district of columbia burden of asthma report

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District o Columbia Department o Health

825 North Capitol Street, NEWashington DC 20002

http://dchealth.dc.gov

Government of theDistrict of Columbia

Adrian M. Fenty, Mayor

H HH

Burden of Asthma in theDistrict of Columbia

2009


2009


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Burden o Asthma in the District o Columbia

Government o the District o Columbia

Adrian M. Fenty, Mayor

Department o Health

Pierre N. D. Vigilance, M.D., M.P.H., Director

Community Health Administration

Carlos E. Cano, M.D. Senior Deputy Director

Center or Policy, Planning, and Epidemiology

John O. Davis-Cole, Ph.D., M.P.H, State Epidemiologist

AuthorsSenkuta G. Riverson, M.P.H.

Mary Frances Kornak, M.P.H.

Gebreyesus Kidane, Ph.D., M.P.H.

LaVerne H. Jones, M.P.H.

Contributing Editors

Aaron Adade, Ph.D.

Carolyn A. Bothuel

Edwina Davis-Robinson, M.S., C.H.E.S

Kerda DeHaan, M.S.

Manzur Ejaz, Ph.D.

racy Garner

We grateully acknowledge the contributions o the ollowing:

Carol Johnson, M.P.H., Centers or Disease Control

Department o Health Center or Policy, Planning and Epidemiology

George Washington University

Deborah Quint, M.P.H. and Stephen each, M.D. Improving Pediatric Care

in the District o Columbia (IMPAC DC)

Johns Hopkins University Applied Physics Laboratory (JHU/APL)

Publication Date: 2009

Development and publication o this report was supported by Cooperative Agreement Number U59/CCU324208-05 rom the Centers o Disease

Control and Prevention (CDC). Its contents are solely the responsibility o the authors and do not necessarily represent the ocial views o the CDC.

For additional inormation, contact the DC Control Asthma Now Program at the

DC Department o Health at (202) 442-5925



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Burden o Asthma in the District o Columbiaiv

4.2.4. Insurance .........................................................................................................................354.2.5. Disposition ......................................................................................................................36

5.0 Asthma Mortality ..................................................................................................................................395.1. Mortality Count by Subgroups ..................................................................................................395.2. Mortality Rate ..............................................................................................................................405.3. Mortality Rate by Sex, Race and Age Group ............................................................................405.4. Mortality Rate by Ward ...............................................................................................................41

6.0 Work-Related Asthma ..........................................................................................................................436.1. Prevalence o Work-Related Asthma in Te District ..............................................................44

6.1.1. WRA Study Description ................................................................................................44

6.1.2. WRA Study Results ........................................................................................................457.0 Air Quality and Asthma .......................................................................................................................47

7.1. Outdoor Environmental Pollutants ...........................................................................................477.1.1. Health Eects ..................................................................................................................48

7.2. Air Quality Standards .................................................................................................................487.3. Te Role o Outdoor Air Pollution in the District ...................................................................49

7.3.1. Study Description ...........................................................................................................507.3.2. Study Results ...................................................................................................................50

8.0 Conclusions ...........................................................................................................................................538.1. Non-Hispanic Black Population ................................................................................................538.2. Populations with Low Socioeconomic Status ...........................................................................54

8.3. Children ........................................................................................................................................548.4. Adult and Elderly Population .....................................................................................................548.5. Female Population .......................................................................................................................558.6. Populations with Other Risk Factors.........................................................................................558.7. Implications on Asthma Management ......................................................................................568.8. Work-Related Asthma .................................................................................................................568.9. Asthma and Environmental Factors ..........................................................................................56

9.0 Recommendations ................................................................................................................................599.1. Surveillance System .....................................................................................................................599.2. Asthma Management ..................................................................................................................60

9.3. Risk Factors and Preventable Events .........................................................................................609.4. Reducing Health Disparities ......................................................................................................6110. Reerences ..............................................................................................................................................63echnical Notes ...............................................................................................................................................67

Acronyms ...............................................................................................................................................68Appendix A: Work-Related Asthma Survey GWU ..................................................................................69

Survey Questions...................................................................................................................................69Appendix B: Data ables ................................................................................................................................71

Table of Contents


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Figure 1-1 Te District o Columbia by Ward designations .................................................................3

Figure 2-1 District o Columbia asthma surveillance data sources ......................................................7

Figure 2-2 Prevalence o adult asthma in District o Columbia ...........................................................9

Figure 2-3 Lietime asthma prevalence in adults over 18, District vs. US ...........................................9

Figure 2-4 Current asthma prevalence in adults over 18, District vs. US ..........................................10

Figure 2-5 Prevalence o adult (18 years) asthma by gender ............................................................10

Figure 2-6 Prevalence o adult (18 years) asthma by race/ethnicity ................................................11

Figure 2-7 Prevalence o adult (18 years) asthma by age group .......................................................12

Figure 2-8 Prevalence o adult (18 years) asthma by education level ..............................................13

Figure 2-9 Prevalence o adult (18 years) asthma by income level ..................................................13Figure 2-10 Prevalence o current adult (18 years) asthma by ward .................................................14

Figure 2-11 Prevalence o ormer adult (18 years) asthma by ward ..................................................14

Figure 2-12 Prevalence o childhood (17 years) asthma .....................................................................16

Figure 2-13 Prevalence o childhood (17 years) asthma by gender ...................................................17

Figure 2-14 Prevalence o childhood (17 years) asthma by race ........................................................17

Figure 2-15 Prevalence o childhood (17 years) asthma by age group ..............................................18

Figure 3-1 Respondent answers regarding episodes o asthma ..........................................................20

Figure 3-2 Episodes o asthma by gender..............................................................................................20

Figure 3-3 Episodes o asthma by race ..................................................................................................21

Figure 3-4 Frequency o visits to a doctor or routine asthma checkups ...........................................21Figure 3-5 Frequency o visits to a doctor or routine asthma checkups

by gender ................................................................................................................................22

Figure 3-6 Frequency o visits to a doctor or routine asthma doctor visit by race ..........................22

Figure 3-7 Frequency o inhaler use to stop asthma episodes ............................................................23

Figure 3-8 Frequency o inhaler use to stop asthma episodes by gender ..........................................23

Figure 3-9 Frequency o inhaler use to stop asthma episodes by race ...............................................24

Figure 3-10 Age at rst diagnosis among respondents with current asthma ......................................25

Figure 3-11 Age when diagnosed with asthma by gender .....................................................................25

Figure 3-12 Age when diagnosed with asthma by race/ethnicity .........................................................26

Figure 3-13 Days o missed work or usual activities because o asthma .............................................26Figure 3-14 Days o missed work or usual activities because o asthma

by gender ................................................................................................................................27

Figure 3-15 Days o missed work or usual activities because o asthma by race ................................27

Figure 4-1 Crude asthma hospitalization rate in the District o Columbia ......................................30

Figure 4-2 Hospitalization rates due to asthma by age group in the District

o Columbia ...........................................................................................................................30

v

List of Figures


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Burden o Asthma in the District o Columbiavi

Figure 4-3 Mean length o stay or asthma-related discharges and total

hospital discharges ................................................................................................................32

Figure 4-4 Age-adjusted rates o emergency department visits due to asthma

among all residents in the District o Columbia ................................................................33

Figure 4-5 otal emergency department visits due to asthma in the

District o Columbia .............................................................................................................33

Figure 4-6 Emergency department visits due to asthma by gender in the


Figure 4-7 Age-adjusted rates or children in the District o Columbia ............................................35

Figure 4-8 Distribution o insurance among emergency discharge asthma

patients in the District o Columbia ...................................................................................35

Figure 4-9 Disposition o emergency department visits due to asthma in the


Figure 4-10 Frequency o disposition o emergency department visits due to

asthma in the District o Columbia ....................................................................................37

Figure 5-1 Annual asthma mortality rate in the District o Columbia,

1999-2005 ...............................................................................................................................40

Figure 5-2 Asthma mortality rate by sex and race, District o Columbia

1999-2005 ...............................................................................................................................41

Figure 5-3 Asthma mortality rate by age group, District o Columbia

1999-2005 ...............................................................................................................................41

Figure 5-4 Crude asthma mortality rate by Ward, District o Columbia

1999-2005 ...............................................................................................................................42

List of Figures


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Burden o Asthma in the District o Columbiaviii


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Asthma is a chronic disease o the lungs bronchi (airways) characterized by airway hyper-respon-siveness to stimuli resulting in airow limitation, and respiratory symptoms including: breathlessness,

wheezing, coughing, and chest tightness. Symptoms can vary in severity rom mild intermittent to severe

persistent. All levels o severity can be lie threatening.

