Why Asthma Matters: Preventable Deaths of Young Children, Minorities and Others

Why Asthma Matters: Preventable Deaths of Young Children, Minorities and Others
By Pamela Appea
Published Online for Why Asthma Matters-A Global Perspective

A Denver area mother recently filed a lawsuit alleging that a Medicaid “glitch” prevented her from getting appropriate medications for her asthmatic 9-year-old son in 2009. Zumante Lucero died of a fatal asthma attack only a few days after their unsuccessful visit to the local pharmacy.

In March 2010, a Texan high-school student named Austin Smith, 15, couldn’t breathe at school baseball practice. His face turned purple, then he collapsed a short while later. Austin was pronounced dead at the local emergency room. The cause? Asthma.

Also in 2010, a year ago this month, many New Yorkers are familiar with the case of the mother who in a rush to get to the hospital drove the wrong way down a street on her way to a Brooklyn hospital, allegedly hitting a parked car. In the backseat was her 11-year-old daughter Briana Ojeda who was in the midst of a serious asthma attack. A NYPD police officer stopped the family car but somehow failed to call for emergency ambulance care. The mother states the officer didn't want to help and didn't know CPR. A short while later, Brianna was pronounced dead at the hospital. Regardless of what happened or not, asthma killed Briana. (CPR probably would have had no to minimal impact on an individual in the throes of a major asthma attack or episode.)
 
As a mother of a five-year-old asthmatic boy, stories like those detailed above are truly appalling, but not entirely uncommon. Unfortunately preventable asthma deaths happen all the time. In fact, in the United States well over 4,000 people die of asthma on an annual basis. As a point of comparison, nearly 3,000 lives were lost on September 1th—. If you compare these deaths with asthma fatalities, not only are 4,000 people dying—1,000 more than 9-11—every year, but the numbers of asthma fatalities are increasing.

There is no little to no outrage or even knowledge about these asthma deaths. Worse yet, particularly when it comes to low-income or minority individuals, some mudslingers (online and otherwise) automatically point the finger at the asthmatics or the parents themselves for being responsible for the asthma death. Incredibly these hateful individuals harp on issues relating to the asthmatic's health insurance or lack thereof, income, socio-economic background, the number of children the parents have, their immigrant status or a variety of other non-issues. The bottom line is that asthma impacts everyone—no one is immune to developing asthma or being impacted by asthma.

According to the American Academy of Allergy, Asthma and Immunology, 34 million American individuals have had asthma at some point in their lifetime, while 23 million have asthma today. Statistics from a Center for Disease Control (CDC) study find that asthma lands as many as 500,000 Americans in the hospital every year. And some 300 million people have asthma worldwide, with over 250,000 individuals dying of asthma every year, according to the American Academy of Allergy, Asthma and Immunology.

And while asthma is a chronic disease, there is no reason why anyone with asthma should be dying. Further, minorities, children and many others are not getting the treatment they need even though they have significantly higher prevalence rates, as much as 20% or more higher.

Due to recent research led by a team of University of Chicago and other EVE national research consortium scientists and researchers, we also now have scientific confirmation that there is a strong genetic-ethnic component to asthma. This may partially explain why some individuals of African descent may have such a high prevalence of the chronic condition.

Yet, still despite all of this knowledge, patients like Zumante Lucero are not getting the medical care and the medications they need when they need them. For example, some insurance companies require patients to get in-person approval from their pediatrician or primary care physician before they can see a specialist like a pulmonologist who treats asthma. Worse yet, sometimes the wait for specialist care can be weeks or months. Medicaid and other patients may find they have more hoops to jump through just to get lifesaving medications.

In certain cases, some asthmatics may feel fine even without medications. Then weeks or months later they suddenly experience a severe asthmatic episode. It seems many people from parents to teachers to coaches to the individuals themselves are taken unaware by the serious asthmatic episode. That's simply how asthma is sometimes: one minute you're seem fine and the next minute, you can't breathe.

Every asthma patient, even those with mild or occasional asthma, should specifically speak to their employers, schools, afterschool and recreational programs, places of worship and neighbors about what to do in the event of an asthma emergency, giving them a copy of their individualized asthma action plan.

And too often people hesitate to call 911—when no medication or nebulizer is available or when the asthma medication is available but doesn't alleviate the asthma symptoms. Clearly, the most sensible thing to do is to seek immediate medical care. Disturbingly I've encountered too many people who seem to think they should wait until an asthmatic is unconscious, not breathing or has turned blue or gray to dial 911. That's way past the point when it may be too late.

