Asthma May 2003 State Actions in Addressing Asthma Asthma—a chronic disease that inflames the airways and lungs—causing shortness of breath, wheezing and, in extreme cases death—affects more than 5 percent of the American population. In the United States, cases of asthma are have increased by 74 percent since 1980, and there is no indication that cases will decline in the near future.1 For a person suffering from asthma, an asthma attack can be terrifying. Airways constrict making breathing like getting air through a tight straw. Cells in the lungs start to produce more mucus, clogging air tubes. The air tubes swell, making the muscles in the air tubes tighten. These changes cause the air tubes to narrow, making breathing difficult.2 In severe cases, asthmatics are unable to breathe. In most cases, however, the attack causes shortness of breath and tightening of the chest, accompanied by coughing and spitting up mucus. Causes of Asthma Asthma is the body's reaction to specific irritants and allergens, such as tobacco smoke, cockroaches, dust mites, certain chemicals and air pollution. Even very small amounts of these substances can reduce an asthmatic's airflow, making it difficult to breathe. Exercise, colds, food additives and stress also can precipitate asthma attacks. Asthma is a chronic condition, meaning it cannot be cured, only controlled with medical treatment and environmental intervention. The medical community has long known that asthma can be triggered by allergens, but uncertainty remains as to why some people develop asthma and others do not. Although it is thought that certain genetic components increase the likelihood of developing asthma, most researchers believe that the interaction of environment with genetic predisposition is important in its development. Some scientists believe that ongoing exposure to allergens very early in life may lead to a sensitization of the airways and, ultimately, to asthma.3 Studies have shown a causal relationship between exposure to house dust mite allergen and the development of asthma in susceptible children, as documented in a report by the National Academy of Science. The report also concludes that there is an association between exposure to tobacco smoke and the development of asthma in younger children. Air Pollution and Asthma A growing number of studies show that air pollution influences asthma and triggers attacks. Research has found that common air pollutants—particulates (very small pollutant particles that can reach the lungs), nitrogen oxides and ozone—exacerbate asthma. A study by the American Lung Association found that children with asthma are 40 percent more likely to suffer asthma attacks on high pollution days than on days when conditions do not violate pollution standards. During the 1996 summer Olympics in Atlanta, traffic was reduced because more commuters used public transportation. During this period of reduced traffic, area hospitals saw fewer patients who complained of respiratory problems, presumably due to reduction in traffic and air pollution.4 Children are more susceptible than adults to outdoor air pollution, since they spend more time outside engaged in vigorous activity. Higher activity levels and longer duration of exposure, combined with a higher breathing rate relative to body weight, result in higher pollutant exposures for children. Air pollution that may cause negligible breathing difficulties in an adult may seriously impair a child's ability to breathe because of children's higher exposures and smaller airways. Nearly half of all Americans, 133 million, live in areas where air pollutants reach unhealthy levels, as measured by the U.S. Environmental Protection Agency's Air Quality Index (see Figure 1). Figure 1. 1999 Total Criteria Pollutant Emissions 
Source: U.S. EPA, 10/01/02 Policy Concerns About Asthma Clinicians define asthma as the presence of variable airflow obstruction that reverses either spontaneously or with treatment. This definition, however, makes it difficult to differentiate asthma from other chronic obstructive lung diseases. Beyond its effect on asthmatics, the disease affects the nation as a whole. Fifteen million people suffer from asthma, which often causes them to miss work and school days and, in serious cases, may lead to hospitalization, at a cost to the nation of an estimated $14.5 billion per year. 5 Rising Rates More than 15 million people in the United States, including 5 million children, have asthma. Its prevalence has steadily increased since the 1980s, rising 75 percent in the general population and 160 percent in children under age 5. In 1980, close to 6 million people were diagnosed with asthma. By 1999, that number had risen to more than 10 million. At the highest point, in 1997, 26.7 million people were diagnosed with asthma by a physician. Figure2 
Source: The Department of Health and Human Services. Figure 3 
Source: The Department of Health and Human Services Asthma, the most common chronic disease in children and the primary cause of missed school days, is responsible for more than 14 million missed days per year. In 1980, that figure was 6.6 million days. Work absences due to asthma attacks have increased as well, from 6.2 million days in 1982 to 14 million days in 1999. If current rates continue, the country will have 29 million people with asthma by the year 2020.6 Figure 4. Asthma Prevalence 
Source: Centers for Disease Control and Prevention Epidemiology of Asthma The federal government, mainly through the Centers for Disease Control and Prevention (CDC), has aggressively tracked these rising rates. By performing epidemiological surveys to study the incidence, distribution and control of asthma in the United States, the CDC has gathered considerable data about those populations and areas where asthma rates are increasing. However, researchers have not yet discovered the reason for these increasing rates. Genetics may play a role in asthma development, but genetic traits change far too slowly to account for the recent increase in asthma cases. Improved recognition and diagnosis of asthma also may play a small role, although research indicates that this change alone cannot explain the recent upward trend. Societal changes could offer some explanation for the increase; children and adults spend more time indoors—thus increasing their exposure to certain allergens and indoor air pollutants—and they are exercising less. Certain pollutants in the air also exacerbate asthma. However, more research is needed to determine asthma's relationship to environmental exposure and genetics for medical scientists to determine its cause and remedy. Figure 6. 