According to the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey data, approximately

9% o adult residents (40,000 adults) and 11% o children (13,000 children) currently have asthma, and

about 15% o adults have been diagnosed with asthma at some point in their lie. Overall, the prevalence

o current asthma in the District o Columbia has been consistently higher than the national rate or

the past seven years. In addition, the Districts asthma prevalence was on an upward trend rom 2000to 2004, but seemed to stabilize at slightly above 15% rom 2004 to 2007. Vital Records data or asthma

related mortality indicate an overall decreased rate rom 1999-2005, despite a rate increase in 2004.

Although asthma aects all portions o the Districts population, certain subgroups are disproportionately

aected. Te non-Hispanic black population: very young children aged 0-4 years, especially male chil-

dren o this age group, adolescent emales, adults 45-50 years and the elderly (65+ years), tobacco

smokers, obese and overweight populations, residents with less than or some high school education,

and households with an income less than $15,000 appear to be most aected by asthma.

Te District o Columbia Department o Health (DOH) Asthma Control Program launched the DCControl Asthma Now (DC CAN) Program in 2001 in order to address the national Healthy People

2010 asthma objectives, and to improve the quality o lie or District residents who suer rom asthma.

Its mission is to develop and implement a viable, comprehensive, community-based, and consumer-

centered approach to asthma diagnosis and management.

Te objectives o DC CAN are to:

Develop interventions to reduceasthma hospitalizations,deaths, and emergency department

visits among high-risk populations;

Identifybarriersinthedeliveryofasthmacareservices,particularlytotheunderservedandhigh-risk groups;

Increaseeducationandawarenessprogramsthatareculturallysensitive,andlinguisticallyappro-

priate or all racial/ethnic groups;

PromotetheuseofguidelinesfromtheNationalInstitutesofHealth(NIH)and theNational

Heart, Lung, and Blood Institutes (NHLBI) or the treatment and management o asthma;

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Executive Summary


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Burden o Asthma in the District o Columbiax

Educatepersonswithasthma,theirfamilymembers/caregivers,aswellashealthcareproviders

and health educators; and

Develop a comprehensive asthma surveillance and data collection system tomonitor trends

and evaluate the eectiveness o program interventions in the reduction o asthma morbidity and

mortality.

Te National Healthy People 2010 (HP 2010) includes seven goals or improving the health o thoseliving with asthma. DC HP 2010 (http://doh.dc.gov/doh/site/deault.asp) has adopted three (3) o these

goals:

Reduceasthmadeaths;

Reduceasthmahospitalization;and

Reduceemergencydepartmentvisitsrelatedtoasthma.

Key FindingsSeveral data sources were analyzed to describe the health status o persons with asthma. Te District

o Columbia Behavioral Risk Factor Surveillance System (BRFSS), hospital discharge data, emergency

department data, mortality records, workers compensation claims, and air quality measurements are

among the data used to outline the ndings in this report.

Adult Asthma Prevalence

In2007,BRFSSrespondentsreportedhaving:approximately15%lifetimeasthma,9%current

asthma and about 6% ormer asthma.

LifetimeasthmaprevalenceintheDistrictwasonanupwardtrendfrom2000through2004,but

stabilized at slightly above 15% between 2004 and 2007. Tere was a 28% increase in prevalencerom 2000 to 2005.

Asthma Prevalence by Gender

In2007,theprevalenceofcurrentasthmaamongadultswas47%higheramongfemales(12%)as

compared to males (6.4%).

Asthma Prevalence by Race/Ethnicity

In2007,theprevalenceofcurrentasthmawas66%higheramongnon-Hispanicblackadults

(11.8%) as compared to Hispanics (4%) and 39% higher than whites (7.2%).

Asthma Prevalence by Age

In 2005, the lifetime asthma prevalence for persons aged 18-24was approximately twice the

prevalence o persons aged 35-44, 45-54, and 55-64; this was statistically signicant. By 2007,

persons aged 25-34 had the highest lietime asthma prevalence, ollowed by 35-44 and 18-24

year olds.


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Asthma Doctor Visits

Approximately30%ofBRFSSrespondentswithcurrentasthmareportedhavingoneroutine

doctor visit, 32% reported 2-4 visits, and 9% reported 5 or more visits in the past 12 months.

Non-Hispanicblackrespondentsindicatedasignicantlyhigherfrequency(morethantwice)of

routine doctor visits at 2-4 times more than their white counterparts.

Inhaler Use

In2005,approximately30%ofBRFSSrespondentswithcurrentasthmareportedusinganinhaler

1-4 times and 9% reported using an inhaler 5 or more times to stop an asthma attack in the past

month.

Almost twice as many women (10.7%) used an inhaler ve or more times as compared to men (5.5%).

Almosttwiceasmanynon-Hispanicblackrespondents(34.6%)withasthmareportedusinginhalers

1-4 times in the past month as compared to their non-Hispanic white counterparts (19.3%).

Reportsofneverusinganinhalerwere43%higheramongnon-Hispanicwhitesthannon-Hispanicblacks.

Age at First Diagnosis

In2005,thehighestproportionofrespondentswithcurrentasthma(22%)reportedaninitial

diagnosis beore the age o 19 ollowed a lower 19% with an initial diagnosis between ages

20-39 years.

edatashowthatmentendtobeinitiallydiagnosedatayoungeragethanwomenintheDistricts

population.

Amajority of non-Hispanic whites reported being initially diagnosed before the age of 19,

while the highest proportion o non-Hispanic blacks reported initial diagnosis between the ages

o 20-39.

Limited Activity

In2005,approximately12%ofrespondentswithcurrentasthmaindicatedthattheywereunable

to work or carry out usual activities due to asthma lasting 1-5 days, and almost 10% indicated that

their work or usual activity was restricted due to asthma lasting six or more days.

Asthma Hospitalization

ereisageneraldecreasingtrendinthecrudeasthmahospitaldischargeratefrom2002(20.2

per 10,000 persons) to 2005 (17.1 per 10,000 persons).

From2002to2005thehighestrateofhospitalizationoccurredamongchildrenunderveyears

old, middle aged (45-50 years) and the elderly (60-75 years).

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Emergency Department (ED) Visits

eage-adjustedratesofEDvisitsduetoasthmaintheDistrictincreasedslightlyfrom208.1per

10,000 in 2005 to 219.2 per 10,000 in 2006.

erateofEDvisitsduetoasthmawashighestamongchildren1to4yearsofageandadults40

to 50 years o age in 2005 and 2006.

In2006,malesundertheageof15yearshadahigherEDvisitratethantheirfemalecounterparts.However, emales had a higher ED visit rate than males afer the age o 15.

In2006,thedatashowedanincreaseinhospitaladmissionsfromtheEDasageincreased.

Mortality

easthmamortalityratefrom1999to2005was11.6per100,000persons.

Fromyear1999to2005,theasthmamortalityrateofnon-Hispanicblackswasapproximately4

times higher than those o non-Hispanic whites.

AsthmamortalityrateamongmaleDistrictresidents(12per100,000)wasslightlyhigherthantheir emale counterparts (11.2 per 100,000) rom 1999 to 2005.

Moreasthmadeathsoccurredamongadultsthanchildren(0-17years)andthenumberofdeaths

increased by age.

Wards7,5and8hadthehighest,andWard3hadthelowestasthmamortalityratesintheDistrict

rom 1999 to 2005.