Over the past 20 years, physicians, researchers and others have a better understanding of asthma and what is needed to treat it. In asthma parlance, asthmatics typically require “maintenance” and “rescue” medications. One or more medications is typically prescribed to be taken once or twice a day to maintain an asthmatic's lungs from developing problems. Rescue medications to exactly what the name implies and assist asthmatics who may have been exposed to a trigger and/or started having difficulty breathing. Unfortunately, too many low-income and minority asthmatics rely on rescue medications along or rescue medications without spacers (a device that helps ensure the young children properly inhale their medications) and worse yet stop taking their medications because they cannot afford the cost.

Asthma is an expensive disease to treat or manage. Medications for one are insanely expensive. One rescue pump alone could be as high as $150. And a person with moderate asthma with no insurance might easily incur expenses anywhere from $3,000 to $4,000 a year and up for asthma medications alone. If one counts medical health visits, specialist visits and emergency room care and hospitalizations, naturally the figure rises to double-digits.

Additionally asthma significantly impacts the entire family on multiple levels. If a child is sick, there is lost productivity since parents miss work to take care of their children. Then in turn, the child or children miss school. Some individuals with poorly managed asthma may visit the emergency room to get appropriate care because they are unable to set up a timely appointment with a specialist and/or don't have insurance These and other instances add up to hundreds of millions of dollars in emergency room care, medical costs, lost salaries and jobs and more.
 
Yes, the United States hopefully has nationalized health care mandates covering all asthmatic kids in the years to come, but the reality is, uninsured and under insured kids are still going to feel the sting of today’s scarlet letter, “the pre-existing condition” routinely dealing with bureaucratic “glitches”, problems and complications. Asthmatic kids couldn’t and shouldn’t have to wait for treatment or have to play cat and mouse games with insurance companies when it comes to treatment and comprehensive insurance policies and higher premiums.
 
Asthma must be taken seriously. I speak from experience: my 48-year-old mother died of an asthma attack in March 1990. She was a teacher who had adult-onset asthma in the last few years of her life. She died in the winter late at night and she had instructed me not to call the ambulance due to the cost since a family friend was going to drive us to the hospital instead. She didn't make it. As I said, I take asthma very seriously and you should too.

Now that my son has asthma, that thankfully is well-controlled due to the excellent medical care he receives, I still find particularly in the winter months that I must monitor him constantly. It seems from time to time, I encounter individuals, including health professionals, who seem to think I am 'overreacting' when I bring up my son's asthma symptoms and what I believe is best for him and his asthma care. Not only is this frustrating, but it is not acceptable.
 
 Let’s all start the dialogue of what to do, how to act, not react, before we have another Briana, Austin or Zumante in our emergency rooms, homes, classrooms or athletic fields, struggling to breathe and losing the battle.
 
 
 
 

University of Chicago genetics team identifies Asthma Susceptibility Gene PYH1N1 Unique to African Americans, Afro-Caribbeans....

University of Chicago genetics team identifies Asthma Susceptibility Gene PYH1N1 Unique to African Americans, Afro-Caribbeans; Two Other ‘Asthma’ Genes CRCT1 and GSDMB Impact European-Americans, African Americans and Latinos

As researchers and others in the scientific and medical community have long suspected, asthma is caused in part by genetic factors, explaining asthma’s high prevalence in minority communities.

A team of geneticists identified an asthma susceptibility gene called PYH1N1 that occurs only in individuals of African descent. The study, published in the July 31, 2011 online issue of Nature Genetics, was led by Dr. Carole Ober, co-chair of the EVE Consortium, and who is Blum-Riese Professor of human genetics and obstetrics/gynecology at the University of Chicago. Dr. Dan Nicolae, associate professor of medicine, statistics, and human genetics at University of Chicago was also a senior author of the study along with other team scientists and researchers.

PYHIN1 "may be the first asthma susceptibility gene identified that is specific to populations of African descent," Ober, Nicolae and other researchers wrote in the Nature Genetics article.

Using data assembled from nine previous genome-wide association studies, collectively known as the EVE Consortium, researchers analyzed a total of more than 2 million single nucleotide polymorphisms (SNPs) in 3,246 asthma patients, 3,385 non-asthmatic controls, 1,702 patient-parent groupings, 355 family-based cases, and 468 family-based controls.

The study found that this gene is not a rare variant, anywhere from 26% to 29% of individuals of African descent carry at least one copy, the researchers wrote.
The populations in these groups mentioned above were broadly categorized as African-American and Afro-Caribbean individuals, Latin Americans and European Americans.
Two other genes that increased the risk of asthma in Whites, Latinos and African-Americans and was also identified. These two genes are known as CRCT1 and GSDMB.

