District of Columbia Burden of Asthma Report

Burden of Asthma in the
District of Columbia
2009
H H H
Government of the District of Columbia Adrian M. Fenty, Mayor
District of Columbia Department of Health 825 North Capitol Street, NE Washington DC 20002 http://dchealth.dc.gov
Burden of Asthma in the District of Columbia

Government of the District of Columbia Adrian M. Fenty, Mayor Department of Health Pierre N. D. Vigilance, M.D., M.P.H., Director Community Health Administration Carlos E. Cano, M.D. Senior Deputy Director Center for Policy, Planning, and Epidemiology John O. Davis-Cole, Ph.D., M.P.H, State Epidemiologist Authors Senkuta 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. Tracy Garner We gratefully acknowledge the contributions of the following: Carol Johnson, M.P.H., Centers for Disease Control Department of Health Center for Policy, Planning and Epidemiology George Washington University Deborah Quint, M.P.H. and Stephen Teach, M.D. Improving Pediatric Care in the District of Columbia (IMPACT DC) Johns Hopkins University Applied Physics Laboratory (JHU/APL) Publication Date: 2009
Development and publication of this report was supported by Cooperative Agreement Number U59/CCU324208-05 from the Centers of Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. For additional information, contact the DC Control Asthma Now Program at the DC Department of Health at (202) 442-5925
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Table of Contents
List of Figure .........................................................................................................................................................v List of Tables....................................................................................................................................................... vii Executive Summary ............................................................................................................................................ix Key Findings................................................................................................................................................x Summary of Recommendations ............................................................................................................xiv 1.0 Introduction ................................................................................................................................................1 1.1. Cause and Triggers ...........................................................................................................................1 1.2. Public Health Significance ...............................................................................................................1 1.3. Who Is Most Affected by Asthma? .................................................................................................2 1.4. Overview of the District of Columbia ...........................................................................................2 1.4.1. DC Control Asthma Now (DC CAN) ..............................................................................4 1.4.2. DC Healthy People 2010 Asthma Objectives ..................................................................5 2.0 Asthma Burden in the District of Columbia...........................................................................................7 2.1. Measuring Asthma Prevalence .......................................................................................................7 2.2. Asthma Prevalence in the District..................................................................................................8 2.2.1. Asthma Prevalence by Gender.........................................................................................10 2.2.2. Asthma Prevalence by Race/Ethnicity ............................................................................11 2.2.3. Asthma Prevalence by Age Group ..................................................................................11 2.2.4. Asthma Prevalence by Socioeconomic Status ...............................................................12 2.2.5. Asthma Prevalence by Ward ............................................................................................14 2.2.6. Risk Factors Associated with Elevated Asthma Prevalence .........................................15 2.2.7. Asthma Prevalence among Children ..............................................................................16 3.0 Asthma Management and Quality of Life .............................................................................................19 3.1. Measuring Asthma Management and Quality of Life ...............................................................19 3.2. Asthma Severity ..............................................................................................................................19 3.2.1. Asthma Episodes (Attacks) ..............................................................................................19 3.2.2. Routine Doctor Visits .......................................................................................................21 3.2.3. Inhaler Use .........................................................................................................................23 3.3. Asthma Quality of Life ...................................................................................................................24 3.3.1. Age at First Diagnosis .......................................................................................................24 3.3.2. Limited Activity .................................................................................................................26 4.0 Asthma Morbidity ....................................................................................................................................29 4.1. Hospitalization Due to Asthma ....................................................................................................29 4.1.1. Asthma Hospitalization by Age .......................................................................................30 4.1.2. Mean Length of Stay..........................................................................................................32 4.2. Emergency Department Visit Due to Asthma ............................................................................32 4.2.1. Age-adjusted ED Visit Rates ............................................................................................32 4.2.2. ED Visits by Gender ..........................................................................................................34 4.2.3. ED Visits among Children ...............................................................................................34
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Table of Contents