Work-Related Asthma

erewere39casesofwork-relatedasthma(WRA)intheDistrictfrom1999to2005asreported

by workers compensation claims. A study was conducted to validate that all WRA cases were

captured using the worker compensation claims database. Te study identied 18% more cases in

one year compared to the workers compensation claims database that spanned seven years.

Outdoor Air Quality and Asthma

estrongestrelationshipbetweenozoneandasthma-relatedMedicaidpatientvisitswasseenin

the age group 5-12 years.

Grasspolleneectsonasthma exacerbationswerestrongest for the 5-12 and 13-20year old

age groups.

Particulatematterlessthan2.5mindiameter(PM2.5)levelsweresignicantlyassociatedwith

asthma-related Medicaid patient visits or 5-12 year olds.

Wards5,6,and8showedsignicantozoneimpactsforagegroups13-20,21-49,andallages,

respectively. When data were urther restricted to 1999 (a year with higher than average ozone

and PM2.5 concentrations, as well as higher summer temperatures), the ward specic impacts o

ozone and PM2.5 on 5-12 year olds were signicant, and strongest in Ward 7.

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Summary o RecommendationsAsthma represents a considerable burden on the District o Columbia. Despite some improvements in

asthma prevalence nationally, the District is lagging behind. Tere are many opportunities or improve-

ment as evidenced by racial, socioeconomic, and geographic disparities. Non-Hispanic blacks, low

income populations, residents in Wards 6, 7 and 8, the homeless population, young children (< 5 years),

school-aged children, middle aged adults (45-50), and the elderly are all subpopulations that need

specic attention when considering reduction o asthma prevalence, severity, and mortality in theDistrict. Te reports ndings suggest the need or improvement in asthma surveillance, management,

health disparities and reduction in risk actors, and preventable events.

eDistrictofColumbianeedstomaintaina consistentdatacollectionmechanism thatwill

capture prevalence, emergency department and hospitalization data by race, ward, and school

district level as well as data on asthma management by subpopulations.

ereisalsoasignicantneedtodevelopabetterdatacollectionmethodologyforwork-related

asthma (WRA) in order to better estimate the prevalence o WRA in the District. Tis may mean

orging partnerships with stakeholders (DC Oce o Workers Compensation, physicians. em-

ployers etc.) to establish an active data collection system.

Asthma interventionprogramsneed toencourage proper asthmamanagement bymitigating

primary health care barriers or at-risk populations. DC DOH needs to continue to orm partner-

ships with the Districts schools to improve asthma management in school-aged children.

WRAisadiseasethatispreventable;asthmainterventionsneedtoeducatehealthcareproviders,

employers and employees on the diagnosis, and prevention o WRA.

Obesityandtobaccosmokeareriskfactorsthatneedtobeintegratedinasthmapreventionstrate-gies especially those targeting children.

Racialandsocioeconomicdisparitiesinasthmamorbidityandmortalityneedtobeaddressedby

targeting resources, orming partnerships, and implementing outcome based interventions that

utilize asthma data to set goals, and routinely assess improvements.

Burden o Asthma in the District o Columbiaxiv


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Asthma is a chronic disease o the lungs bronchi (airways) characterized by airway hyper-respon-siveness to stimuli resulting in airow limitation and respiratory symptoms including breathlessness,

wheezing, coughing, and chest tightness. Symptoms can vary in severity rom mild intermittent (aect-

ing activity levels) to severe persistent. All levels o severity can be lie- threatening.

1.1. Cause and TriggersWhy a person develops asthma depends on complex interactions o genetic and environmental ac-

tors that are not thoroughly understood. However, triggers that exacerbate asthma episodes have been

well studied and are much better understood. Asthma triggers and symptoms vary rom person to

person. Common asthma triggers include:

Allergenspollen, animal dander, dust, mites, cockroaches, and mold

Irritantscold air, perume, pesticides, strong odors, weather changes, cigarette smoke, and

chalk dusts

Respiratoryinfectionscold or u

Physicalexerciseespeciallyincoldweather

Stress

1.2. Public Health SignifcanceIn 2005, more than 22 million Americans had asthma and o these 6 million were children.1 Asthma is

one o the most common chronic diseases aecting children in the United States. Te burden o asthma

not only aects the patients, but also their amilies and society in terms o: lost days o work and school,

lessened quality o lie, and avoidable emergency department visits, hospitalizations, and deaths.2

Asthma is one o the leading causes o school absenteeism.3 In 2003, an estimated 12.8 million school

days were missed due to asthma among more than our million children who reported at least one

asthma attack in the preceding year.4

In addition, asthma is the leading cause o preventable hospital-ization with approximately 500,000 hospitalizations and 1.5 million emergency department visits, thus

burdening the health care system.5 It also accounts or over 5,500 avoidable deaths each year.6

Te direct cost o asthma (hospitalization, physician, and prescription drugs) in the US in 2007 was

estimated to be $14.7 billion. Indirect costs such as loss o school days, loss o work, and deaths were

estimated at an additional $5 billion with the total economic cost o $19.7 billion. Prescription drugs

represented the largest single direct medical expenditure at $6.2 billion.7

1

1. Introduction


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Te disparity in wealth is evident in neighborhoods that exist with economic challenges. Studies show

that low-income amilies, minorities, and children living in inner cities are at a higher risk o emer-

gency department visits, hospitalizations, and deaths due to asthma than the general population. Te

income distribution or the District is outlined below in able 1-2.

able 1-2: District o Columbia population, race and socio-economic distribution by Ward

1.4.1. Control Asthma Now (DC CAN)Te District o Columbia Department o Health (DOH) launched the DC Control Asthma Now (DC

CAN) Program in 2001 in order to address the national Healthy People 2010 asthma objectives and

to improve the quality o lie or District residents who suer rom asthma. Its mission is to develop

and implement a viable, comprehensive, community-based, consumer-centered approach to asthma

diagnosis, and management.

Te Districts rst Burden o Asthma Report was published in 2003, and its Asthma Strategic Plan was

completed in 2004. It was anticipated that implementation o the plan would enable the District to achieve

more optimal levels o eectiveness and eciency in the use o available care delivery resources and

thus, reduce the burden o asthma in the District.

Te objectives o DC CAN are as ollows:

Developandimplementinterventionstoreduceasthmahospitalizations,deaths,andemergency

department visits, especially or the high-risk population (children, seniors, blacks, and Hispanics).

Developandimplementinterventionstoreduceasthmahospitalizations,deaths,andemergency

department visits, especially or the high-risk population (children, seniors, blacks, and Hispanics).

Burden o Asthma in the District o Columbia4

Population a Age a, b Race a Medicaid b Income d Unemployed d

WardCensus,

200018+ 65+ Black

HispanicLatino

Number ofRecipients

Median,1999

Percent

1

2

3

4

5

67

8

73,364

68,869

73,718

74,092

72,527

68,03570,540

70,914

17%

11%

13%

21%

22%

19%28%

37%

8%

9%

14%

17%

18%

11%14%

6%

43%

30%

6%

78%

88%

69%97%

92%

23%

9%

7%

13%

3%

2%1%

2%

15,218

20,864

1,649

15,009

18,969

16,67624,199

28,841

$36,802

$44,742

$71,875

$46,408

$34,433

$41,554$30,533

$25,017

5%

6%

7%

4%

8%

6%7%

12%

DC 572,059 20% 12% 60% 8% 141,941 c $40,127 7%

a DC State Center or Health Statistics; Policy, Planning, and Research Administration, Vital Statistics 2004.

b Working Together or Health: MEDICAID Annual Report, FY 2005. DC Department o Health, Medical Assistance Admin.

c Total includes those missing

d DC Oce o Planning, 1999 Median Household and Per Capita Income by Ward


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As partners across the District work towards developing and implementing asthma interventions, itis vital to know the current asthma prevalence in order to target and measure the impact o interven-

tions. Tis report summarizes the DC CAN surveillance that utilizes data rom various sources and

key stakeholders to portray a comprehensive picture o asthma in the District o Columbia, as shown

in Figure 2-1. Te goal o the report is to provide baseline data and guidance or the development o

targeted asthma intervention programs and policies.