Naturally, there are numerous reasons why an individual may develop asthma and simply because an individual (of any ethnic background) does not have this gene does not automatically protect them from ever developing asthma.
The researchers noted while the associations found in this research are key they do not necessarily imply causality. In other words asthma’s genetic component is only partially a factor and/or potentially influenced by other genes, environmental factors, susceptibility factors and perhaps other reasons as well.
Having any of these ‘asthma’ genes does not necessarily mean a 100% guarantee of asthma in one’s lifetime, but makes it much more likely. Additional questions could include why do some individuals develop asthma as children, while others as adults? Why do asthma symptoms seemingly recede in some children as they grow? Is there a genetic factor in this process or is it a environmental and/or a benefit of older and stronger lungs and general constitutions?
While the study did not explicitly cover this topic since such widespread mass market asthma genetics tests in doctor’s offices may not be common for years, perhaps even decades, I was wondering when and if individuals might be able to take a test and know if they have this PYH1N1 gene. Will they be able to give you a useful approximation if you will develop asthma? Would such a test or genetic screening really benefit us? And thinking even further down the line about pre-natal genetic testing: imagine the scenario, of a doctor telling a mother-to-be, Congratulations, your baby is doing well, but may be at a higher risk of developing asthma since we have identified the PYH1N1 gene.

Torgerson D, et al "Meta-analysis of genome-wide association studies of asthma in ethnically diverse North American populations" Nature Genetics 2011; DOI: 10.1038/ng.888.

Anxiety, stress and depression during a woman's pregnancy may lead to a higher risk of asthma for her child

According to the July 2011 issue of American College of Allergy, Asthma and Immunology (ACAAI), anxiety, stress and depression during a woman’s pregnancy may lead to a higher risk of asthma for a woman’s child. The population study at Columbia Center for Children’s Environmental Health focused exclusively on inner city African-American and Latino mothers before, during pregnancy and after birth.

So while this study may simply confirm what we already know, it is frustrating we still don’t know what to do next. In other words if there is a higher likelihood from a genetic standpoint that minority women and/or their children may develop asthma; a higher likelihood that due to their socio-economic status, minority background and/or single mother status their children will develop asthma, it’s clear there isn’t going to be any easy fix for this issue. Additionally, due to socio-economic constraints many women in these populations are less likely to be able to pursue a comprehensive avenue of care for themselves and their children, so that complicates the issue even more.

While most know already that minority populations have higher incidence rates of asthma, including low-income, inner city minority individuals, it is still not clear exactly how medical health professionals can work with pregnant women to prevent these higher rates of pediatric asthma since this research seems to suggest the future child’s asthma might be pre-determined during a woman’s pregnancy, “during the prenatal period.”

Other research about why people develop asthma seems to indicate it is a combination between environment, lifestyle choices and genetics. This research may suggest the pregnancy environment may play a larger role in pediatric asthma than we previously thought. While the study doesn’t specify this, it is likely the majority of these women were not smokers or living with smokers, but it does not explicitly say this so its important not to assume.

Similar studies have already found a correlation that stress factors during pregnancy aren’t good for any woman regardless of income level, marital status, or cultural or ethnic background, but it seems that this study just shows medical health professionals have their work cut out for them in the years and decades going forward.

The study goes on to note:

“The symptoms of pediatric asthma can range from a nagging cough that lingers for days or weeks to sudden and scary breathing emergencies,” said Dr. Rachel Miller, MD, study senior author and allergist.

The study points out that common asthma symptoms include:

• Coughing, especially at night
• Wheezing or whistling sound, especially when breathing out
• Trouble breathing or fast breathing that causes the skin around the ribs or neck to pull in tightly
• Frequent colds that settle in the chest
If your child’s symptoms keep coming back, it might be asthma. If you think your child may have asthma, see an allergist. To learn more about asthma and allergies, and find an allergist near you visit www.AllergyAndAsthmaRelief.org

My Two Cents on the new Family Smoking and Tobacco Control Act

As required by the new Family Smoking and Tobacco Control Act in the United States, the Food Drug and administration has enacted a new rule that requires graphic health warnings. The warnings combine graphic images with bolded comments like "Cigarettes Cause Cancer" to speak directly to the harmful effects of tobacco products.

It’s about time. Now I’m just wondering what other countries across the world will start to follow suit and in what order. Unfortunately many so-called “third world countries” in Africa, Asia and elsewhere may not follow suit for years, perhaps decades.

It also would be wonderful if more asthmatics and those with respiratory ailments, and caretakers of asthmatics and those with respiratory ailments would make the obvious connection between smoking, that hacking cough and their continued asthma, COPD, lung cancer and other respiratory health problems. Exposure to cigarette smoke (first hand or second hand) does not make for healthy lungs or a healthy lifestyle!

African-American children in the United States were four times more likely than white children to be hospitalized for a severe asthma attack

According to a June 30th news release, the Agency for Healthcare Research and Quality finds that African-American children in the United States were four times more likely than white children to be hospitalized for a severe asthma attack
in 2007.