4.2.4. Insurance .........................................................................................................................35 4.2.5. Disposition ......................................................................................................................36 5.0 Asthma Mortality ..................................................................................................................................39 5.1. Mortality Count by Subgroups ..................................................................................................39 5.2. Mortality Rate ..............................................................................................................................40 5.3. Mortality Rate by Sex, Race and Age Group ............................................................................40 5.4. Mortality Rate by Ward...............................................................................................................41 6.0 Work-Related Asthma ..........................................................................................................................43 6.1. Prevalence of Work-Related Asthma in The District ..............................................................44 6.1.1. WRA Study Description ................................................................................................44 6.1.2. WRA Study Results ........................................................................................................45 7.0 Air Quality and Asthma .......................................................................................................................47 7.1. Outdoor Environmental Pollutants ...........................................................................................47 7.1.1. Health Effects ..................................................................................................................48 7.2. Air Quality Standards .................................................................................................................48 7.3. The Role of Outdoor Air Pollution in the District ...................................................................49 7.3.1. Study Description ...........................................................................................................50 7.3.2. Study Results ...................................................................................................................50 8.0 Conclusions ...........................................................................................................................................53 8.1. Non-Hispanic Black Population ................................................................................................53 8.2. Populations with Low Socioeconomic Status ...........................................................................54 8.3. Children ........................................................................................................................................54 8.4. Adult and Elderly Population.....................................................................................................54 8.5. Female Population .......................................................................................................................55 8.6. Populations with Other Risk Factors.........................................................................................55 8.7. Implications on Asthma Management ......................................................................................56 8.8. Work-Related Asthma.................................................................................................................56 8.9. Asthma and Environmental Factors..........................................................................................56 9.0 Recommendations ................................................................................................................................59 9.1. Surveillance System .....................................................................................................................59 9.2. Asthma Management ..................................................................................................................60 9.3. Risk Factors and Preventable Events .........................................................................................60 9.4. Reducing Health Disparities ......................................................................................................61 10. References ..............................................................................................................................................63 Technical Notes ...............................................................................................................................................67 Acronyms ...............................................................................................................................................68 Appendix A: Work-Related Asthma Survey GWU..................................................................................69 Survey Questions...................................................................................................................................69 Appendix B: Data Tables ................................................................................................................................71 iv Burden of Asthma in the District of Columbia
List of Figures
Figure 1-1 Figure 2-1 Figure 2-2 Figure 2-3 Figure 2-4 Figure 2-5 Figure 2-6 Figure 2-7 Figure 2-8 Figure 2-9 Figure 2-10 Figure 2-11 Figure 2-12 Figure 2-13 Figure 2-14 Figure 2-15 Figure 3-1 Figure 3-2 Figure 3-3 Figure 3-4 Figure 3-5 Figure 3-6 Figure 3-7 Figure 3-8 Figure 3-9 Figure 3-10 Figure 3-11 Figure 3-12 Figure 3-13 Figure 3-14 Figure 3-15 Figure 4-1 Figure 4-2 The District of Columbia by Ward designations .................................................................3 District of Columbia asthma surveillance data sources......................................................7 Prevalence of adult asthma in District of Columbia ...........................................................9 Lifetime asthma prevalence in adults over 18, District vs. US ...........................................9 Current asthma prevalence in adults over 18, District vs. US..........................................10 Prevalence of adult (18 years) asthma by gender ............................................................10 Prevalence of adult (18 years) asthma by race/ethnicity ................................................11 Prevalence of adult (18 years) asthma by age group .......................................................12 Prevalence of adult (18 years) asthma by education level ..............................................13 Prevalence of adult (18 years) asthma by income level ..................................................13 Prevalence of current adult (18 years) asthma by ward .................................................14 Prevalence of former adult (18 years) asthma by ward ..................................................14 Prevalence of childhood (17 years) asthma .....................................................................16 Prevalence of childhood (17 years) asthma by gender ...................................................17 Prevalence of childhood (17 years) asthma by race ........................................................17 Prevalence of childhood (17 years) asthma by age group ..............................................18 Respondent answers regarding episodes of asthma ..........................................................20 Episodes of asthma by gender..............................................................................................20 Episodes of asthma by race ..................................................................................................21 Frequency of visits to a doctor for routine asthma checkups...........................................21 Frequency of visits to a doctor for routine asthma checkups by gender ................................................................................................................................22 Frequency of visits to a doctor for routine asthma doctor visit by race ..........................22 Frequency of inhaler use to stop asthma episodes ............................................................23 Frequency of inhaler use to stop asthma episodes by gender ..........................................23 Frequency of inhaler use to stop asthma episodes by race ...............................................24 Age at first diagnosis among respondents with current asthma ......................................25 Age when diagnosed with asthma by gender .....................................................................25 Age when diagnosed with asthma by race/ethnicity .........................................................26 Days of missed work or usual activities because of asthma .............................................26 Days of missed work or usual activities because of asthma by gender ................................................................................................................................27 Days of missed work or usual activities because of asthma by race ................................27 Crude asthma hospitalization rate in the District of Columbia ......................................30 Hospitalization rates due to asthma by age group in the District of Columbia ...........................................................................................................................30 Burden of Asthma in the District of Columbia v