Figure 2-1: District o Columbia asthma surveillance data sources

2.1. Measuring Asthma PrevalenceAsthma prevalence is estimated using the District o Columbia Behavioral Risk Factor Surveillance

Systems (BRFSS) survey data. Te BRFSS is an annual telephone health survey o approximately 4,000

adults aged 18 years and older. Te survey uses standardized interviewing methods and questionnaires,

and covers a broad spectrum o health behaviors. For this report, data rom 2000-2007 has been used

7

Data Sources

DC

CA

N

Surveillanc

eData

AsthmaPrevalence

Severity andQuality o Lie

Environmental

Work-related

Mortality

BRFSS

HospitalDischarge

Medicaid

WorkersCompensation

Vital Statistics

EmergencyDepartment

Air Quality

GWU Survey

2. Asthma Burden in theDistrict of Columbia


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Figure 2-2: Prevalence o adult asthma in the District o Columbia

Figure 2-3 shows that asthma prevalence in the District has been on an upward trend rom 2000 through2005. In 2000, the prevalence was estimated at 11% and rose steadily to 15.5% in 2006, which is a 29%

increase. Te prevalence increase rom 2000 to 2006 is statistically signicant at p


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Burden o Asthma in the District o Columbia 11

2.2.2. Asthma Prevalence by Race/Ethnicity

Non-Hispanic black respondents have a higher prevalence o current asthma as compared to Hispanics

or non-Hispanic whites as shown in Figure 2-6. Tere is a statistically signicant dierence in preva-

lence o current asthma among non-Hispanic whites, and non-Hispanic blacks, with non-Hispanic

blacks experiencing a 37% higher prevalence than non-Hispanic whites. Similarly, non-Hispanic blacks

experience current asthma at a 23% higher rate than Hispanics. Tere was a 23% higher prevalence

o lietime asthma among non-Hispanic blacks as compared to non-Hispanic whites. Te prevalence olietime asthma among Hispanics is 33% higher than their non-Hispanic black counterparts. Te prev-

alence rate or ormer asthma by race was more than twice as high or Hispanics in comparison to

non-Hispanic blacks or whites.

Figure 2-6: Prevalence o adult (18 years) asthma by race/ethnicity

2.2.3. Asthma Prevalence by Age Group

In 2007, the highest lietime asthma prevalence was reported among 18-24 year old residents (24.8%)

ollowed by the 25-34 year olds (18%), as shown in Figure 2-7. Te lietime asthma prevalence or both

18-24 and 25-34 year old respondents was signicantly higher than their 65 year, and older counterparts.

In addition, the prevalence or 18-24 year olds was approximately twice the prevalence or ages 35-44,

45-54, and 55-64; this was statistically signicant.

Source: District o Columbia Behavioral Risk Factor Surveillance System, 2007

Percentage


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Figure 2-8: Prevalence o adult (18 years) asthma by education level

Figure 2-9 shows the highest prevalence o lietime, and current asthma among respondents reporting a

household income less than $15,000. Data analysis showed no statistical signicant dierences between

income groups or lietime, and ormer asthma. However, there was a signicantly higher current asth-

ma rate among residents reporting an income less than $15,000 as compared to those reporting an

income above $75,000. Current asthma prevalence rate was more than two times higher among respon-

dents reporting less than a $15,000 household income than those reporting an income above $75,000.

Figure 2-9: Prevalence o adult (18 years) asthma by income level



Per

centage

Percentage


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Wards 3 and 4 have the lowest prevalence o current asthma, and correspondingly have the highest

ormer adult asthma. Ward 3 and 4 both have the highest median household incomes, and the lowest

number o Medicaid recipients in the District. Tese results are consistent with earlier ndings that

respondents with higher socioeconomic status have lower current asthma prevalence.

2.2.6. Risk Factors Associated with Elevated Asthma Prevalence

BMI and Asthma

In 1998, the National Institutes o Health (NIH) released clinical guidelines or the identication o

overweight, and obesity based on the body mass index (BMI); an individuals weight in kilograms

divided by their height in meters, squared. According to the guidelines, individuals with a BMI greater

than or equal to 30 are considered to be obese, those with BMI greater than 25, but lower than 29.9

are considered overweight. In 2005, approximately 14% o respondents who were obese, 8% who were

overweight,andanother8%ofnormalweight(BMI>18and


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Figure 2-15 shows that approximately 8% o District children under the age o 9, and almost 16%

between ages 9 to 17 had asthma in 2005. Tere is a 47% higher current asthma prevalence rate among

9 to 17 year old children compared to those less than 9 years o age.

Figure 2-15: Prevalence o childhood (17 years) asthma by age group


Percentage


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Appropriate disease management improves the quality o lie o persons with asthma. Tis sectioncharacterizes the experience o individuals with asthma in the District by describing their asthma man-

agement, and quality o lie as measured by age at rst diagnosis, requency o inhaler use, routine doc-

tor visits, rate o asthma attack, and activity limitation due to asthma.

3.1. Measuring Asthma Management and Quality o Lie

In 2003, the Districts BRFSS surveillance study began to include questions related to asthma management

and quality o lie issues that would be used to estimate the severity o symptoms in those with currentasthma. Tese questions were administered to adult (18 years) respondents who reported having

current asthma. Te number sampled in this module was small because this section o the total survey

only sampled persons with current asthma (a smaller segment o the population). In this section o

the report, only results rom data collected in 2005 were available or analysis. In uture reports, data

or multiple years will be combined in order to better describe the quality o lie and disease manage-

ment or subgroups with asthma.

3.2. Asthma SeverityAsthma severity can be measured by the number o asthma episodes reported, the number o asthmarelated doctors visits, and the requency o inhaler use. Te ollowing three sections examine each o

these indicators or signicant trends.

3.2.1. Asthma Episodes (Attacks)

Respondents who were determined to have current asthma were asked: During the past 12 months,

have you had an episode o asthma or an asthma attack? As shown in Figure 3-1 or the year 2005,

approximately 45% answered yes, indicating that they had an episode o asthma or an asthma attack

in the past 12 months.

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Figure 3-1: Occurrence o asthma episodes

In 2005, male respondents (50.7%) reported experiencing a higher proportion o asthma attacks in thepast 12 months as compared to emales (41%). However, Figure 3-2 indicates that the dierences were

not statistically signicant by gender. Similarly, there was no signicant dierence in the respondents

experiencing asthma attacks by race. Figure 3-3 shows that 43.5 % o non-Hispanic whites and 45.8%

o non-Hispanic blacks who currently have asthma responded that they had experienced an episode o

asthma or an asthma attack during the previous year. Data on Hispanics was insucient to include in

the analysis.

Figure 3-2: Episodes o asthma by gender




Percentage

Percentage


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Figure 3-3: Episodes o asthma by race

3.2.2. Routine Doctor VisitsTe BRFSS was also used to estimate the requency o routine doctor visits among those reporting cur-

rent asthma. Tese respondents were asked: During the past 12 months, how many times did you see

a doctor, nurse, or other health proessional or a routine checkup or your asthma? Figure 3 4 shows

that the majority o respondents (32%) with current asthma reported that they have routine doctor

visits two to our times a year. About 30% reported either zero or one routine visit per year. Te survey

data shows that a signicantly lower proportion o respondents (8.6%) with current asthma have ve

or more routine doctor visits a year.

Figure 3-4: Frequency o visits to a doctor or routine asthma checkups



Percentage

Percentage


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3.2.3. Inhaler Use

Respondents with current asthma were asked: During the past 30 days how ofen did you take a pre-

scription asthma inhaler during an asthma attack to stop it? Figure 3-7 shows that a majority (61%)

never used an inhaler to stop asthma episodes in the past month. However, approximately 30% indi-

cated they had used an inhaler 1-4 times, and 9% had used an inhaler 5 or more times in the past 30

days to stop an asthma attack in 2005.

Figure 3-7: Frequency o inhaler use to stop asthma episodes

As illustrated in Figure 3 8, a higher percent o males (34.4%) used an inhaler 1-4 times in the past month

as compared to emales (27.4%). However, almost twice as many women (10.7%) used an inhaler 5 or

more times as compared to men (5.5%).

