The document I am going to review is ‘2011 Burden of Asthma in Indiana’ from the Indiana State Department of Health (ISDH).

Writer’s note- as I reviewed this I got confused and I was not sure what year I was looking at. The same concerns may occur with your reading. The basis for the confusion is that this is the 2011 Asthma Burden Report. The first sentence in the Introduction says it is the 2010 Indiana Asthma Burden Report, yet all the data is 2009? Since it takes time to collect information and to run an analysis, my guess is that this is the Burden of Asthma in the State of Indiana in 2009 with some 2007 information included. Just watch the dates on the data.

A few facts regarding asthma in Indiana-in children;

• Asthma is the third leading cause of hospitalization for children under the age of 17 years.
• In 2009, an estimated 150,000 children (9.9%) reported currently having asthma.
• Nearly 15% of children reported having been diagnosed with asthma at some point during their lifetime.
• Nearly 24% of high school students reported having asthma at some time in their lives and 12.2% reported having current asthma in 2009.

The information in the report comes from a questionnaire, the Behavioral Risk Factor Surveillance System (BRFSS). This is a telephone survey. Using 2009 (the ISDH website as of 5-23-2011), there were 9,288 randomly selected individuals who were called and asked to participate. The response rate was just over 47%. What follows is asthma information for the state of Indiana regarding children (17 years of age or younger) from the BRFSS 2009 and a few interesting points regarding the entire sample.

            Since 2007 the lifetime and current rates of asthma have increased significantly. The prevalence of lifetime asthma is close to 15% and is above the national average for the year 2009. The prevalence of current asthma is also higher than the national average in 2009 (just under 10%). 

            The hospitalization rate for asthma (age-adjusted) has increased since 2007 and is 13.9 hospitalizations/10,000 residents in 2009.

            Age-adjusted emergency department visits for asthma have increased significantly since 2004; 30.4/10,000 residents to the 2009 rate of 49.7/10,000.

            Asthma mortality- death due to asthma is rare and are below national averages and continues to decline (end point was 2007).

            The highest rate of hospitalizations in Indiana was found among boy’s ages 0-4 years – 36.5/10,000 residents. Boys tended to have higher hospitalization rates until age 14 years at which time girls and women had significantly higher rates of hospitalization. Emergency department visits followed the same trend- more seen in boys less than 15 years of age then females more than males after age 15 years.

            Asthma can and does affect people of all races and ethnicities. This information was not broken down for children. The report is only on adults but does show which groups tend to be more or less affected. Hispanic adults had the lowest rate of asthma prevalence at 4.3% as well as the lowest rate of emergency department visits and hospitalizations. The white population had a prevalence of 9.2% and the black population had 12% asthma prevalence. Hospitalization occurred three times more often in the black population when compared to the white population.

            The report also looked at income, education, and geographic variation (county prevalence).

            There is a very interesting page on risk factors or behaviors associated with asthma. This however is not from 2009. This is information from the 2007 BRFSS. The following is a selection from that 2007 listing of behaviors reported by adults with asthma in Indiana.

• 40% were advised about changing the environment
• 10% had seen, smelled, or suspected mold in their environment
•   4% had seen cockroaches
•    5% had seen mice/rats in their homes
•  20% used a house dust mite cover on their bedding
•  80% had carpeting or rugs in their bedrooms
•  27% used a dehumidifier to reduce moisture
•  34% used an air purifier
•  57% had pets
•  28% had someone smoke in their home within the past week
•  29% were smokers

Writer’s note; look at all the allergy potential in this listing. Allergen triggers for asthma would include mold, roach, mice, dust mites, and pets.

Protecting them against asthma. This also comes from 2007 and deals with adults with asthma.

• 69% reported on getting instruction on how to recognize signs of an attack
• 77% were taught what to do during an asthma attack
• 33% received an asthma action plan
•   6% had taken a course on how to manage asthma

Health Interventions

            The document lists a number of endeavors out there to help with education including the ISDH Asthma Program and the Indiana Joint Asthma Coalition (InJAC).

 Reviewers Notes

These reports are notable. My tendency is to pick away at details and ask questions. There is a wealth of information within the report, however it can be confusing and sometimes it is not totally clear why something appears and for what year. A suggestion would be to make sure the reader knows the ‘when’ of the information- 2011, 2010, or 2009, or even 2007. You can see this report on the ISDH website. There are links to background information. However, the final document should be considered a ‘stand alone’ document and should mention the methodology and specifics of the population. I was also not clear about information that clearly was not from 2009. There were presentations of information from 2007. Was this new for a burden report? Was this a re-iteration from a past report? These reports follow a format; Introduction, Goals, Trends, Disparities, Risk & Protective Factors, Conclusion, Resources, References, and Appendices. Was all the information available from the 2009 BRFSS? Will we see 2009 data later? There should have been some explanation as to why the timeline skipped around so much. That would have been very helpful for this reader.

