Data. National Center for Health Statistics, 2006.

Asthma. 2010. 30 November 2010 .

Asthma Community Network. 2010. 2 December 2010.

Asthma Triggers: Cockroaches and Pests. 2010. 27 October 2010.

Asthma: What is It? September 2008. 2 December 2010.

Asthma-American Lung Association. 2010. 4 December 2010.

CDC Asthma. 2010. 2 December 2010 .

Davis, A M, et al. "Asthma prevalance in Hispanic and Asian American ethnicsubgroups: results from the California Healthy Kids Survey." Pediatrics 118.2 (2006):e363-70.

"Global surveillance, prevention, and control of chronic respiratory diseases: acomprehensive approach." WHO Report. 2007.

Grant, E N, R Wagner and Weiss KB. "Observations on emerging patterns of asthmain out society." J Allergy Clinical and Immunology 104.2 Pt 2 (1999): S1-S9.

Lara, M, et al. "Heterogeneity of childhood asthma among Hispanic children: PuertoRican children bear a disproportionate burden." Pediatrics 117.1 (2006): 43-53.

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Melnick, M. "Lungs Have Bitter Taste Receptors That May Help Treat Asthma." TimeMagazine 25 October 2010.

Miller, RL and SM Ho. "Environmental epigenetics and asthma: current concepts andcall for studies." American Journal of Respiratory and Critical Care Medicine 177.6

(2008): 567-573.Ramsey, CD and JC Celedon. "The hygiene hypothesis and asthma." Current Opinionin Pulmonary Medicine 11.1 (2005): 14-20.

The Global Initiative for Asthma. 2010. 2 December 2010.

"Tufts University Scientists explain prevalence of asthma in US children." 26October 2010. Medical Daily. 28 October 2010.

West Virginia Asthma Coalition. 23 November 2010. 4 December 2010.

West Virginia Asthma Education and Prevention Program. 2010. 4 December 2010.

WHO Asthma. 2010. 30 November 2010.

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Catherine.asthma.final.fall10