Asthma-related Health Outcomes Research Articles

The ATLAS ASMA Study: Assessing the Impact of Asthma on Patients' Life - The Spanish Patients' Perspective.

ATLAS ASMA described the psychosocial impact of asthma on patients' daily life from patients' perspectives (in terms of impaired personal and intimate relationships, sleep quality, leisure time, daily activities, and others) in Spain. Secondary objective includes description of time since diagnosis, expectations, and satisfaction of patients about disease, treatment and medical assistance received, adherence to treatment, perceived control of asthma, and health-related quality of life. This was a cross-sectional, observational study, based on a self-administered online survey for adult patients (≥18 years) with asthma. Patients with asthma diagnosis of any type and severity who voluntarily participated in the survey through a web link were included consecutively. In the present manuscript, only adult patients' data are included. A total of 132 adults with asthma were included. Moderate/severe asthma constituted 59.1% of the patients (females 71.2%). Overall, most relevant areas affected due to asthma were leisure activities (67.0%) and the quality/quantity of sleep (52.3%). Moderate/severe patients perceived some degree of impairment in work, school, or at home due asthma more frequently vs mild patients (55.2% vs 10.9%). Poorly controlled asthma (ACT≤19) was reported in 41 (70.7%) and 10 (21.7%) moderate/severe and mild patients (p<0.000), respectively. Mild patients obtained higher mean (SD) Mini-AQLQ score than moderate/severe asthma patients (5.6 [1.0] vs 4.3 [1.1], p<0.000), likewise higher significant results for every individual dimension. Most patients cited little limitation to intense efforts (20.5%). Half of the patients mentioned needing more information about asthma. Topics those patients like to have more information were difficulties that may can have and legal topics (78.6%), asthma evolution (78.6%), secondary effects or issues related to the treatment (61.9%) and legal topics (61.9%). The study reported important insights on psychosocial impact of asthma on patients' daily life from patients' perspectives along with health determinants in asthma-related health outcomes, sociodemographic and psychosocial factors.

Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma: A Randomized Clinical Study

To determine if environmental control measures (1) school-wide integrated pest management (IPM) program and/or (2) use of high-efficiency particulate air (HEPA) filter purifiers in inner city elementary school classrooms would reduce asthma morbidity in students with active asthma.Forty-one inner city elementary schools in the Northeastern United States were recruited for this study. There were 236 students with active, physician-diagnosed asthma randomized to IPM (by school) and/or HEPA filter purifiers (by classroom). Physician-diagnosed asthma was defined as the child having had unscheduled doctor visits, hospitalization, corticosteroid bursts, symptoms, or controller medication use in the past year. Fifty seven percent of the children were Hispanic and 24% were Black. Mean age was 8.1 years, 48% female, mean FEV1 97% to 99.7% predicted at randomization. Forty-fifty percent of the children were using short acting β agonists alone and the rest were on inhaled corticosteroids and/or leukotriene modifiers. The study was conducted during the school years 2015 to 2020.All students with active physician-diagnosed asthma had a screening visit with questionnaires, skin testing, and spirometry as well as 2 follow-up visits with the same assessments during the year. Baseline environmental assessment for a panel of allergens (mouse, rat, dust mite, cockroach, cat, dog, Alternaria alternate, and Aspergillus fumigatus) were conducted at the schools by collecting a 1-week air sample, immediately followed by vacuum–settled dust samples from each students’ primary classroom and in the participants homes. The allergens were analyzed using a multiplex assay (MARIA, Indoor Biotechnologies). Follow-up environmental assessment after randomization took place once each winter and spring during the school year.The allocation to free standing classroom HEPA filter purifiers, active or sham, was blinded to the participants and those assessing the outcomes. The IPM program consisted of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for the school staff. Infestation was assessed every 3 months and IPM reapplied as needed. Trained pest management specialists providing the school-wide IPM program were unblinded, but the student participants and trial investigators remained blinded throughout the trial.Four groups of 59 students each were randomized using a factorial design to either intervention alone, both interventions together, or neither for the entire school year. Classroom and home allergen and particle levels at randomization were balanced between the 4 groups.The asthma-related health outcomes of the students were assessed by parent survey at baseline and every 2 months until the end of the school year. The primary outcome was the number of symptom-days with asthma during a 2-week period assessed over the 10 months of randomization. Prespecified secondary outcomes were school absences, Composite Asthma Severity Index score, healthcare utilization, and spirometry measurements.Ninety eight percent of the classrooms had detectable levels of mouse allergen and 26% of the participants were sensitized to mouse allergen. More than 90% of baseline classroom allergen levels for cockroach, rat, Alternaria, Aspergillus and dust mite were undetectable.Use of the school-wide IPM program resulted in a mean of 1.5 symptom-days with asthma during a 2-week period versus 1.9 symptom-days for no IPM; use of HEPA filter purifiers resulted in a mean of 1.6 symptom-days with asthma versus 1.8 symptom-days for sham HEPA filter purifiers; neither comparison was statistically significant. Other prespecified secondary outcomes, including healthcare utilization or missed school days because of asthma also did not differ significantly between the intervention groups. The HEPA filter purifiers significantly reduced mouse and dog allergens in the classrooms. The IPM program did not significantly reduce concentrations of any of the allergens or particles measured. A post hoc exploratory analysis found a statistically significant association of reduction in asthma symptoms with the school wide IPM program but only for a limited time (mid-November to February).In an inner-city population of elementary school students with active asthma, use of a school-wide IPM program or HEPA filter purifiers in the classrooms did not significantly reduce symptom-days with asthma.It is possible that these children had asthma that was too mild to see a significant difference in these environmental interventions. Also unclear is whether resources to perform environmental control measures are best used at the school level or at home. As an accompanying editorial notes, “as allergen sensitization is related to the pathogenesis and pathophysiology of childhood asthma,” allergen avoidance should still be a basic tenet of treatment and worth continued investigation.URL: www.pediatrics.org/cgi/doi/10.1542/peds.10.1001/jama.2021.11559