List of Figures
Figure 4-3 Figure 4-4 Figure 4-5 Figure 4-6 Figure 4-7 Figure 4-8 Figure 4-9 Figure 4-10 Figure 5-1 Figure 5-2 Figure 5-3 Figure 5-4 Mean length of stay for asthma-related discharges and total hospital discharges ................................................................................................................32 Age-adjusted rates of emergency department visits due to asthma among all residents in the District of Columbia................................................................33 Total emergency department visits due to asthma in the District of Columbia .............................................................................................................33 Emergency department visits due to asthma by gender in the District of Columbia .............................................................................................................34 Age-adjusted rates for children in the District of Columbia ............................................35 Distribution of insurance among emergency discharge asthma patients in the District of Columbia ...................................................................................35 Disposition of emergency department visits due to asthma in the District of Columbia .............................................................................................................36 Frequency of disposition of emergency department visits due to asthma in the District of Columbia ....................................................................................37 Annual asthma mortality rate in the District of Columbia, 1999-2005 ...............................................................................................................................40 Asthma mortality rate by sex and race, District of Columbia 1999-2005 ...............................................................................................................................41 Asthma mortality rate by age group, District of Columbia 1999-2005 ...............................................................................................................................41 Crude asthma mortality rate by Ward, District of Columbia 1999-2005 ...............................................................................................................................42
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List of Tables
Table 1-1 Table 1-2 Table 2-1 Table 2-2 Table 4-1 Table 5-1 Table 7-1 District of Columbia population distribution by race and age group ..................................2 District of Columbia population, race and socio-economic distribution by ward ...................................................................................................................4 Asthma prevalence category definitions: respondent answers to BRFSS survey questions.............................................................................................................8 Prevalence of risk factors among BRFSS respondents with current asthma, 2005 .............................................................................................................................16 Number and rate of hospitalization due to asthma by age group in the District of Columbia ..........................................................................................................31 Annual asthma mortality count in the District of Columbia, 1999-2005 ..................................................................................................................................39 National Ambient Air Quality Standards ..............................................................................49
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Executive Summary Asthma is a chronic disease of the lungs bronchi (airways) characterized by airway hyper-respon-
siveness to stimuli resulting in airflow limitation, and respiratory symptoms including: breathlessness, wheezing, coughing, and chest tightness. Symptoms can vary in severity from mild intermittent to severe persistent. All levels of severity can be life threatening. According to the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey data, approximately 9% of adult residents (40,000 adults) and 11% of children (13,000 children) currently have asthma, and about 15% of adults have been diagnosed with asthma at some point in their life. Overall, the prevalence of current asthma in the District of Columbia has been consistently higher than the national rate for the past seven years. In addition, the Districts asthma prevalence was on an upward trend from 2000 to 2004, but seemed to stabilize at slightly above 15% from 2004 to 2007. Vital Records data for asthma related mortality indicate an overall decreased rate from 1999-2005, despite a rate increase in 2004. Although asthma affects all portions of the Districts population, certain subgroups are disproportionately affected. The non-Hispanic black population: very young children aged 0-4 years, especially male children of this age group, adolescent females, 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 affected by asthma. The District of Columbia Department of Health (DOH) Asthma Control Program 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 of life for District residents who suffer from asthma. Its mission is to develop and implement a viable, comprehensive, community-based, and consumercentered approach to asthma diagnosis and management. The objectives of DC CAN are to: Develop interventions to reduce asthma hospitalizations, deaths, and emergency department visits among high-risk populations; Identify barriers in the delivery of asthma care services, particularly to the underserved and highrisk groups; Increase education and awareness programs that are culturally sensitive, and linguistically appropriate for all racial/ethnic groups; Promote the use of guidelines from the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institutes (NHLBI) for the treatment and management of asthma;
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Educate persons with asthma, their family members/caregivers, as well as health care providers and health educators; and Develop a comprehensive asthma surveillance and data collection system to monitor trends and evaluate the effectiveness of program interventions in the reduction of asthma morbidity and mortality. The National Healthy People 2010 (HP 2010) includes seven goals for improving the health of those living with asthma. DC HP 2010 (http://doh.dc.gov/doh/site/default.asp) has adopted three (3) of these goals: Reduce asthma deaths; Reduce asthma hospitalization; and Reduce emergency department visits related to asthma.
Key Findings
Several data sources were analyzed to describe the health status of persons with asthma. The District of 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 findings in this report.
Adult Asthma Prevalence