Figure 3-8: Frequency o inhaler use to stop asthma episodes by gender




Percentage

Percentage


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4.1.2. Mean Length of Stay

Te mean length o stay (LOS) or asthma hospital discharges rom 1997 to 2003 had very little vari-

ability with an average LOS o 3.7 days. For all hospitalizations in the District, the mean LOS decreased

rom 6.7 days in 1997 to 5.8 days in 2003 as shown in Figure 4-3.

Figure 4-3: Mean length o stay or asthma-related discharges and total hospital discharges

4.2. Emergency Department Visit Due to Asthma

Emergency department (ED) data or asthma was collected and analyzed or the years 2002 through

2006. Te dataset captured all resident visits made by children (age 12 months to 17 years). Data on

adult use o the emergency department were captured or the years 2005 and 2006. Data include all

visits with primary, secondary or tertiary diagnosis o asthma and is collected retrospectively. Te EDdata were collected uniormly rom all non-military District hospitals ollowing established protocols.

While some proportion o these visits are made by individuals who do not live in the District (or ex-

ample, 30% o all visits and nearly 40% o pediatric visits in 2005), the data presented below include

only ED visits made by District residents.

4.2.1. Age-adjusted ED Visit Rates

Te age-adjusted ED visit rate due to asthma in the District in 2005 and 2006 was 208 and 219 per

10,000 persons respectively. Figure 4-4 shows that the age-adjusted rate o ED visits increased rom

2005 to 2006. However, this increase was primarily among emales who had an 11% increase in their

ED visit rate in the same period.


Source: District o Columbia Hospital Association

NumberofDays


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Figure 4-4: Age-adjusted rates o emergency department visits due to asthma

among all residents in the District o Columbia

Figure 4-5 shows that in 2005 and 2006, the rate o ED visits was the highest among children 1-4 years

old and adults 40 to 50 years old which is consistent with hospitalization rates presented above. However,

asthma data or the 1-4 year old age group should be interpreted with caution or several reasons. o

begin with, it is ofen dicult to elicit enough cooperation rom these young children to obtain accu-

rate objective pulmonary unction assessments. More importantly, these young children are prone to

temporary reactive airway conditions or developmental reasons. Also, it is possible that these children

may spend less time outdoors than older school-age children. Tereore, there is some debate over

whether children younger than ve years are always accurately diagnosed as asthmatic when in act

some o them might be suering rom a more temporary reactive airway condition that may or will dis-

appear as they grow older.11 (Tis is a controversial statement and/or issue in the asthma community.)

Figure 4-5: otal emergency department visits due to asthma in the District o Columbia


Source: Improving Pediatric Asthma Care in the District o Columbia, 2005 -2006

Source: Improving Pediatric Asthma Care in the District o Columbia, 2005 -2006

Rate(per10

,000)

Rate(per10,0

00)


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Figure 4-10: Frequency o disposition o emergency department visits due

to asthma in the District o Columbia

Source: Improving Pediatric Asthma Care in the District o Columbia, 2006

Percentage


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Asthma mortality data was obtained rom the District o Columbia State Center or Health Statistics,Vital Records Division. Data on death was abstracted rom death certicates. Asthma deaths weredened as the primary cause o death as coded by the enth Revision o the International Classicationo Diseases (ICD-10), code J45 and J46.

5.1. Mortality Count by SubgroupsTe annual asthma deaths in the District o Columbia rom 1999 to 2005 were low (less than 15 per year).However, some patterns can be observed. From years 1999 to 2005, a total o 67 deaths were attributed

to asthma. A majority o the asthma deaths occurred among non-Hispanic blacks. Meanwhile, or allthe six years combined only six deaths (as compared to 61 deaths in non-Hispanic blacks) occurredamong Non-Hispanic whites. Mortality data by age group reveals that more asthma deaths occurredamong adults as compared to children (0-17 years), and the number o asthma deaths increased by age.Tere were no deaths due to asthma among 0-4 year-old children rom 1999 to 2005.

able 5-1: Annual asthma mortality count in the District o Columbia, 1999-2005

39

1999 2000 2001 2002 2003 2004 2005 1999-2005

SexMale

Female

3

8

5

5

5

4

3

3

5

4

7

7

4

4

32

35

Race/Ethnicity

WhiteBlackOther

1100

0100

090

060

180

2120

260

6610

Age

0-45-17

18-4445-6465+

01244

00127

00243

01311

00144

00464

00224

02

152327

Ward

12

345678

22

010042

10

041121

11

012031

10

011201

11

101113

03

014132

11

022020

78

110115

1510

Total 11 10 9 6 9 14 8 67

Source: District o Columbia State Center or Health Statistics

5. Asthma Mortality


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Figure 5-2: Asthma mortality rate by sex and race, District o Columbia, 1999-2005

Figure 5-3: Asthma mortality rate by age group, District o Columbia 1999-2005

5.4. Mortality Rate by WardTe Districts asthma mortality rate was stratied by Ward in order to determine the geographical di-

erences. Wards 7, 5 and 8 had the highest asthma mortality rates and Ward 3 had the lowest asthmamortality rates in the District rom 1999 to 2005. Te data revealed that most asthma deaths occurred

amongst non-Hispanic black individuals. Wards 7, 5 and 8 have the highest proportion o non-Hispan-

ic black residents in the District, while Ward 3 has the lowest (see able 1-2).




Rate(per

100,0

00)

Rate(per100,0

00)


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Work-related asthma (WRA) is the most prevalent occupational lung disease in industrial countries.WRA a disease that is attributable to or is made worse by environmental exposure in the workplace.

It is diagnosed by conrming the cause o the diagnosis o asthma and by establishing a relationship

between asthma and the workplace. WRA is suspected in every adult-onset case or asthma that is ex-

acerbated in adult lie.

Tere are over 250 workplace agents associated with WRA. Te most common include protein molecules

(wood dust, grain dust, animal dander, ungal substances, and latex) or chemicals like diisocyanates.

Tis type o asthma is partially or completely preventable and reversible, i irritants are controlled or

stopped.12 Workers at an increased risk include those in proessions that deal with wood or metal works,laboratory and health care workers, and drug and detergent manuacturers. Based on previous studies

in other states, work-related asthma has occurred more in operators, abricators, and laborers (32.9%),

ollowed by managerial and proessional specialties (20.2%).13 Smoking in the workplace which also

contributes to the exposure to secondhand smoke is another known asthma irritant.

Te District o Columbia has an economic prole that includes industries in which occupational asth-

ma is a requent health risk. Tese include construction (associated with numerous triggers including

di-isocyanates), the hospitality industry (solvents and cleaning agents), printing (solvents and inks),

health care (latex and medications), biomedical research (latex and animal antigens), and automotive

repair (solvents and epoxy compounds).

Generally, WRA is underestimated. Tis is likely true o all occupational diseases, especially occu-

pational respiratory disorders which are ofen misattributed to non-occupational etiologies such as

smoking or non-occupational allergens. Furthermore, measuring the prevalence o reported WRA in

the United States has been challenging due to the lack o a centralized comprehensive reporting or

surveillance system. Currently, most WRA data are ascertained rom workers compensation databases

and the social security disability index. However, the National Institute o Occupational Saety and

Health (NIOSH) has unded a state-based surveillance program. Te program includes our states:

New Jersey, Caliornia, Massachusetts, and Michigan which actively solicit occupational asthma re-

ports rom physicians. Data rom these our states rom 1993-1999 show over 2,500 cases o WRA.

Alternatively, the respiratory disease surveillance system, Surveillance o Work and Occupational Re-

spiratory Diseases (SWORD) located in the United Kingdom has proven to be an ecient and eective

model to provide inormation on WRA incidences. Tis system has demonstrated that WRA is more

common and involves more antigen and trigger exposures than previously estimated.

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6.1. Prevalence o Work-Related Asthma in the DistrictData on work related asthma were acquired by DC CAN rom the DC Oce o Workers Compensation.