Impacts of residential indoor air quality and environmental risk factors on adult asthma-related health outcomes in Chicago, IL.

Residential environments are known to contribute to asthma. To examine the joint impacts of exposures to residential indoor and outdoor air pollutants and housing risk factors on adult asthma-related health outcomes. We analyzed >1-year of data from 53 participants from 41 homes in the pre-intervention period of the Breathe Easy Project prior to ventilation and filtration retrofits. Health outcomes included surveys of asthma control, health-related quality of life, stress, and healthcare utilizations. Environmental assessments included quarterly measurements of indoor and outdoor pollutants (e.g., HCHO, CO, CO2, NO2, O3, and PM), home walk-throughs, and surveys of environmental risk factors. Indoor pollutant concentrations were also matched with surveys of time spent at home to estimate indoor pollutant exposures. Cross-sectional analyses using mixed-effects models indicated that lower annual average asthma control test (ACT) scores were associated (p < 0.05) with higher indoor NO2 (concentration/exposure: β = -2.42/-1.57), indoor temperature (β = -1.03 to -0.94), and mold/dampness (β = -3.09 to -2.41). In longitudinal analysis, lower ACT scores were also associated (p < 0.05) with higher indoor NO2 concentrations (β = -0.29), PM1 (concentration/exposure: β = -0.12/-0.24), PM2.5 (concentration/exposure: β = -0.12/-0.26), and PM10 (concentration/exposure: β = 10.14/-0.28). Emergency department visits were associated with poorer asthma control [incidence rate ratio (IRR) = 0.84; p < 0.001], physical health (IRR = 0.95; p < 0.05), mental health (IRR = 0.95; p < 0.05), higher I/O NO2 ratios (IRR = 1.30; p < 0.05), and higher indoor temperatures (IRR = 1.41; p < 0.05). Findings suggest that residential risk factors, including indoor air pollution (especially NO2 and particulate matter), higher indoor temperature, and mold/dampness, may contribute to poorer asthma control. This study highlights the importance of residential indoor air quality and environmental risk factors for asthma control, health-related quality of life, and emergency department visits for asthma. Two timescales of mixed models suggest that exposure to indoor NO2 and particulate matter, higher indoor temperature, and mold/dampness was associated with poorer asthma control. Additionally, emergency department visits were associated with poorer asthma control and health-related quality of life, as well as higher I/O NO2 ratios and indoor temperatures. These findings deepen our understanding of the interrelationships between housing, air quality, and health, and have important implications for programs and policy.