In 2007, BRFSS respondents reported having: approximately 15% lifetime asthma, 9% current asthma and about 6% former asthma. Lifetime asthma prevalence in the District was on an upward trend from 2000 through 2004, but stabilized at slightly above 15% between 2004 and 2007. There was a 28% increase in prevalence from 2000 to 2005.
Asthma Prevalence by Gender

In 2007, the prevalence of current asthma among adults was 47% higher among females (12%) as compared to males (6.4%).
Asthma Prevalence by Race/Ethnicity

In 2007, the prevalence of current asthma was 66% higher among non-Hispanic black adults (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 18-24 was approximately twice the prevalence of persons aged 35-44, 45-54, and 55-64; this was statistically significant. By 2007, persons aged 25-34 had the highest lifetime asthma prevalence, followed by 35-44 and 18-24 year olds. x Burden of Asthma in the District of Columbia
The prevalence of current asthma among 18-24 year olds was more than twice that of those 65 years and over, at p<0.05 in 2005, but was reduced by half in 2007.
Asthma Prevalence by Education

In 2007, the prevalence of current asthma among adult respondents with less than a high school education was almost two times higher as compared to those with a college graduate education.
Asthma Prevalence by Household Income

The current asthma prevalence rate was more than two (2) times higher among respondents reporting less than a $15,000 annual household income compared to those reporting an annual income above $75,000 in 2007.
Asthma Prevalence by Ward

Wards 2 and 8 had the highest prevalence of current adult asthma and Wards 3 and 4 had the lowest prevalence of current asthma in adults and correspondingly had the highest rate of former adult asthma.
Asthma Prevalence by Risk Factors

Persons who reported being obese (body mass index >30) were two (2) times more likely to report having current asthma than their counterparts who reported being normal (BMI < 25) or overweight (BMI > 25). Persons who reported being current tobacco smokers were two (2) times more likely to report having current asthma than their non-smoking counterparts. Persons over the age of 65 who reported receiving an influenza shot were twice as likely to report having current asthma as their counterparts who did not receive influenza shots. Persons over the age of 65 who reported receiving a pneumonia vaccination were 1.43 times more likely to report having current asthma than their counterparts who did not receive a pneumonia vaccination.
Childhood Asthma Prevalence

In 2005, current asthma prevalence among children under the age of 17 years was reported to be 11.4%. Four percent (4%) were reported as having had asthma symptoms in the past.
Asthma Episode Prevalence

In 2005, 45% of BRFSS respondents with current asthma reported experiencing at least one asthma episode or attack in the past 12 months. Male respondents (50.7%) reported experiencing a higher proportion of asthma attacks in the past 12 months as compared to females (41%). Burden of Asthma in the District of Columbia xi
Asthma Doctor Visits

