WHAT WORKS
ASTHMA SURVEILLANCE SYSTEMS
According to the Centers for Disease Control and Prevention (CDC), asthma affects more than 17 million Americans - including almost 5 million children - and costs the nation an estimated $14.5 billion each year. For children age 19 and younger the death rate attributable to the disease increased by 78 percent between 1980 and 1993. In addition, asthma is the number one chronic condition that causes children to be absent from school, accounting for more than 10 million days of missed school annually. It is also the highest ranked cause of pediatric hospitalizations in the United States. On average, a child with asthma will miss one full week of school each year due to the disease. Recent reports also suggest that the incidence of childhood asthma may be increasing due to poor asthma management and education, more air pollution and limited access to care, particularly for those in inner-city neighborhoods. Some researchers suspect that reduced exposure to certain allergens and respiratory illnesses like colds as a young child may be partially responsible for the increase. It is theorized that these exposures may help build the immune system and prevent it from becoming hypersensitive to allergens.
To properly respond to what is being viewed as an epidemic, public health officials and legislators are working to understand the extent of the illness and the relationship between asthma and environmental triggers. A critical element of a response to the asthma problem is a tracking or surveillance system. According to Dr. Rick Kruetzer, chief of the Environmental Health Investigations Branch in the California Department of Health Sciences, characterizing the scope of asthma presents challenges to public health officials because the disease presents itself across the spectrum of the health care system. To obtain an accurate picture of the severity of the problem and guide program efforts, states will need to gather data from a variety of sources in order to target outreach and evaluate program effectiveness. Otherwise, he said, public health officials are "simply working in the dark." In a report released in July 2001 by The Trust for America's Future, researchers used CDC data to determine that most states have no ongoing asthma monitoring program. According to the study, 27 states have no timely information that describes asthma within their borders and 12 of the 20 states with the highest levels of outdoor air pollutants do not have any mechanisms for tracking respiratory disease.
Some states are beginning to respond and are developing comprehensive asthma management and tracking programs using existing state or federal data sources. Approximately 17 states have emergency room data available for surveillance purposes, 44 states have hospitalization data, and 50 have mortality data. North Carolina uses a modified version of the questionnaire from the International Study of Asthma and Allergy in Children to measure prevalence of wheezing in schools. California, Massachusetts, Michigan and New Jersey participate in the Sentinel Events Notifications Systems for Occupational Risk (SENSOR) to assess the prevalence of work-related asthma. Maine uses a respiratory health surveillance system that collects information on self-reported medications to estimate disease severity. In 2000, Virginia became the first state to pass a law that requires the development of a comprehensive asthma strategy, including disease surveillance; public and professional education; and public and private partnerships with health care providers, local school divisions and community coalitions.
In Michigan, public health officials analyze hospital discharge and mortality data on asthma to guide program efforts and inform activities of the 11 asthma coalitions across the state. In 1993, Michigan was using hospitalization reports on asthma to look for high-prevalence counties. In 1998, the state began working with local coalitions to conduct outreach and education. Recognizing the need for better surveillance data, the state conducted a needs assessment to determine the data elements and reporting format that would be most useful to the coalitions. As a result, a surveillance system was begun that will continue to evolve as the nature of the disease in the state is better understood.
The asthma program in Oregon seeks to develop an infrastructure to address asthma, a statewide asthma coalition, and a comprehensive surveillance system. Since 1999, Oregon has been using the Behavioral Risk Factor Surveillance System (BRFSS), the hospital discharge database, and death certificates to monitor the severity of the asthma problem among the adult population. Collecting data on children remains a challenge that state officials continue to address. In 2001, questions on children in the household diagnosed with asthma were added to the BRFSS. In addition, the state is working with the local school health systems and are able to use health enrollment statistics in eight school districts. Three questions have been added to the state's Youth Risk Behavioral Surveillance System (YRBSS) in their state eighth and 11th graders. California also uses the BRFSS to track prevalence in the adult population and is using the California Healthy Kids Survey (its version of the YRBSS) to monitor prevalence in fifth, seventh and 11th graders.
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