Parent-child conflict and physical health trajectories among youth with asthma

ObjectiveTo investigate the role of caregiver- and youth-reports of parent-child conflict on trajectories of asthma-related health outcomes over 2 years. MethodsIn a sample of 193 youth with asthma (42.7% female; M age = 12.78) and their primary caregivers, we used a multi-method and multi-informant approach to assess self-reported parent-child conflict from youth and caregivers at both the daily and global levels at baseline. Next, we annually assessed subjective (i.e., youth self-reported asthma symptoms) and clinical (i.e., peak flow) asthma health outcomes for 2 years. ResultsLatent growth curve models revealed an effect of baseline youth-reported global family conflict on peak flow trajectories such that youth who reported greater parent-child conflict at baseline experienced less of an increase in peak flow over time than youth who reported less parent-child conflict at baseline (standardized β = −0.27, p = .003). ConclusionsYouth with asthma who perceive greater overall conflict with their caregivers experience less improvement in peak flow as they age. The research and clinical implications of these findings are discussed.

Impact of COVID-19 on Pediatric Asthma-related Healthcare Utilization in New York City: A Community-Based Study

BACKGROUND AND AIM: Emerging data suggests that during the Coronavirus Disease-19 (COVID-19) pandemic care for chronic health conditions, such as asthma, decreased. Nationally, children were 84% less likely to seek care for asthma in emergency departments during the initial stages of the pandemic compared to the same period in 2019; little is known about the various barriers to asthma-related care for children during this time. Here, we aim to understand the impact of COVID-19 on two adjacent neighborhoods with historic differences in social determinants of health by evaluating their access and need for acute and chronic healthcare in New York City (NYC) during the pandemic. METHODS: We will conduct a community-based participatory survey of families in each neighborhood: 25 families from East Harlem (EH) and 25 families from the Upper East Side (UES). There are documented disparities in asthma-related health outcomes between these neighborhoods, where the prevalence of asthma is 3.5 times greater in school-aged children in EH compared to the UES. We will include families with children who have active asthma between 5 and 17 years of age. This survey will evaluate differences in environmental conditions, including the built environment, social determinants of health and health care utilization during the first 6 months of the pandemic (March 1st through August 31st 2020). RESULTS:We will present survey responses and analyze the differences in environmental exposures, social determinants of health and healthcare utilization during the pandemic in each respective neighborhood. CONCLUSIONS:Our community-based survey results will identify differences regarding environmental exposures as well as barriers and facilitators to healthcare during the initial stages of the COVID-19 pandemic in two distinct neighborhoods in NYC. These data provide an initial step in identifying potential areas of concern to inform future public health interventions and clinical responses to optimize care in vulnerable communities. KEYWORDS: Asthma, Respiratory outcomes, Children's environmental health, Environmental disparities, Socio-economic factors (non-chemical stressors),COVID-19

The Breathe Easy Study: Impacts of Ventilation Improvements on IAQ and Adult Asthma in 40 Existing Homes in Chicago, IL

BACKGROUND AND AIM: This paper presents preliminary results of the Breathe Easy Project, which as designed to improve indoor air quality (IAQ) and asthma-related health outcomes by installing residential mechanical ventilation systems in forty existing homes in Chicago, IL. Each home had at least one self-reported adult resident with asthma and received one of three types of ventilation systems half-way through the study: exhaust-only system, central-fan-integrated-supply (CFIS) system, or balanced system with an energy recovery ventilator (ERV). METHODS: We conducted quarterly field measurements to monitor indoor and outdoor pollutants, including size-resolved particles (0.3-10 µm), ozone (O3), nitrogen dioxide (NO2), carbon dioxide (CO2), carbon monoxide (CO), and formaldehyde (HCHO). Monthly asthma control test (ACT) surveys were administered for each participant throughout the study. Wilcoxon signed-rank tests were used to evaluate the impacts of ventilation system retrofits on IAQ, indoor/outdoor (I/O) ratio, and ACT score. Chi-square tests for independence and multiple logistic regression were used to analyze associations between IAQ, asthma severity, and baseline characteristics of participants and homes. RESULTS:Indoor pollutant concentrations and I/O ratios were significantly lower after ventilation system retrofits for indoor concentrations of HCHO, CO2, PM1.0, PM2.5, and PM10, and I/O ratios of CO2, NO2, PM1.0, and PM2.5 (P 0.05). There was a small but significant increase in average ACT score of 1.04 across the entire study population after the ventilation system retrofits (P 0.001). Based on association analysis of the pre-intervention period, higher NO2 concentrations were associated with increased odds of poorly controlled asthma, with crude odds ratios (OR) (95% CI) of 2.8 (1.2−6.4). Also, Black participants showed OR (95% CI) of 5.7 (1.3−25.9) for poorly controlled asthma compared to White participants. CONCLUSIONS:The results can potentially provide information on the influence of exposure for many air toxics and will furnish an opportunity to evaluate exposure models for these compounds. KEYWORDS: Air pollution, asthma, exposures, occupational epidemiology