Approximately 30% of BRFSS respondents with current asthma reported having one routine doctor visit, 32% reported 2-4 visits, and 9% reported 5 or more visits in the past 12 months. Non-Hispanic black respondents indicated a significantly higher frequency (more than twice) of routine doctor visits at 2-4 times more than their white counterparts.
Inhaler Use
In 2005, approximately 30% of BRFSS respondents with current asthma reported using an inhaler 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 five or more times as compared to men (5.5%). Almost twice as many non-Hispanic black respondents (34.6%) with asthma reported using inhalers 1-4 times in the past month as compared to their non-Hispanic white counterparts (19.3%). Reports of never using an inhaler were 43% higher among non-Hispanic whites than non-Hispanic blacks.
Age at First Diagnosis

In 2005, the highest proportion of respondents with current asthma (22%) reported an initial diagnosis before the age of 19 followed a lower 19% with an initial diagnosis between ages 20-39 years. The data show that men tend to be initially diagnosed at a younger age than women in the Districts population. A majority of non-Hispanic whites reported being initially diagnosed before the age of 19, while the highest proportion of non-Hispanic blacks reported initial diagnosis between the ages of 20-39.
Limited Activity
In 2005, approximately 12% of respondents with current asthma indicated that they were unable 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
There is a general decreasing trend in the crude asthma hospital discharge rate from 2002 (20.2 per 10,000 persons) to 2005 (17.1 per 10,000 persons). From 2002 to 2005 the highest rate of hospitalization occurred among children under five years old, middle aged (45-50 years) and the elderly (60-75 years). xii Burden of Asthma in the District of Columbia
Emergency Department (ED) Visits

The age-adjusted rates of ED visits due to asthma in the District increased slightly from 208.1 per 10,000 in 2005 to 219.2 per 10,000 in 2006. The rate of ED visits due to asthma was highest among children 1 to 4 years of age and adults 40 to 50 years of age in 2005 and 2006. In 2006, males under the age of 15 years had a higher ED visit rate than their female counterparts. However, females had a higher ED visit rate than males after the age of 15. In 2006, the data showed an increase in hospital admissions from the ED as age increased.
Mortality
The asthma mortality rate from 1999 to 2005 was 11.6 per 100,000 persons. From year 1999 to 2005, the asthma mortality rate of non-Hispanic blacks was approximately 4 times higher than those of non-Hispanic whites. Asthma mortality rate among male District residents (12 per 100,000) was slightly higher than their female counterparts (11.2 per 100,000) from 1999 to 2005. More asthma deaths occurred among adults than children (0-17 years) and the number of deaths increased by age. Wards 7, 5 and 8 had the highest, and Ward 3 had the lowest asthma mortality rates in the District from 1999 to 2005.
Work-Related Asthma
There were 39 cases of work-related asthma (WRA) in the District from 1999 to 2005 as reported by workers compensation claims. A study was conducted to validate that all WRA cases were captured using the worker compensation claims database. The study identified 18% more cases in one year compared to the workers compensation claims database that spanned seven years.
Outdoor Air Quality and Asthma

The strongest relationship between ozone and asthma-related Medicaid patient visits was seen in the age group 5-12 years. Grass pollen effects on asthma exacerbations were strongest for the 5-12 and 13-20 year old age groups. Particulate matter less than 2.5 m in diameter (PM2.5) levels were significantly associated with asthma-related Medicaid patient visits for 5-12 year olds. Wards 5, 6, and 8 showed significant ozone impacts for age groups 13-20, 21-49, and all ages, respectively. When data were further restricted to 1999 (a year with higher than average ozone and PM2.5 concentrations, as well as higher summer temperatures), the ward specific impacts of ozone and PM2.5 on 5-12 year olds were significant, and strongest in Ward 7. Burden of Asthma in the District of Columbia xiii
Summary of Recommendations
Asthma represents a considerable burden on the District of Columbia. Despite some improvements in asthma prevalence nationally, the District is lagging behind. There are many opportunities for improvement 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 specific attention when considering reduction of asthma prevalence, severity, and mortality in the District. The reports findings suggest the need for improvement in asthma surveillance, management, health disparities and reduction in risk factors, and preventable events. The District of Columbia needs to maintain a consistent data collection mechanism that will capture prevalence, emergency department and hospitalization data by race, ward, and school district level as well as data on asthma management by subpopulations. There is also a significant need to develop a better data collection methodology for work-related asthma (WRA) in order to better estimate the prevalence of WRA in the District. This may mean forging partnerships with stakeholders (DC Office of Workers Compensation, physicians. employers etc.) to establish an active data collection system. Asthma intervention programs need to encourage proper asthma management by mitigating primary health care barriers for at-risk populations. DC DOH needs to continue to form partnerships with the Districts schools to improve asthma management in school-aged children. WRA is a disease that is preventable; asthma interventions need to educate health care providers, employers and employees on the diagnosis, and prevention of WRA. Obesity and tobacco smoke are risk factors that need to be integrated in asthma prevention strategies especially those targeting children. Racial and socioeconomic disparities in asthma morbidity and mortality need to be addressed by targeting resources, forming partnerships, and implementing outcome based interventions that utilize asthma data to set goals, and routinely assess improvements.
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1. Introduction Asthma is a chronic disease of the lungs bronchi (airways) characterized by airway hyper-respon-
siveness to stimuli resulting in airflow limitation and respiratory symptoms including breathlessness, wheezing, coughing, and chest tightness. Symptoms can vary in severity from mild intermittent (affecting activity levels) to severe persistent. All levels of severity can be life- threatening.
1.1. Cause and Triggers