I apologize for sounding so grumpy (writing this early in the morning) but why when is it 2011 are we still looking at 2007 numbers in a 2010 report as breaking news? We know this already and have for decades. Now let’s move to the next, obvious step, how to prevent this disparity and improve the lives of all families that must deal with asthma, including minority families.

Naturally, this information is important but I just don’t understand why there is such a lag in reporting, compiling and analyzing health information.
It’s clear there are health disparities in other countries although haven’t seen any recent academic research to compare it to this study. Will do some electronic digging.

According to the 2007 statistics, “…For every 100,000 children age 2 to 17 hospitalized for asthma attacks ….384 were black, 94 were white, and 135 were Hispanic.” One interesting fact was that Asian and Pacific Islander children were the least likely to need inpatient hospital care for asthma
I’d be interested to know how many are first generation, second-generation immigrants.

Other data from the research and hospital admittance rates found:

• Children from poor families were more than twice as likely as those from high-income families to be admitted, (231 versus 102)

• Boys had about 50 percent more hospitalizations than girls, (181 versus 119).

• Children ages 2 to 4 were over 6 times more likely than children ages 15-17 to be hospitalized, (310 versus 50).

• Children in the Northeast were more likely to be hospitalized than those in the West, (196 versus 102).

For more information:
This AHRQ News and Numbers is based on information in the 2010 National Healthcare Disparities Report, which examines the disparities in Americans' access to and quality of health care, with breakdowns by race, ethnicity, income, and education.

Suspect Herbal Treatment Touted for South Indian Asthma Sufferers

The Associated Press recently covered one of those odd news stories (June 8, 2011)that just makes absolutely no sense. Apparently thousands of asthma sufferers in Southern India who are seeking relief from severe asthma symptoms flock to Hyderabad to receive ‘treatment’ from the Goud family who claim their secret herbal formula originates from a Hindu saint from over 100 years ago.

Once the patient swallows the live fish, sardines, reports say, patients are instructed to begin a strict 45-day diet of 25 different foods, including lamb, rice, white sugar, dried mango and spinach.

The Associated Press states they must abstain from deep-fried food and repeat the treatment within two years.

Naturally, improving one’s diet and eating a balanced diet can help one’s overall health. But in creating a buzz for a raw fish ‘treatment’ is will most likely not have any effect on asthma sufferers’ relief.

So why do thousands of Indians who have asthma flock to this family’s home?

Probably because they’re have limited means and resources and doctors who know their patients can’t afford or have access to the pricy medications, may simply throw up their hands and advise asthma sufferers to think of asthma with a mind over matter philosophy.

According to a World Health Organization India report in 2004, some 57,000 deaths were attributed to asthma and other pulmonary complaints. Another study says average prevalence varies from state to state, with anywhere from 3.5% prevalence rates per 1,000 all the way up to over 15% per 1,000 depending on how broadly asthma is defined (to include allergies and other pulmonary complaints.)

Canadian Asthma Pioneer Dies

Dr. Frederick Hargreave was an internationally renowned respirologist who changed the way asthma is diagnosed. He died suddenly of a heart attack.

Here is his biography and research information from McMaster's University (located in Hamilton, Ontario) where he was a Professor Emeritus, Division of Respirology, Department of Medicine

Education and Professional Standing
Dr. F. E. Hargreave, in his training as clinical researcher with Jack Pepys and his subsequent collaboration with Jerry Dolovich, has been a pioneer in the improved understanding and treatment of asthma and its association with chronic cough and COPD. This has been achieved by the use of objective measurements of airway inflammation, airway responsiveness and airflow limitation.

Research Interests
With allergen inhalation tests, Dr. Hargreave validated the occurrence of late asthmatic responses, showed that they were common, that they could result from the combination of allergen with IgE antibodies, that they were associated with allergen-induced increases in airway responsiveness to non-allergic stimuli and with airway inflammation and that they could be (and were subsequently) used to study the anti-inflammatory effect of new drugs. He also standardized and evaluated measurements of non-allergic airway responsiveness to histamine and methacholine. He showed that these are the most sensitive measurements to identify the presence of current asthma when symptoms are present but spirometry is normal and that they are important determinants of the degree of variable airflow limitation. They are now widely used in research and clinical practice.

Dr. Hargreave also introduced sputum induction and refined the processing of sputum, to measure airway inflammation relatively non-invasively. He evaluated the measurements and applied them to study the pathogenesis, pathophysiology and treatment of asthma, chronic cough and COPD. The observations emphasize the occurrence of different types of airway inflammation, their different causes and different response to treatment.

Sputum inflammatory markers are now being increasingly used in research and in practice.