Evaluating an Air Quality Health Index (AQHI) amendment for communities impacted by residential woodsmoke in British Columbia, Canada

ABSTRACT Smoke from burning biomass is an important source of fine particulate matter (PM2.5), but the health risks may not be fully captured by the Canadian Air Quality Health Index (AQHI). In May 2018, the province of British Columbia launched an evidence-based amendment (AQHI-Plus) to improve AQHI performance for wildfire smoke, but the AQHI-Plus was not developed or tested on data from the residential woodsmoke season. This study assesses how the AQHI and AQHI-Plus are associated with acute health outcomes during the cooler seasons of 2010–2017 in British Columbia, Canada. Monthly and daily patterns of temperature and PM2.5 concentrations were used to identify Local Health Areas (LHAs) that were impacted by residential woodsmoke. The effects of the AQHI and AQHI-Plus on five acute health outcomes (including non-accidental mortality, outpatient physician visits, and medical dispensations for cardiopulmonary conditions) were estimated using generalized linear mixed effect models with Poisson distributions adjusted for long- and short-term temperature trends. Values of the Akaike information criterion (AIC) were compared to evaluate whether the AQHI or AQHI-Plus was better fitted to each health outcome. Eleven LHAs were categorized as woodsmoke-impacted. In these LHAs, the AQHI and AQHI-Plus associations with acute health outcomes were sensitive to temperature adjustments. After temperature adjustments, the most consistent associations were observed for the two asthma-specific outcomes where the AQHI-Plus was better fitted than the AQHI. The improved performance of the AQHI-Plus for susceptible populations with asthma is consistent between communities impacted by residential woodsmoke and wildfire smoke. Implications: Canada’s Air Quality Health Index (AQHI) is a three pollutant index used to communicate the short term health impact of degraded air quality. As fine particulate matter (PM2.5) is the lowest weighted pollutant in the AQHI, the index is poorly reflective of woodsmoke impacts. The present analysis found that an AQHI amendment developed for improved sensitivity to PM2.5 during wildfire seasons (AQHI-Plus) is also more predictive of acute asthma-related health outcomes in communities impacted by residential woodsmoke. The BC Ministry of Environment and Climate Change Strategy has piloted the AQHI-Plus year-round. Other jurisdictions should consider whether their air quality indices are reflective of the risks posed by woodsmoke.

Asthma-Related Health Outcomes Associated with Short-Acting β2-Agonist Inhaler Use: An Observational UK Study as Part of the SABINA Global Program.

Patients with asthma typically increase short-acting β2-agonists (SABA) use with worsening symptoms. Excessive SABA use may lead to a higher risk of adverse outcomes. We evaluated, in a large population cohort, an association between SABA inhaler use and asthma exacerbations and healthcare utilization. As part of the SABINA (SABA use IN Asthma) global program, we conducted a retrospective longitudinal observational study (SABINA I) using UK primary care electronic healthcare records (Clinical Practice Research Datalink; 2007-2017) from asthma patients aged ≥ 12years. SABA inhaler use was classified as 'high use', ≥ 3 canisters/year versus 'low use', 0-2canisters/year. Taking into consideration all their asthma prescriptions, patients were categorized into a treatment step according to 2016 British Thoracic Society (BTS) asthma management guidelines. Multivariable regression assessed the association of SABA inhaler use by BTS treatment steps (grouped as BTS steps 1/2 and 3-5), separately, and with outcomes of exacerbations or asthma-related healthcare utilization (primary care and hospital outpatient consultations); only patients with linked hospital data were included in this analysis. Of the 574,913 patients included, 218,365 (38%) had high SABA inhaler use. Overall, 336,412 patients had linked hospital data. High SABA inhaler use was significantly associated with an increased risk of exacerbations [adjusted hazard ratio, 95% confidence interval (CI): BTS steps 1/2 = 1.20, 1.16-1.24; BTS steps 3-5 = 1.24, 1.20-1.28], asthma-related primary care consultations [adjusted incidence rate ratio (IRR), 95% CI: BTS steps 1/2 = 1.24, 1.23-1.26; BTS steps 3-5 = 1.13, 1.11-1.15], and asthma-related hospital outpatient consultations (adjusted IRR, 95% CI: BTS steps 1/2 = 1.19, 1.12-1.27; BTS steps 3-5 = 1.19, 1.13-1.26). High SABA inhaler use was frequent across BTS steps and was associated with a significant increase in exacerbations and asthma-related healthcare utilization.