Why a person develops asthma depends on complex interactions of genetic and environmental factors 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 from person to person. Common asthma triggers include: Allergens pollen, animal dander, dust, mites, cockroaches, and mold Irritants cold air, perfume, pesticides, strong odors, weather changes, cigarette smoke, and chalk dusts Respiratory infections cold or flu Physical exercise especially in cold weather Stress
1.2. Public Health Significance

In 2005, more than 22 million Americans had asthma and of these 6 million were children.1 Asthma is one of the most common chronic diseases affecting children in the United States. The burden of asthma not only affects the patients, but also their families and society in terms of: lost days of work and school, lessened quality of life, and avoidable emergency department visits, hospitalizations, and deaths.2 Asthma is one of the leading causes of school absenteeism.3 In 2003, an estimated 12.8 million school days were missed due to asthma among more than four million children who reported at least one asthma attack in the preceding year.4 In addition, asthma is the leading cause of preventable hospitalization with approximately 500,000 hospitalizations and 1.5 million emergency department visits, thus burdening the health care system.5 It also accounts for over 5,500 avoidable deaths each year.6 The direct cost of asthma (hospitalization, physician, and prescription drugs) in the US in 2007 was estimated to be $14.7 billion. Indirect costs such as loss of school days, loss of work, and deaths were estimated at an additional $5 billion with the total economic cost of $19.7 billion. Prescription drugs represented the largest single direct medical expenditure at $6.2 billion.7 Burden of Asthma in the District of Columbia 1
1.3. Who is Most Affected by Asthma?

In the United States, rates of asthma hospitalizations, emergency department visits, and deaths due to asthma have been increasing for the last two (2) decades. Although asthma is a debilitating disease that affects all ages, races, and ethnic groups, certain populations continue to have a higher prevalence. Asthma tends to be prominent in areas with high concentrations of poverty, environmental risks, and marginalized health care system. This is evident by the increasingly high prevalence of asthma observed among African Americans, and children under five (5) years of age.8 Factors that affect asthma including access to primary, routine, emergency care, and quality of care vary among populations by gender, race, and age. As a result, these disparities affect asthma related emergency department visits, hospitalizations, and death rates.
1.4. Overview of Asthma Trends in the District of Columbia