Asthma Costs Lost days -- from treatments, from lost work days, from days missed from school, costs the nation dearly. In 1990, the CDC estimated that costs related to asthma totaled $6.2 billion. By 1998, those figures rose to $12.7 billion. For 2000, CDC projected that the cost of asthma in this country had grown to $14.5 billion (although the final costs have not been calculated). Direct medical expenses—from hospital care and physicians' services—cost the nation more than $8 billion. Indirect costs—including lost school days, lost work days, and deaths from asthma—are estimated at $4.6 billion.8 Each year, 100 million days are estimated to be lost due to asthma. These missed days represent cost in sick leave, time away from work to tend to sick children and family, prescriptions, and other factors.9 Costs for each state (See Appendix A) have been estimated for 1998. Costs in California were $1.2 billion for medical and indirect costs for Florida, $571 million, for New York, $748 million, and for Illinois $485 million. The states with the lowest costs were Alaska at $24 million, Delaware at $29 million, Montana at $34 million, North Dakota at $26 million, Vermont at $23 million, and Wyoming at $19 million.10 New York and Cleveland have programs to clean homes of asthma allergens. Costs have been estimated at about $500 per home, including about $150 for educational interventions. It has been noted that homes with lead-based paint hazards also may be more likely to pose asthma-related hazards, making abatement or remediation of lead hazards an asthma prevention strategy.11 Illness, Hospitalization and Mortality Hospital visits for asthma have increased to nearly 2 million per year—nearly 500,000 of these visits lead to hospitalization. More than 5,000 people die from the disease each year. The significant increase in asthma in poor areas—where medical care and follow-up are lacking—means that asthma symptoms are more likely to result in full-blown attacks that require costly trips to the emergency room. Medicating Asthmatic Children and Drug Policies Recent policies that restrict children from carrying medications has led to some tragic consequences. These policies, aimed at illegal drug use, cover medications for asthmatic children who need the medications at the onset of an attack. Often, school, daycare or other institutions that care for children (such as sports and summer camps) are required to hold the medication for the child; often it is locked away in a medicine cabinet. In some instances, school administrators or counselers cannot administer the medicine without a doctor's permission. Sometimes, they simply are not allowed to administer medication and must wait for the child's parent to arrive to provide treatment. These policies have cost asthmatic children their lives, and some school districts millions of dollars. In Illinois, a school rule prohibiting school officials from giving medicine led to the death of an asthmatic student. Other schools in Illinois allow staff to administer only limited medication, requiring the parent to come and treat the child. In California, an 11-year-old asthmatic died as the school staff prepared his nebulizer (the staff was untrained). The child, who was severely asthmatic and always carried an inhaler, was prohibited under the state's education code from having his inhaler at school. The death cost the school district $9 million in a wrongful death lawsuit. Other deaths have occured in California schools due to restrictions on administering medications. In Louisiana, a student died while the school tried to reach her mother to gain permission to treat the child. That case cost the school $1 million. Similar cases have occured in schools in Minnesota and Nebraska and at a New Hampshire YMCA, where state law prohibits children from carrying prescription medicine. Several states have amended their laws or revised their guidelines to allow students to self-medicate under certain circumstances. Figure 7. 