Impact of indoor air pollution in nursery and primary schools on childhood asthma

Poor indoor air quality in scholar environments have been frequently reported, but its impact on respiratory health in schoolchildren has not been sufficiently explored. Thus, this study aimed to evaluate the associations between children's exposure to indoor air pollution (IAP) in nursery and primary schools and childhood asthma. Multivariate models (independent and multipollutant) quantified the associations of children's exposure with asthma-related health outcomes: reported active wheezing, reported and diagnosed asthma, and lung function (reduced FEV1/FVC and reduced FEV1). A microenvironmental modelling approach estimated individual inhaled exposure to major indoor air pollutants (CO2, CO, formaldehyde, NO2, O3, TVOC, PM2.5 and PM10) in nursery and primary schools from both urban and rural sites in northern Portugal. Questionnaires and medical tests (spirometry pre- and post-bronchodilator) were used to obtain information on health outcomes and to diagnose asthma following the newest international clinical guidelines. After testing children for aeroallergen sensitisation, multinomial models estimated the effect of exposure to particulate matter on asthma in sensitised individuals. The study population were 1530 children attending nursery and primary schools, respectively 648 pre-schoolers (3–5 years old) and 882 primary school children (6–10 years old). This study found no evidence of a significant association between IAP in nursery and primary schools and the prevalence of childhood asthma. However, reported active wheezing was associated with higher NO2, and reduced FEV1 was associated with higher O3 and PM2.5, despite NO2 and O3 in schools were always below the 200 μg m−3 threshold from WHO and National legislation, respectively. Moreover, sensitised children to common aeroallergens were more likely to have asthma during childhood when exposed to particulate matter in schools. These findings support the urgent need for mitigation measures to reduce IAP in schools, reducing its burden to children's health.

Workplace indoor environmental quality and asthma-related outcomes in healthcare workers.

Asthma-related health outcomes are known to be associated with indoor moisture and renovations. The objective of this study was to estimate the frequency of these indoor environmental quality (IEQ) factors in healthcare facilities and their association with asthma-related outcomes among workers. New York City healthcare workers (n = 2030) were surveyed regarding asthma-related symptoms, and moisture and renovation factors at work and at home during the last 12 months. Questions for workplace moisture addressed water damage (WD), mold growth (MG), and mold odor (MO), while for renovations they addressed painting (P), floor renovations (FR), and wall renovations (WR). Regression models were fit to examine associations between work and home IEQ factors and multiple asthma-related outcomes. Reports of any moisture (n = 728, 36%) and renovations (n = 1412, 70%) at work were common. Workplace risk factors for asthma-related outcomes included the moisture categories of WD by itself, WD with MO (without MG), and WD with MG and MO, and the renovation category with the three factors P, FR, and WR. Reports of home IEQ factors were less frequent and less likely to be associated with health outcomes. Data analyses suggested that MG and/or MO at work and at home had a synergistic effect on the additive scale with a symptom-based algorithm for bronchial hyperresponsiveness. The current study determined that moisture and renovation factors are common in healthcare facilities, potentially putting workers at risk for asthma-related outcomes. More research is needed to confirm these results, especially prospective studies.

Perfluoroalkyl substances, airways infections, allergy and asthma related health outcomes – implications of gender, exposure period and study design