In 2006 the U.S. census estimated (based on the 2000 census data) that the District of Columbia was home to 581,530 residents of diverse races and ethnicities. Table 1-1 shows a demographic summary of the District of Columbia population. Table 1-1: District of Columbia population distribution by race/ethnicity and age group
District of Columbia Population, 2000 * Black/ African American Race/ Ethnicity White Hispanic/Latino** Asian 0-4 5-9 10 -14 15 - 19 20 - 24 Age (years) 25 34 35 44 45 54 55 64 65 74 75 84 85+ Percent (%) 55.4% 34.5% 8.2% 3.4% 6.0% 5.0% 5.3% 6.7% 8.8% 18.0% 14.6% 12.9% 10.3% 6.2% 4.5% 1.5% N 322,105 200,395 47,775 19,827 34,980 29,331 31,081 39,235 51,273 104,518 84,648 75,160 59,849 36,338 26,199 8,918
* Source: US Census Bureau, 2006 American Community Survey ** Persons of Hispanic Origin may be of any race
The Districts 63 square miles are divided into eight (8) wards on which local political representation is based and public services are administered. Figure 1-1 shows the map of the District of Columbia ward designations. Ward designations have not changed since 2000 and will remain the same until 2010. Ward boundaries are based on the population and will change with the decennial census. Groups of people, families, or clans often congregate heavily in one ward over another. There is a vast difference in the economic wealth in each ward, as well as differences in ethnic diversity. For example, in Ward 8 about 92% of the residents are non-Hispanic black and 36% of the residents live in poverty. Whereas in Ward 3, about 6% of the residents are non-Hispanic black, and some 7% of residents live in poverty.9 Figure 1-1: The District of Columbia by ward designations
Source: Department of Health, Community Health Administration
African American residents are concentrated in Wards 5, 7, and 8. Wards 7 and 8 also have the largest number of youth under the age of 18. However, non-Hispanic white residents are concentrated in Wards 1, 2, and 3. Ward 1 is also the most diverse with a resident population that is a mixture of Black/ African American, white Non-Hispanic, Hispanic/Latino, Asian/Pacific Islander, and Others.
The disparity in wealth is evident in neighborhoods that exist with economic challenges. Studies show that low-income families, minorities, and children living in inner cities are at a higher risk of emergency department visits, hospitalizations, and deaths due to asthma than the general population. The income distribution for the District is outlined below in Table 1-2. Table 1-2: District of Columbia population, race and socio-economic distribution by Ward
Population a Ward 1 2 3 4 5 6 7 8 DC
a b c d
Age a, b 18 + 17% 11% 13% 21% 22% 19% 28% 37% 20% 65 + 8% 9% 14% 17% 18% 11% 14% 6% 12%
Race a Black 43% 30% 6% 78% 88% 69% 97% 92% 60% Hispanic Latino 23% 9% 7% 13% 3% 2% 1% 2% 8%
Medicaid b Number of Recipients 15,218 20,864 1,649 15,009 18,969 16,676 24,199 28,841 141,941 c
Income d Median, 1999 $36,802 $44,742 $71,875 $46,408 $34,433 $41,554 $30,533 $25,017 $40,127
Unemployed d Percent 5% 6% 7% 4% 8% 6% 7% 12% 7%
Census, 2000 73,364 68,869 73,718 74,092 72,527 68,035 70,540 70,914 572,059
DC State Center for Health Statistics; Policy, Planning, and Research Administration, Vital Statistics 2004. Working Together for Health: MEDICAID Annual Report, FY 2005. DC Department of Health, Medical Assistance Admin. Total includes those missing DC Office of Planning, 1999 Median Household and Per Capita Income by Ward
1.4.1. Control Asthma Now (DC CAN)

The District of Columbia Department of 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 of life for District residents who suffer from asthma. Its mission is to develop and implement a viable, comprehensive, community-based, consumer-centered approach to asthma diagnosis, and management. The Districts first Burden of Asthma Report was published in 2003, and its Asthma Strategic Plan was completed in 2004. It was anticipated that implementation of the plan would enable the District to achieve more optimal levels of effectiveness and efficiency in the use of available care delivery resources and thus, reduce the burden of asthma in the District. The objectives of DC CAN are as follows: Develop and implement interventions to reduce asthma hospitalizations, deaths, and emergency department visits, especially for the high-risk population (children, seniors, blacks, and Hispanics). Develop and implement interventions to reduce asthma hospitalizations, deaths, and emergency department visits, especially for the high-risk population (children, seniors, blacks, and Hispanics). 4 Burden of Asthma in the District of Columbia
Identify barriers in the delivery of asthma care services, particularly to the underserved and highrisk groups. Increase education and awareness programs that are culturally sensitive and linguistically appropriate for all races and differing socioeconomic status. Promote the use of the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) guidelines. Educate persons with asthma and their family members, as well as providers and health educators. Develop a comprehensive asthma surveillance and data collection system to monitor trends and evaluate the effectiveness of program interventions in the reduction of asthma morbidity and mortality.
1.4.2. DC Healthy People 2010