Healthy Homes The time people spend indoors has increased substantially during the past century, creating the need for safe, healthful indoor environments. Much can be done to alleviate suffering by making homes and buildings healthier for asthma sufferers. Older and low-income homes are more prone to moisture due to deterioration, poor maintenance or design deficiencies. Moisture can promote the growth of mold and also attracts cockroaches, dust mites, rats and other vermin, which create the unhealthy conditions that exacerbate asthma. Low-income, inner-city children with asthma are at particular risk from these conditions. Techniques exist for measuring household allergen levels, but standardized protocols, action thresholds, and the infrastructure to support widespread testing and remediation are not yet available. Research into the effects of cleaning a house to make it more healthful—including cleaning mold from under sinks and heating and cooling vents, installing impervious mattress and pillow covers (that can reduce allergens by 90 percent), and cleaning carpets with tannic acid solution to reduce dust mites—have shown that these techniques reduce the environmental allergens that trigger asthma attacks.12 Disparities Although asthma affects people at all socioeconomic levels, poor and minority populations tend to experience a greater burden when measured by the chances of dying or being hospitalized for the disease. Some evidence indicates that inner-city children in poor neighborhoods are likely to have higher rates of asthma than their wealthier counterparts living elsewhere. Work done by the Harlem Hospital Center and Harlem Children's Zone found that one in four school-age children in central Harlem have asthma. The reasons for this disparity, although not fully understood, probably include poor nutrition, a lack of preventive care, and exposure to higher levels of indoor and outdoor air pollution. | "Asthma steals vitality and well-being both from its victims and from their families, and asthma rates are increasing in the United States. Environmental efforts, good therapy, and careful management can turn around the assault of this disease on our health." Richard J. Jackson, MD, MPH
Director, CDC's National Center for Environmental Health Clinicians define asthma as the presence of variable airflow obstruction that reverses either spontaneously or with treatment. This definition, however, makes it difficult to differentiate asthma from other chronic obstructive lung diseases. "It's a burden to society when you don't take risks into account. Once children get sick, treatment ends up costing more than prevention." James Hubbard
Delegate, Maryland General Assembly The Department of Health and Human Services' Healthy People 2010 lists asthma as a key health concern. Eight objectives within the report concern asthma, encouraging this country to reduce deaths, hospitalizations, and emergency room visits due to asthma; reduce the number of school and work days missed due to asthma; increase patient education on asthma; and request states to implement asthma surveillance programs—tracking occupational and environmental causes of asthma, and access of asthma sufferers to medical care.7 Figure 5. 
Source: Morbidity and Mortality, Chartbook 2000, NHLBI, National Institute of Health | | Notes:
1. The Centers for Disease Control and Prevention, Surveillance for Asthma - United States, 1980- 1999, MMWR, March 29, 2002 / 51(SS01); 1-13. 2. American Lung Association, Facts about Asthma, November 2001, http://www.lungusa.org/asthma/astasthma.html. 3. Institute of Medicine of the National Academies of Science, Asthma Report ( January 2000). 4. Friedman, "Impact of Changes in Transportation and Commuting Behaviors during the 1996 Summer Olympic Games in Atlanta on Air Quality and Childhood Asthma. Journal of the American Medical Association 285:897-905. 5. Centers for Disease Control and Prevention, "Surveillance for Asthma --- United States, 1980--1999" MMWR March 29, 2002 / 51(SS01); 1-13. 