IntroductionExposure to perfluoroalkyl substances (PFASs) has been inconsistently associated with asthma, allergic diseases and airways infections in early childhood. The aim of the study was, therefore, to investigate the effect of childhood exposure to PFASs on asthma and allergy related outcomes and on airways infections before and during puberty using the prospective birth cohort Environment and Childhood Asthma (ECA) Study. Aspects of gender, exposure period and study design (cross-sectional and longitudinal) were also taken into consideration. Material and methodsIncluded in the study was 378 participants with PFAS measurements at age 10 years and follow-up data at ages 10 years (cross sectional data) and 16 years (longitudinal data). Eight PFASs with at least 70% of measurements above the limit of quantification (LOQ) in the child’s serum were included in the present study: perfluoroheptanoate (PFHpA), perfluorooctanoate (PFOA), perfluourononanoate (PFNA), perfluorodecanoate (PFDA), perfluoroundecanoate (PFUnDA), perfluorohexane sulfonate (PFHxS), perfluoroheptane sulfonate (PFHpS) and perfluorooctane sulfonate (PFOS). The PFAS levels were converted into interquartile range (IQR). In addition, perfluorooctane sulfonamide (PFOSA) detected in 60% of the samples, was recoded into “not detected /detected”. Binomial, multinomial and linear regression were used, followed by Bonferroni adjustment to correct for multiple comparisons. Sensitivity analyses evaluating the effect of extreme PFAS values and gender were performed. ResultsIn the cross sectional data at 10 years a positive statistically significant association was seen between PFHpA and asthma in girls. In the longitudinal data, PFNA, PFDA and PFUnDA were inversely associated with atopic dermatitis (AD) in girls and with PFHxS in all participants and in boys. Further, PFNA and PFHpS were positively associated with rhinitis in girls and with PFOA in all participants. There seems to be a suggestive pattern of increased risk of allergic sensitisation in all participants and a decreased risk in boys, but due to different results in main and sensitivity analyses these findings should be interpreted with caution. No associations were found between PFASs and lung function. For airways infections and longitudinal data, PFDA was inversely associated with common cold, while positive association was found for PFHpA, PFOA, PFHpS and PFOS and lower respiratory tract infections (LRTI). Discussion and conclusionOur results lend further support for an immunosuppressive effect of PFASs on AD and LRTI. Gender seems to be important for some exposure-health associations. No clear pattern in exposure-health associations was observed with regard to exposure period or study design, with the exception of asthma where significant findings have mostly been reported in cross-sectional studies.

Relationship between parent mood and resilience and child health outcomes in pediatric asthma.

Asthma is the most common pediatric chronic disease and disproportionately affects urban, minority, and disadvantaged youth. This study explored the relationship between parent and child psychosocial functioning and asthma-related health outcomes in a sample of at-risk children with asthma. We hypothesized that greater parent resilience would be associated with better parent mood, more symptom-free days (SFDs), better child mood, and less child anxiety. Further, we hypothesized that parent resilience would moderate the relationship between parent mood and SFDs. We performed a secondary analysis of baseline cross-sectional enrollment data. Parents of African American children on Medicaid with persistent asthma reported their children's asthma SFDs and their own measures of parent quality of life, mood, and resilience, and child mood and anxiety. Baseline data from 217 parents (92.2% female, Mage = 33.8 years ± 9.5) of children (Mage = 6.6 years ± 2.3) were available. Parent resilience was significantly associated with parent mood. Better parent-reported quality of life (QOL) and mood were significantly associated with more child asthma SFDs. In contrast to our hypothesis, parent resilience did not moderate the relationship between parent mood and SFDs. Higher parent-reported QOL and mood were significantly associated with better parent report of child asthma SFDs. Although parent resilience was associated with parent mood, it did not moderate the relationship to child SFDs. Future research is warranted to better understand the unique contribution of resilience in families with children with asthma. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The British Columbia Asthma Prediction System (BCAPS): A Surveillance System to Forecast the Public Health Impacts of Wildfire Smoke

Smoke from severe wildfires during the summers of 2015 and 2017 affected most of the population of British Columbia (BC), Canada. Asthma-related health outcomes are consistently elevated when populations are exposed to wildfire smoke in BC. Timely information during smoke events is important to inform the actions of public health authorities. We developed a surveillance system using short-term wildfire smoke forecasts to predict the potential health impacts of smoke over the coming days and provide this information to public health authorities in easy-to-interpret daily reports.The BCAPS framework is modular such that different data, modelling approaches, and visualizations can be applied. We used daily fine particulate matter (PM2.5) measurements, daily counts of asthma-related population health outcomes, and PM2.5 forecasts to predict and visualize smoke exposures and their health impacts across different geographic areas over the coming 48 hours. We applied BCAPS retrospectively during a 2015 smoke event using a Bayesian latent process model to forecast health outcomes. We prospectively applied BCAPS in 2017 using random forest models to predict PM2.5 exposure and health outcomes.Daily PM2.5 measurements ranged from 0.03 µg/m3 to 301.2 µg/m3 during the 2015 event and from 0.05 µg/m3 to 293.8 µg/m3 in 2017. Daily PM2.5 and daily counts of asthma-related physician visits and medication dispensations were increased during smoky periods in 2015 and 2017. In general, BCAPS predicted the smoke-related increases in asthma outcomes with good accuracy, though performance was dependant on the performance of the smoke forecasts. In 2017 there was a marked decrease in population response to smoke towards the end of the season even though PM2.5 concentrations remained high.Integrating data from multiple sources into a modular framework such as BCAPS can usefully predict the health impacts of smoke exposure in a timely manner to inform public health decision-making and action.