From 1999-2005, thirty nine (39) claims were led by District employers whose employees worked in

the District o Columbia. Tis equates to 5.6 per year or the seven-year period. Tis is an exceptionally

low gure and most likely an undercount. Te majority o individuals with work-related illnesses how-

ever, do not le Workers Compensation Claims. Many sel-employed workers such as independent

contractors, ederal employees, or railroad workers are not covered by the state compensation claimsoce. In addition, hospital discharge data was reviewed to identiy claims paid by workers compensa-

tion. However, these eorts yielded minimal results. Because there are no parallel reporting mecha-

nisms or surveillance systems, it is dicult to obtain an accurate estimate o WRA.

o ascertain a better estimation o WRA prevalence in the District; in 2006, the DC CAN partnered with

the George Washington University Department o Environmental and Occupational Health School o

Public Health and Health Services to conduct a WRA study.14 Te two objectives o this study were:

TodetermineifcasesofWRAareundercountedintheDistrictofColumbia;and

TodeterminethefeasibilityofasimpleactivereportingsystemtomonitorWRAcases.

Te ollowing two sections describe the study and summarize the study results.

6.1.1. WRA Study Description

A questionnaire developed at the George Washington University was sent to 220 physicians who practice

in the District o Columbia. Te survey population that was chosen consisted o a broad range o

disciplines including occupational medicine, pulmonary disease, internal medicine, amily practice,

and general practice. Each specialty was chosen or an increased probability o capturing practicing

physicians who were specialists in lung disease, working in a large academic hospital or amily practicephysicians at a ree clinic who would potentially diagnose occupational asthma cases.

Te survey was administered via internet and US mail. It contained seven questions that took ve to

seven minutes to complete. Te details o this survey are summarized in Appendix A. It consisted o

both open ended and restricted choice answers. Te survey questions were designed to ascertain:

enumberofWRAcasesdiagnosedin2005;

IfpatientswithWRAhadsubmittedaworkerscompensationclaimagainsttheiremployer;and

WhichoccupationsweremostlikelytobeperformedbythosewithWRA.

A third party, Medical Marketing Service (MMS), distributed the link to physicians asking them to

complete this ree-internet survey. Afer having the internet version o the survey open or three weeks,

an additional step was taken to increase the response rate. A mass mailing was sent to all physicians in

the District o Columbia via the United States Postal Service, assuming that the ones who responded

via the internet would not respond to the mailing.



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6.1.2. WRA Study Results

Te response rate or both the internet and mail survey was 16.8%. Te study ound 46 work related

asthma cases in 2005 alone (29 males and 17 emales). Te average age or those being diagnosed with

occupational asthma was 38.6 years old. Te most common occupations among patients with WRA re-

ported by physicians in the study were construction laborers and workers in the public administration

eld (guards, police ocers, environmental quality, and housing inspectors).

Te study resulted in the identication o 18% more cases in one year compared to the Workers Com-

pensation Claims database that spanned seven years. Tis result conrms the hypothesis that work

related asthma is underreported in the District o Columbia. Te studys low response rate and relative

insensitivity suggests that there are more cases than captured by the study. In order to measure an ac-

curate prevalence o WRA, a more sophisticated survey system with strict case denitions and incen-

tives to solicit increased physician response would be necessary. Alternatively, a surveillance system

similar to the GWU WRA Survey and SWORD would eciently capture data necessary to estimate and

characterize WRA in the District. A WRA surveillance tool would help expand the existing DC CAN

asthma surveillance system where WRA data can be studied along with the other sources o asthma.



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Asthma is associated with a variety o environmental risk actors such as indoor air pollution (smok-ing, cockroach, dust, etc.) in addition to outdoor air pollution (ozone, particulate matter, tree pollen,

weed pollen, mold, etc.). Current evidence suggests that environmental exposure is at least one o the

most important causative actors that contribute to asthma aggravation. Additionally, environmental

exposures may be risk actors that are more amenable to change as compared to social or psychosocial

problems.15

7.1. Outdoor Environmental PollutantsTere are a variety o outdoor environmental pollutants such as ozone (O3) and particulate matter(PM) that have been ound to have an adverse impact on health.

Ozone is a gas that is present in two layers o the atmosphere and orms and reacts under the action o sun-

light. Higher up in the atmosphere, ozone acts as a protective layer that shields the earth rom high levels

o Ultra-Violet (UV) radiation. However, ozone at ground-level is considered a major air pollutant.

Particulate matter is the sum o all solid and liquid particles suspended in air, many o which are hazardous.

Tis complex mixture contains organic and inorganic particles such as dust, pollen, soot, smoke, and

liquid droplets. Tese particles vary in size, composition and origin. Based on size, particulate matter

is divided into two main groups:

ecoarsefractioncontainsthe larger particleswithsizesranging from2.5 to10m(PM10

PM2.5).

enefractioncontainsthesmalleroneswithsizesupto2.5m(PM2.5).eparticlesinthe

nefractionwhicharesmallerthan0.1marecalledultraneparticles.

When particulate matter is combined with other air pollutants, the individual health eects o each

pollutant are cumulative. In certain cases, especially or combinations o particulate matter with ozone

or allergens, harmul eects were shown to be even greater than the sum o the individual eects.

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7. Air Quality and Asthma


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7.1.1. Health Effects

Certain groups o people are more susceptible to suer adverse health eects due to ambient air pollution.

Tese include elderly people, children, people with pre-existing heart and lung disease, asthmatics, and

socially disadvantaged and poorly educated populations.

Pollutants, O

3

16, 17

and PM,18

have been directly linked to airway inammation and obstruction thatleads to respiratory morbidity. Inner cities in the United States, including the District, have social and

economic inuences (e.g. psychosocial stress, high smoking rates, inappropriate medication use, inad-

equate resources, and poor access to quality health care) that increase their vulnerability to outdoor

environmental exposures.15

7.2. Air Quality Standards

In response to adverse health eects o outdoor air pollutants, the Environmental Protection Agency

(EPA) has legislated standards or air quality.

Te Clean Air Act, which was last amended in 1990, requires EPA to setNational Ambient Air

Quality Standards (40 CFR part 50) for pollutants considered harmful to public health and the

environment. Te Clean Air Act established two types of national air quality standards. Primary

standards set limits to protect public health, including the health of sensitive populations

such as asthmatics, children, and the elderly. Secondary standards set limits to protect public

welfare, including protection against decreased visibility, damage to animals, crops, vegetation,

and buildings.19

Te EPA Oce o Air Quality Planning and Standards (OAQPS) has set National Ambient Air Quality

Standards or six principal pollutants, which are called criteria pollutants. able 7-1 lists national

ambient air quality standards. Units o measure or the standards are parts per million (ppm) by vol-

ume,milligramspercubicmeterofair(mg/m3),andmicrogramspercubicmeterofair(g/m3).


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Te specic objectives o this program were to:

Documentfurthertherelationshipbetweenenvironmentalexposuresandhumanhealtheects;

Gain greater ability to undertake health impact assessment, policy development and assurance;

and

Generateinformationthatwouldguidepolicydevelopmentanddecisionmakingonprevention

and treatment activities, as well as resource allocation.

7.3.1. Study Description

Te study employed three sources o data:

Dailyasthma-relatedMedicaidpatientvisitsforallagescovering135monthsfromOctober1994

to December 2005;

AirqualitydatafromDCmonitoringstations,includingaero-allergendataformoldsporesand

tree, weed, and grass pollen rom the US Army Centralized Allergen Extract Laboratory at the

Walter Reed Army Medical Center; and

WeatherdatafromtheNationalWeatherServicedatafromReaganNationalAirport.

Case denitions were developed or both asthma-related emergency department (ED) and general

acute care visits among Medicaid patients. Asthma-related Medicaid patient ED visits were dened as

hospital ED visits o Medicaid patients with asthma-related discharge ICD-9 codes in one o the rst three

positions o their record. Tese data are subsets o the data in the next case denition. Asthma-related

Medicaid patient general acute care visits were dened as records included in the case denition

above plus Medicaid records designated as physician services, outpatient services, nurse practitioner

services, ederally-qualied health center services, clinic services, emergency ambulance services, Mental

Retardation and Developmental Disabilities Administration waiver services, and ambulance services

(representing about 63% o the overall Medicaid database). Tese additional records were also restrictedto those with asthma-related ICD-9 codes in one o the rst three diagnosis code positions.