This is the state of asthma within our state. Clearly more needs to be done. There is clearly more ‘asthma’ out there. We are higher than the national average for children. There are more emergency department visits for asthma. There are a number of possible allergy issues involved.

The ISDH has a state asthma plan and a partner organization InJAC that is looking for interested partners to help make a difference. Checkout the InJAC website and join us.

FEL

During a career you hear many words of wisdom from your mentors who are with you seeing children in the office and from meetings, curbside conversations/consultations, and from the literature. The adage that allergic children get sick easier, more frequently, and have more severe illnesses has been out there for many years. There are a number of theories for this contention. Children with allergy tend to remedy their itchy nose with internal manipulation, otherwise known as nose-picking. The finger serves as the vector for direct inoculation of viral particles onto the respiratory tract. Also, a number of years ago a publication reported that allergic noses actually had more receptors for the cold virus than non-allergic noses.

The May issue of the  Journal of Allergy, Asthma, and Immunology (Volume 125 No 5.) has an article by Jaime Olenec, ‘Weekly monitoring of children with asthma for infections and illness during common cold seasons’ concluded that atopic (showing IgE antibodies) children with asthma do have more frequent and more severe asthma exacerbations due to the common cold. The bottom line for me is the impact that the specialty of allergy and the determination of sensitization to allergens can make on children with asthma. The study did not address allergen control measure effects on frequency/severity of asthma symptoms.

My review of the study-

The group who did this is excellent and has a long established research track record and publication record regarding the role of viruses and allergy in pediatric asthma.

The journal in which this was published is peer-reviewed and a top-notch allergy journal. Also of note is that the manuscript was submitted in September, 2010 and was accepted for publication four months later.

The support for the work was from the National Institutes of Health.

The purpose of the study was to look at the impact of viral infections and allergic sensitization on the loss of asthma control during the peak ‘cold’ season.

The study involved 58 children between the ages of 6-8 years who were known to have asthma. These children were followed for three years. Skin testing and specific IgE testing was performed on all. Nasal samples were collected and analyzed for human rhinovirus infection. Diary cards were kept for symptoms. Cold and asthma symptom scores were collected along with peak flow value recordings and notations of the frequency albuterol (rescue inhaler) usage.

There were 42 children who had at least one season of complete data. The average age was 6.5 years and there were 30 boys and 12 girls. In this group 50% had one or more positive skin prick test for an allergen. Of note is that 69% had one or more positive blood tests for an allergen. Additional baseline information included; daily asthma controller medications used by 88%, and oral corticosteroids were used by 57% in the past year. Fifty five percent of the mothers and 40% of the fathers had allergy.

The number of viral illnesses per season was higher in the allergen sensitized group; 47% more virus-associated illness per season. During documented viral infections (viral cultures were frequently performed), the non-atopic children commonly reported no or mild cold symptoms. In the sensitized (atopic) children symptoms tended to be more moderate or severe. Also, almost half of the viral infections in the sensitized children caused moderate or severe asthma symptoms.

The author’s conclusions were that respiratory tract illnesses (asthma symptoms) due to viruses were more severe and were more frequent in children who are atopic.

These were children with asthma who had a positive allergy test. The terms sensitized and atopy were used to describe the group. Asthma frequency and asthma severity was increased in those who have made at least one IgE antibody to something.

This was a small study which was done in only one site. Larger studies in a variety of populations need to be done to confirm these observations.

This work re-affirms my practice of being aggressive with my allergic asthmatic children when the first signs of a cold occur. I advocate stepping-up the treatment program and continuing it for up to 14 days. One of the charts shows that the average duration of cold symptoms was 8.1 +/- 5.6 days and the average duration of asthma symptoms was 7.2 +/- 7.8 days in those who had a documented rhinovirus infection. For me this fits nicely with what I advise- on the average cold symptoms may begin the day prior to asthma symptoms and at the extremes of the range, asthma symptoms may last 14 days in some children.

FEL

A message was forwarded to me about a news broadcast from Chicago that highlighted a tool that can be used to help with asthma diagnosis and management. The FDA has recently approved this according to the message. This tool is the measurement of exhaled nitric oxide (eNO). In allergic asthma  airway inflammation involves numerous inflammatory cells especially eosinophils. These inflammatory cells have a marker for their involvement and activation called nitric oxide. We are able to measure this by-product of airway inflammation in the breath. I also received another link on this measure of airway inflammation. In this second newsbroadcast Dr. Wolfe, an allergist, does a nice job in explaining this test, this measure, and allergic asthma.

This is not a new procedure. At Riley Hospital our group has been using this measurement in the care of children with asthma. It is nice to see that the concept of eNO is catching on and its value is appreciated.

I feel that a measure of eNO offers a significant amount of information regarding the role of allergy and the level of control patients with asthma have. I use eNO measures frequently in my Allergy/Asthma practice.

FEL