6. The Trust for America's Health, Short of Breath (July 2001). 26. 7. U.S. Department of Health and Human Services, "Repiratory diseases", Healthy People 2010 Goal 24, (Washington, D.C.: HHS, Washington DC, (2000). 8. National Heart, Lung and Blood Institute, National Institute of Health, Morbidity and Mortality, Chartbook 2000 9. Centers for Disease Control and Prevention, National Center for Environmental Health, National Asthma Control Program, Reducing Costs and Improving Quality of Life 2002. 10. Asthma and Allergy Foundation of America, Costs of Asthma in the United States, 2000. 11.U.S Department of Housing and Urban Development, Office of Lead Hazard Control, The Healthy Homes Initiative, April 1999. Page 23. 12. U.S. Department of Housing and Urban Development, Office of Lead-Based Paint, Healthy Homes Initiative, April 1999. Page 23. | | | Asthma
State Costs at a Glance - 1998 | State/Jurisdiction | Estimated Prevelance (percent) | People with Asthma
(in 1000s) | Direct Medical Expenditures (in $1000s) | Indirect Costs (in $1000s) | Total Costs (in $1000s) | Alabama | 5.56% | 234.6 | $100,932 | $76,729 | $177,661 | Alaska | 5.40 | 32.7 | 13,919 | 10,366 | 24,285 | Arizona | 5.41 | 220.3 | 94,501 | 71,466 | 165,967 | Arkansas | 5.52 | 135.3 | 58,190 | 44,215 | 102,405 | California | 5.35 | 1,680.7 | 720,826 | 544,749 | 1,265,575 | Colorado | 5.41 | 197.8 | 85,071 | 64,658 | 149,729 | Connecticut | 5.36 | 175.6 | 75,819 | 58,025 | 133,844 | Delaware | 5.45 | 38.7 | 16,660 | 12,707 | 29,367 | District of Columbia | 5.59 | 31.7 | 13,707 | 10,527 | 24,235 | Florida | 5.38 | 749.9 | 323,893 | 248,037 | 571,929 | Georgia | 5.58 | 393.5 | 168,945 | 127,917 | 296,862 | Hawaii | 4.88 | 57.5 | 24,545 | 18,388 | 42,933 | Idaho | 5.51 | 62.4 | 26,722 | 20,120 | 46,842 | Illinois | 5.47 | 642.3 | 276,208 | 209,782 | 485,990 | Indiana | 5.45 | 313.5 | 135,070 | 102,931 | 238,001 | Iowa | 5.41 | 153.0 | 65,909 | 50,231 | 116,140 | Kansas | 5.44 | 138.9 | 59,696 | 45,283 | 104,979 | Kentucky | 5.46 | 208.8 | 90,003 | 68,661 | 158,663 | Louisiana | 5.68 | 245.1 | 104,900 | 78,960 | 183,860 | Maine | 5.37 | 66.5 | 28,725 | 21,973 | 50,698 | Maryland | 5.47 | 273.4 | 117,674 | 89,512 | 207,186 | Massachusetts | 5.34 | 322.8 | 139,506 | 106,938 | 246,444 | Michigan | 5.49 | 521.2 | 224,079 | 170,103 | 394,183 | Minnesota | 5.41 | 247.3 | 106,284 | 80,628 | 186,912 | Mississippi | 5.72 | 152.6 | 65,302 | 49,172 | 114,474 | Missouri | 5.46 | 288.4 | 124,086 | 94,369 | 218,455 | Montana | 5.41 | 46.4 | 19,895 | 15,056 | 34,951 | Nebraska | 5.45 | 88.4 | 38,001 | 28,826 | 66,826 | Nevada | 5.33 | 77.6 | 33,411 | 25,416 | 588,827 | New Hampshire | 5.36 | 60.9 | 26,245 | 20,025 | 46,270 | New Jersey | 5.39 | 425.6 | 183,554 | 140,151 | 323,705 | New Mexico | 5.46 | 90.4 | 38,635 | 29,027 | 67,663 | New York | 5.42 | 985.8 | 424,798 | 323,875 | 748,673 | North Carolina | 5.49 | 388.1 | 167,208 | 127,444 | 294,651 | North Dakota | 5.40 | 34.5 | 14,822 | 11,245 | 26,067 | Ohio | 5.46 | 606.5 | 261,171 | 198,895 | 460,066 | Oklahoma | 5.43 | 176.8 | 75,933 | 57,509 | 133,442 | Oregon | 5.35 | 165.2 | 71,175 | 54,275 | 125,450 | Pennsylvania | 5.39 | 650.1 | 280,711 | 214,840 | 495,551 | Rhode Island | 5.36 | 53.4 | 23,074 | 17,669 | 40,743 | South Carolina | 5.59 | 204.7 | 87,975 | 66,764 | 154,739 | South Dakota | 5.44 | 39.4 | 16,861 | 12,713 | 29,574 | Tennessee | 5.49 | 283.9 | 122,332 | 93,275 | 215,606 | Texas | 5.52 | 1,015.1 | 434,915 | 328,065 | 762,979 | Utah | 5.67 | 108.1 | 45,918 | 34,071 | 79,989 | Vermont | 5.38 | 31.2 | 13,462 | 10,286 | 23,748 | Virginia | 5.44 | 356.5 | 153,688 | 117,266 | 270,955 | Washington | 5.36 | 286.1 | 123,069 | 93,498 | 216,567 | West Virginia | 5.40 | 98.5 | 42,590 | 32,670 | 75,261 | Wisconsin | 5.43 | 276.2 | 118,777 | 90,245 | 209,021 | Wyoming | 5.48 | 26.1 | 11,179 | 8,438 | 19,617 | Asthma and Allergy Foundation of America (AAFA)
1233 20th Street, N.W., Suite 402, Washington, D.C. 20036
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