Racial Disparities in Asthma-Related Health Outcomes in Children with Severe/Difficult-to-Treat Asthma

There are limited data that examine differences in asthma etiology between black and white children with severe or difficult-to-treat asthma. To describe demographic, clinical, and asthma-related outcomes in black and white children and examine whether differences in outcomes are explained by confounding factors in sequential multivariable models. Black (n= 86) and white (n= 262) children aged 6-11 years from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens 3-year observational study were analyzed. Baseline demographics and clinical characteristics were described for both cohorts, and outcomes at month 12 were analyzed using statistical models, sequentially adjusting for potential confounders. Black children were more likely to be male (79.1% vs 66.4%; P < .05), obese (12.8% vs 1.5%; P < .001), and from a lower income stratum (USD43,400 vs 55,770; P < .001) than white children. Black children had higher geometric mean IgE levels (434.8 vs 136.8 IU/mL; P < .001), were more likely to have very poorly controlled asthma (72.1% vs 53.4%), use long-term systemic corticosteroids (30.2% vs 9.2%; P < .001), have poorer quality of life (5.5 vs 6.1; P < .001), and have an emergency department visit (27.4% vs 7.7%, P < .001) in the 3 months before month 12. Differences in asthma control and the severity of exacerbations persisted even after accounting for all confounding factors. Among children with severe or difficult-to-treat asthma, asthma burden is greater in black than white children particularly related to several clinical and patient-reported outcome measures that are not explained by differences in background or clinical characteristics.

Prenatal exposure to perfluoralkyl substances (PFASs) associated with respiratory tract infections but not allergy- and asthma-related health outcomes in childhood

BackgroundPrenatal exposure to perfluoralkyl substances (PFASs) has been reported to be associated with immunosuppression in early childhood, but with contradictory findings related to atopic and lung diseases. AimWe aimed to determine if prenatal exposure to PFASs is associated with asthma or other allergic diseases or respiratory tract infections in childhood. MethodsNineteen PFASs were measured in cord blood available from 641 infants in the Environment and Childhood Asthma (ECA) prospective birth cohort study. The six most abundant PFASs were perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorooctanesulfonamide (PFOSA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and perfluoroundecanoic acid (PFUnDA). Health outcomes were assessed at two and ten years of age, and included reported obstructive airways disease (wheeze by 10 years; asthma by 2 and 10 years; reduced lung function at birth; allergic rhinitis by 10 years), atopic dermatitis (AD) by 2 and 10 years, allergic sensitization by 10 years, and episodes of common respiratory tract infections (common cold by 2 years, lower respiratory tract infections (LRTI) by 10 years). The associations between exposure and health outcomes were examined using logistic and Poisson regression. ResultsThe number of reported airways infections were significantly associated with cord blood concentrations of PFAS; common colds by two years with PFUnDA (β = 0.11 (0.08–0.14)) and LRTIs from 0 to 10 years of age with PFOS (β = 0.50 (0.42–0.57)), PFOA (β = 0.28 (0.22–0.35)), PFOSA (β = 0.10 (0.06–0.14)), PFNA (β = 0.09 (0.03–0.14)) and PFUnDA (β = 0.18 (0.13–0.23)) concentrations. Neither reduced lung function at birth, asthma, allergic rhinitis, AD nor allergic sensitization were significantly associated with any of the PFASs. ConclusionAlthough prenatal exposure to PFASs was not associated with atopic or lung manifestations by 10 years of age, several PFASs were associated with an increased number of respiratory tract infections in the first 10 years of life, suggesting immunosuppressive effects of PFASs.

The Association Between Adverse Childhood Experiences in the Home and Pediatric Asthma

BackgroundNumerous studies suggest that psychosocial factors may contribute to pediatric asthma. ObjectiveTo examine the relationship between single and cumulative Adverse Childhood Experiences (ACEs), a measure of household dysfunction, on parent report of lifetime asthma among children. MethodsThis cross-sectional study used 2011-2012 National Survey of Children’s Health data, a nationally representative sample of children 0 to 17 years (n = 92,472). The main exposure was parent/guardian report of 6 ACE exposures (for example; witnessing domestic violence). The relationship between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression, controlling for demographic, socioeconomic and behavioral covariates. ResultsOverall asthma prevalence was 14.6%. Exposure to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14, 1.43) for those reporting one ACE, and increased to 1.73 (95% CI 1.27, 2.36) for those with 4 ACEs and 1.61 (95% CI 1.15, 2.26) for those with 5 or 6 ACEs compared to those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46, 8.08); white children had a 1.19 times increase (95% CI 0.80, 1.79) compared to those exposed to zero ACEs. ConclusionsThis study further supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Access to health care and food in children with food allergy