7.3.2. Study Results

When seasonal trends o asthma-related visits were examined, the investigators ound two annual

peaks in both ED and general acute care Medicaid patient visits. Te highest peak ell during Sep-

tember to November and the second-highest peak during March to May. Air quality measurements

revealed that June through September typically had the highest daily concentrations o ozone, PM2.5,

and PM10 with relatively small spatial variation among monitoring stations. Weather measurements

were included in this study because high temperatures are associated with more sunlight, which reactswith automobile emissions to produce ozone. Tereore, as expected, high temperature days tended to

correlate with high ozone days.

As expected, weekly pollen and mold counts were seasonal with tree pollen peaking in April, grass

in May-June, weed pollen in August-September, and mold in September-October. Mold also peaked

occasionally in May or August.



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In the District o Columbia, approximately 9% o adult residents (40,000 people) and 11% o children(13,000 children) currently have asthma and about 15% o adults have been diagnosed with asthma at

some point in their lietime (DC BRFSS, 2005). Overall, the prevalence o current asthma has been con-

sistently higher than the national rate or the past six years. In addition, the Districts lietime asthma

prevalence has been on an upward trend rom 2000 to 2004 but seems to be stabilizing at 15.2% in

2007.

Although asthma aects all segments o the District population, certain subgroups are disproportionately

aected by asthma including:

Non-Hispanicblackpopulation,

Veryyoungchildrenaged0-4years,especiallymalechildrenofthisagegroup,

Femalesaerpuberty(startingfromtheearlyteens);

Adultsaged45-50years,

eelderly(over65years),

Tobaccosmokers,

Obeseandoverweightresidents,

Residentswithlessthanorsomehighschooleducation,and

Residentswithhouseholdincomeslessthan$15,000.

8.1. Non-Hispanic Black PopulationAsthma disparities continue to be an issue in the District, with the non-Hispanic black population

being aected most severely. Non-Hispanic black adults have the highest current and lietime asthma

prevalence at 10% and 16%, respectively as compared to the non-Hispanic white population at 7% and

12%, respectively (BRFSS DC, 2007). Non-Hispanic blacks appear to have a higher requency o doctor

visits and inhaler use than their non-Hispanic white counterparts. Te majority o asthma deaths oc-

cur in this population, accounting or 91% o asthma deaths rom 1999 to 2005. Similarly, Wards 7, 5and 8, which are predominantly (over 88%) non-Hispanic black, have the highest District-wide asthma

mortality rates.

Te signicant dierence in morality rates among non-Hispanic blacks and whites may be an indica-

tion o the increased severity among the black population. Tere is an approximately two old dierence

in prevalence (according to the 2005 BRFSS) o asthma among non-Hispanic blacks (10.4%) and whites

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8. Conclusions


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(6.6%) in the District. However, there is an almost ourold dierence in the mortality rate between the

two races. Tere are multiaceted actors that may be causing the increased severity among non-Hispanic

blacks: poor asthma management, complications with other respiratory diseases and environmental

triggers. However, all these actors are interconnected and linked to poor socioeconomic status. For

example, poor asthma management can be due to lack o knowledge and access to care, which in turn

can lead to poor overall health outcomes and possible complications with asthma and poor housing

situations can lead to high indoor pollution and exposure to indoor asthma triggers.

8.2. Populations with Low Socioeconomic StatusIn addition to black Non-Hispanics, populations with low socioeconomic status (populations with

a low household income and low education attainment) appear to be disproportionately aected by

asthma. Te current asthma prevalence rate was more than two times higher among households with

an income less than $15,000 as compared to those with an income above $75,000 (BRFSS DC, 2005).

Similarly, populations with less than a high school education had current asthma prevalence rates that

were two times higher than those with a college graduate education. Wards 7, 5 and 8, which have thehighest unemployment rate, highest Medicaid recipients, and lowest median income in the District,

also have the highest mortality rates.

8.3. ChildrenTe National Health Interview Survey 2005 reported that 6.5 million or 9% o US children (


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8.5. Female PopulationDistrict emales (11%), 18 years, have a higher current asthma prevalence rate than males (7%).

Females, afer puberty, have a higher hospital ED visit rate than males. Among District adults with

current asthma, emales appear to receive the rst diagnosis o asthma at a later age (20-39 years) than

males, who are diagnosed at an earlier age (19 years). Tis data suggests that asthma intervention

programs need to target teenage and adult emales.

8.6. Populations with Other Risk FactorsFourteen percent (14%) o the Districts residents who are obese (BMI30) and 8% who are overweight

(25


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8.7. Implications or Asthma ManagementAmong District adults with current asthma, it appears that asthma management can be improved. O

adults with current asthma, 45% reported having an asthma attack in the past twelve months, 30%

reported using an inhaler 1-4 times, and 9% reported using an inhaler ve or more times in the past

month to stop asthma episodes (DC BRFSS, 2005). In addition, 22% o the Districts adult residents

with current asthma reported having at least one day in the past twelve months when they were un-

able to carry out normal activities because o their asthma. Approximately 30% o adults with currentasthma reported not visiting the doctor or a routine asthma checkup in the past twelve months thus,

not managing their asthma through their primary care giver. Tis is according to the 2007 Asthma

National Asthma Education and Prevention Program (NAEPP) guidelines.

Tere are many obstacles that may impede residents with asthma rom managing their asthma

eciently. As indicated by this report, a majority o the Districts residents who are aected by asthma

are at-risk, i.e., the poor, children, and the elderly. In 2006, a study targeting these populations con-

ducted ocus groups in Wards 7 and 8 on health care and barriers to health care in the District.25 While

not specically related to asthma, the results can be translated to the asthma situation. Findings rom

the ocus groups echo what other research shows i.e., that many complex, interrelated barriers deterresidents rom accessing health care in general and rom receiving primary or preventive care. Tese

barriers include:

Lackofinsurance,limitednances,andschedulingconicts;

Fearandmistrustofthemedicalsystemfromlackofunderstandingof the importanceofprimary

care;

Negativeexperienceswiththemedicalsystem;and

Lackofknowledgeofthehealthcaresystemandneedforcare.

8.8. Work-Related AsthmaWork-related asthma has proven dicult to estimate in the District due to the lack o an active surveil-

lance system that is designed to capture WRA. Te George Washington University study has shown that

using worker compensation claims dataset alone underestimates the prevalence o work-related asthma.

8.9. Asthma and Environmental FactorsTere is an association between socioeconomic risk actors and environmental actors, as determined

by the Johns Hopkins University Ambient Air Study. Te wards with poorer socioeconomic status(Wards 5, 6, 7, & 8) and higher Medicaid enrollment tend to show the most signicant association with

air quality on asthma-related general acute care visits. Tereore, the socioeconomically disadvantaged

residents appear to be more susceptible to air pollutants which increase their asthma symptomology.

Although the study had limitations and urther research needs to be done, the results were consistent

with similar studies o asthma and air quality. Te results o this study (i.e., that ambient ozone has



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Asthma represents a considerable burden on the District o Columbia. Despite some improvementsin asthma prevalence nationally, the District lags behind. Tere are many opportunities or improve-

ment, as evidenced by racial, socioeconomic, geographic disparities. Non-Hispanic blacks, low income

populations, the homeless population, residents in Wards 7, 8, and 6, young children (< 5 years), school-

aged children, middle aged adults (45-50), and the elderly subpopulations need specic attention when

considering the reduction o asthma prevalence, severity and mortality. Te reports ndings suggest

recommendations or improvement in asthma surveillance, management, health disparities and reduction

o risk actors and preventable events as outlined below.

