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A Growing Epidemic
Andrew Catherine 9-8487-8026 Final Project Paper Fall 2010 BBH 440
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 (CDC Asthma).
being reduced via the now common asthma inhaler
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 today’s western culture than in the past (Ramsey and Celedon). Reason for Selection
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 today’s system).
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,
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 CDC’s website about the growing numbers of asthma cases. There has been much debate and
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
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.
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).
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 today’s 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 current
information on why this disparity exists and is another area where research is needed.
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
link is thought to exists between obesity and asthma. Asthma is also thought to possibly be related to better hygiene in today’s 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,
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 patient’s, 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 person’s 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 airway
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
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.
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.
Akinbami, Lara J. "The State of Childhood Asthma, United States, 1980-2005." Advanced Data. National Center for Health Statistics, 2006. Asthma. 2010. 30 November 2010 <http://www.asthma.com>. Asthma Community Network. 2010. 2 December 2010 <http://AsthmaCommunityNetwork.org>. Asthma Triggers: Cockroaches and Pests. 2010. 27 October 2010 <http:L//www.epa.gov/asthma/pests.html>. Asthma: What is It? September 2008. 2 December 2010 <http://www/nhlbi/nih/gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html>. Asthma-American Lung Association. 2010. 4 December 2010 <http://www.lunguas.org/lung-disease/asthma/>. CDC Asthma. 2010. 2 December 2010 <http://www.cdc.gov/asthma/default.htm>. Davis, A M, et al. "Asthma prevalance in Hispanic and Asian American ethnic subgroups: results from the California Healthy Kids Survey." Pediatrics 118.2 (2006): e363-70. "Global surveillance, prevention, and control of chronic respiratory diseases: a comprehensive approach." WHO Report. 2007. Grant, E N, R Wagner and Weiss KB. "Observations on emerging patterns of asthma in 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: Puerto Rican children bear a disproportionate burden." Pediatrics 117.1 (2006): 43-53. 15
Melnick, M. "Lungs Have Bitter Taste Receptors That May Help Treat Asthma." Time Magazine 25 October 2010. Miller, RL and SM Ho. "Environmental epigenetics and asthma: current concepts and call 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 Opinion in Pulmonary Medicine 11.1 (2005): 14-20. Salam, Muhammad T, Talat Islam and Frank D Gilliland. "Recent evidence for adverse effects of residential proximity to traffic sources on asthma." Current Opinion in Pulmonary Medicine 14 (2008): 3-8. The Global Initiative for Asthma. 2010. 2 December 2010 <http://www.ginasthma.org>. "Tufts University Scientists explain prevalence of asthma in US children." 26 October 2010. Medical Daily. 28 October 2010 <http://medicaldaily.com/new/20101026/2909/tufts-university-scientists-explainprevalence-of-asthma-in-us-children.htm>. West Virginia Asthma Coalition. 23 November 2010. 4 December 2010 <http://wvasthma.wordpress.com>. West Virginia Asthma Education and Prevention Program. 2010. 4 December 2010 <http://www.wvasthma.org>. WHO Asthma. 2010. 30 November 2010 <http://www.who.int/respiratory/asthma/pests.html>.
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