Access to health care and food in children with food allergy

Phenotypes determined by cluster analysis in severe or difficult-to-treat asthma

Asthma phenotyping can facilitate understanding of disease pathogenesis and potential targeted therapies. To further characterize the distinguishing features of phenotypic groups in difficult-to-treat asthma. Children ages 6-11 years (n = 518) and adolescents and adults ages ≥12 years (n = 3612) with severe or difficult-to-treat asthma from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study were evaluated in this post hoc cluster analysis. Analyzed variables included sex, race, atopy, age of asthma onset, smoking (adolescents and adults), passive smoke exposure (children), obesity, and aspirin sensitivity. Cluster analysis used the hierarchical clustering algorithm with the Ward minimum variance method. The results were compared among clusters by χ(2) analysis; variables with significant (P < .05) differences among clusters were considered as distinguishing feature candidates. Associations among clusters and asthma-related health outcomes were assessed in multivariable analyses by adjusting for socioeconomic status, environmental exposures, and intensity of therapy. Five clusters were identified in each age stratum. Sex, atopic status, and nonwhite race were distinguishing variables in both strata; passive smoke exposure was distinguishing in children and aspirin sensitivity in adolescents and adults. Clusters were not related to outcomes in children, but 2 adult and adolescent clusters distinguished by nonwhite race and aspirin sensitivity manifested poorer quality of life (P < .0001), and the aspirin-sensitive cluster experienced more frequent asthma exacerbations (P < .0001). Distinct phenotypes appear to exist in patients with severe or difficult-to-treat asthma, which is related to outcomes in adolescents and adults but not in children. The study of the therapeutic implications of these phenotypes is warranted.

Pre-natal exposure to perfluoroalkyl substances may be associated with altered vaccine antibody levels and immune-related health outcomes in early childhood

Perfluoroalkyl substances (PFAS) are suggested to have immunosuppressive effects; exposure in utero and in the first years of life is of special concern as fetuses and small children are highly vulnerable to toxicant exposure. The objective of this study was to investigate the effect of pre-natal exposure to PFAS on responses to pediatric vaccines and immune-related health outcomes in children up to 3 years of age. In the prospective birth-cohort BraMat, a sub-cohort of the Norwegian Mother and Child Cohort Study (MoBa), pregnant women from Oslo and Akershus, Norway, were recruited during 2007–2008. Three annual questionnaire-based follow-ups were performed. Blood samples were collected from the mothers at the time of delivery and from the children at the age of 3 years. As a measure of pre-natal exposure to PFAS, the concentrations of perfluorooctanoate (PFOA), perfluorononanoate (PFNA), perfluorohexane sulfonate (PFHxS), and perfluorooctane sulfonate (PFOS) were determined in maternal blood from 99 BraMat participants. Main outcome measures were anti-vaccine antibody levels, common infectious diseases and allergy- and asthma-related health outcomes in the children up to the age of 3 years. There was an inverse association between the level of anti-rubella antibodies in the children’s serum at age 3 years and the concentrations of the four PFAS. Furthermore, there was a positive association between the maternal concentrations of PFOA and PFNA and the number of episodes of common cold for the children, and between PFOA and PFHxS and the number of episodes of gastroenteritis. No associations were found between maternal PFAS concentrations and the allergy- and asthma-related health outcomes investigated. The results indicate that pre-natal exposure to PFAS may be associated with immunosuppression in early childhood.

Assessment of asthma control and asthma exacerbations in the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) observational cohort.

Patients with severe or difficult-to-treat asthma account for substantial asthma morbidity, mortality, and healthcare burden despite comprising only a small proportion of the total asthma population. TENOR, a multicenter, observational, prospective cohort study was initiated in 2001. It enrolled 4,756 adults, adolescents and children with severe or difficult-to-treat asthma who were followed semi-annually and annually for three years, enabling insight to be gained into this understudied population. A broad range of demographic, clinical, and patient self-reported assessments were completed during the follow-up period. Here, we present key findings from the TENOR registry in relation to asthma control and exacerbations, including the identification of specific subgroups found to be at particularly high-risk. Identification of the factors and subgroups associated with poor asthma control and increased risk of exacerbations can help physicians design individual asthma management, and improve asthma-related health outcomes for these patients.