9.1. Surveillance System

eDistrictofColumbianeedstoimproveitsabilitytocollectinformationonthenumberof

people with asthma in all District populations. Te District is an ethnically diverse population

with a large group o immigrants. However, data on the number o people with asthma or all sub-

groups (or example, immigrants, Hispanics, Asians etc.) are not available. Data on emergency

department (ED) visits are currently not available by race. Sucient data are also not available

at the level o geographic detail that would aid in planning eective asthma interventions (e.g.

wards, districts, school district levels etc.).

Smokingis theonlyasthmatrigger informationcollectedbytheBRFSS.Triggers intheworkplace, homes, and schools have not yet been developed into a questionnaire that can be distrib-

uted nor captured routinely by any other data system. Te District has many aging homes and

schools that may be sources o allergens. Data is needed on home, work and school environments,

and their health eects on the population. Tis data can be used to aid patients, health care pro-

viders, and asthma project programmers who may be able to eectively target asthma reduction

plans.

eDistrict lacksadequatework-relatedasthmadata.Currently,theDistrictrelieson theDC

Oce o Workers Compensation database to estimate work-related asthma. However, many sel-

employed workers including independent contractors, ederal employees, or railroad workers are

not covered by the state compensation claims oce. Tis underscores the need or developing a better

data collection methodology or work-related asthma in order to better estimate the prevalence

o WRA in the District. Tis may mean orging partnerships with stakeholders (DC Oce o

Workers Compensation, physicians, employers etc.) to establish an active data collection system.

Ourknowledgeofasthmamanagementcompletelyreliesonself-reportedsurveydataforadults.

Tere is limited inormation readily available in the District related to:

59

9. Recommendations


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DCDOHshouldfundandconductoutreachprogramstoeducateemployersandemploy-

ees on the work place triggers o asthma.

isreportfoundthatahighproportionofobeseresidentsalsosuerfromasthma.Althoughthe

causal relationship between asthma and obesity is not clear, there is enough research to suggest

that obesity is a risk actor linked to asthma. Tereore, asthma reduction interventions need to

have a comprehensive ocus on improving the overall health o residents, and specically reducing

the obesity epidemic among children and adults as part o the asthma intervention strategy.

Preventionofsmokingaroundchildrenshouldbeanothercomponentof theasthmaprimary

prevention strategy. DC DOH and other asthma stakeholders should continue to educate parents

(especially those with a history o asthma), day care providers, and others who routinely deal with

young children on the dangers o second hand smoke.

9.4. Reducing Health Disparities

Tere are vast racial and socioeconomic disparities in asthma prevalence, emergency department vis-its, and mortality rates in the District. Eorts to reduce the burden o asthma in the District must ad-

dress this issue. Tereore:

DCDOHshouldidentifyandtargetresourcesincludingprogramsandactivitiestogeographic

areas and populations that are experiencing the highest burden o asthma.

Partnershipsandstrategicalliancesshouldbeforgedamongagenciesandorganizationsaddressing

asthma in order to access these populations. For example, racial and ethnic minorities constitute

more than hal o those who get their health care through Medicaid. Tereore, Medicaid should

be an active partner in addressing asthma in the District o Columbia.

Coalitionsandasthmastakeholdersneedtoevaluatetheircurrentprogramstoensuretheyareaccessing and reaching these populations eectively.

ProgramsshouldutilizeavailableDCDOHdata to target activities, setmeasurableprogram

goals, and routinely assess improvements.



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1 American Lung Association, Epidemiology and Statistics Unit, Research and Program Services.

rends in Asthma Morbidity and Mortality; November 2007.

2 U.S. Department o Health and Human Services, National Institutes o Health, National Heart,

Lung and Blood Institute. Guidelines or the Diagnosis and Management o Asthma, October

2007.

3 CentersforDiseaseControlandPrevention(CDC),2003.

4 Akinbami LJ. Te State o Childhood Asthma, United States: 1980-2005, Advance Data rom Vi-

tal and Health Statistics: no 381, Revised December 29, 2006. Hyattsville, MD: National Center or

Health Statistics, 2006.


Lung and Blood Institute; Data Fact Sheet: Asthma Statistics; January 1999.


Lung and Blood Institute Data Fact Sheet: Asthma Statistics; January 1999.

7

American Lung Association; rends in Asthma Morbidity and Mortality; August 2007.

8 National Institutes o Health. News Release; NHLBI Reports New Asthma data or World Asthma

Day; 2001.

9 District o Columbia Oce o Planning. Census 2000 Data.

10 National Center or Health Statistics, Centers or Disease Control and Prevention,Morbidity and

Mortality Report. 2003.

11

Wright, A. Epidemiology o Asthma and Recurrent Wheeze in Childhood. Clinical Reviews inAllergy and Immunology: 2002; 22:33-44.

12 Friedman-Jimnez G, Beckett WS, Szeinuk J, Petsonk EL, Clinical Evaluation, Management, and

Prevention o Work-Related Asthma,American Journal of Industrial Medicine. 2000; 37:121-141.

13 Department o Health and Human Services, Centers or Disease Control and Prevention, National

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Institute or Occupational Saety and Health: Work-Related Lung Disease Surveillance Report, 2002.

14 Breedlove, J., Occupational Asthma is More Common in the District o Columbia than Represent-

ed

in Compensation Statistics, George Washington University Masters Tesis, 2006.

15 Eggleston PA, Buckley J, Breysse PN, Wills-Karp M, Kleeberger SR, Jaakkola JJK, Te Environmentaland Asthma in U.S. Inner Cities. Environmental Health Perspectives Supplements, Vol. 107, S3,

June 1999.

16 Diaz-Sanchez A, sien A, Casillas A, Dotson AR, Saxon A, Enhanced nasal cytokine production in

human beings afer in vivo challenge with diesel exhaust particles,Journal of Allergy and Clinical

Immunology, 1996; 98:114-123.

17 Rosenstreich DL, Eggleston P, Kattan M, Baker D, Slavin RG, Gergen P, Mitchell H, McNi-Mortimer

K, Lynn H, Ownby D, et al. Te role o cockroach allergy and exposure to cockroach allegen in

causing morbidity among inner-city children with asthma, New England Journal of Medicine,1997;336:1356-1363.

18 Department o Health and Human Services: National Asthma Education Program Expert Panel

Report: Guidelines or Diagnosis and Management o Asthma DHHS Publ. No 91-3042. Bethesda,

MD: 1991.

19 USEnvironmentalProtectionAgency,

20

Babin SM, Burkom HS, abernero N, Holtry R S, Ambient Air Quality and Medicaid PatientAsthma Data Summary Report or the Investigation o the Linkage between Ambient Air Quality

and Medicaid Patient Asthma Exacerbations in Washington, DC, Te Johns Hopkins University

Applied Physics Laboratory Report, 2006.

21 Ross M and Patrick K, Te Brookings Institute: A Policy Brie or the Medical Homes DC Area

Health Education Center Leaders Among Us: Developing a Community Health Worker Program

in Washington, DC, October 2006.

22 Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyper responsiveness,Journal of

Allergy and Clinical Immunology, 2005; 115:925- 927.

23 Strachan DP, Butland BK, Anderson HR, Incidence and prognosis o wheezing illness rom early

childhood to age 33 in a national British cohort. British Medical Journal, 1996; 312:1195 -1199.

24 Piipari R, Jaakkola JJk, Jaakkola N, Jaakkola MS., Smoking and asthma in adults, European

Respiratory Journal. 2004: 24: 734-739.



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25 Ross, M and K Patrick, Te Brookings Institute Leaders Among Us: Developing a Community

Health Worker Program in Washington DC October 2006.

26 Weisel CP, RP Cody, and PJ Lioy, Relationship between summertime ambient ozone levels and

emergency department visits or asthma in central New Jersey. Environmental Health Perspectives,

1995: 103, 2: pp 97-102.

27 olbert, PE, Mulholland JA, Macintosh DL, Xu F, Daniels D, Devine OW, Carlin BP, Klein M, Dor-

ley J, Butler AJ, Nordenberg DF, Frumkin H, Ryan PB, and White, MC: Air quality and pediatric

emergency room visits or asthma in Atlanta, Georgia, American Journal of Epidemiolo

district of columbia burden of asthma report

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