The National Healthy People 2010 (HP 2010) Plan includes seven goals targeted to improve the health of those living with asthma. DC HP 2010 (http://doh.dc.gov/doh/site/default.asp) has adopted three of these goals: Reduce asthma deaths; Reduce asthma hospitalizations; and Reduce emergency department visits for asthma. DC CANs approach to asthma prevention and control include: a better physician/patient partnership and effective education for both providers and patients regarding the factors associated with asthma, proper medical management, and policies that support the Student Access to Treatment Act 2007 which permits asthmatic children to carry and self-administer emergency asthma medication while attending school and school sponsored events.
2. Asthma Burden in the District of Columbia

is vital to know the current asthma prevalence in order to target and measure the impact of interventions. This report summarizes the DC CAN surveillance that utilizes data from various sources and key stakeholders to portray a comprehensive picture of asthma in the District of Columbia, as shown in Figure 2-1. The goal of the report is to provide baseline data and guidance for the development of targeted asthma intervention programs and policies. Figure 2-1: District of Columbia asthma surveillance data sources Data Sources Asthma Prevalence Severity and Quality of Life Environmental
As partners across the District work towards developing and implementing asthma interventions, it
BRFSS
DC CAN Surveillance Data
Hospital Discharge
Emergency Department
Medicaid
Air Quality
Work-related
Workers Compensation
GWU Survey
Mortality
Vital Statistics
2.1. Measuring Asthma Prevalence

Asthma prevalence is estimated using the District of Columbia Behavioral Risk Factor Surveillance Systems (BRFSS) survey data. The BRFSS is an annual telephone health survey of approximately 4,000 adults aged 18 years and older. The survey uses standardized interviewing methods and questionnaires, and covers a broad spectrum of health behaviors. For this report, data from 2000-2007 has been used Burden of Asthma in the District of Columbia 7
to determine the proportion of individuals who have asthma at a specific point in time. The estimates provided in this report reflect self-reported cases of asthma that have been diagnosed by a health care professional. Therefore, the true prevalence of asthma may be underestimated. The report has categorized prevalence of asthma into three groups: lifetime, current and former. Since the severity of asthma can vary over time, the BRFSS estimates both Lifetime and Current asthma prevalence. This was done in order to make the distinction between those that currently show symptoms of asthma, and those that do not. Current asthma prevalence is the proportion of the population that currently has asthma. Former asthma prevalence is the proportion of the population that was diagnosed with asthma but no longer show symptoms. Table 2-1 defines the prevalence categories according to the respondents answers to survey questions. Lifetime asthma prevalence is a proportion of all respondents who answered yes to the question: Did a doctor (or other health professional) ever tell you that you had asthma? Thus, lifetime asthma prevalence approximately estimates all respondents that report having asthma at some point in their lives (i.e., Lifetime Current + Former). Table 2-1: Asthma prevalence category definitions: respondent answers to BRFSS survey questions
Prevalence Category Lifetime Current Former Never 1. Has a doctor ever told you that you have asthma? YES YES YES NO 2. Do you Still have asthma? YES, NO, DONT KNOW, or REFUSED YES NO Not Applicable
In 2005, in an attempt to estimate the prevalence of asthma among children, the DC BRFSS survey asked the following two (2) questions to households with children: Has a doctor, nurse or health professional ever said that the child has asthma? Does the child still have asthma? The same interpretation of the prevalence categories applies to the survey questions related to childhood prevalence of asthma.
2.2. Asthma Prevalence in the District

The District of Columbia BRFSS survey results were evaluated in search of significant trends, and patterns of asthma prevalence. Figure 2-2 illustrates the relationship between lifetime, current, and former asthma prevalence. In 2005, 15.3% of respondents reported having lifetime asthma. Of these, approximately 9% reported having current asthma, and about 6% reported being diagnosed with asthma sometime in their lifetime, but no longer have asthma symptoms (former asthma prevalence).
Figure 2-2: Prevalence of adult asthma in the District of Columbia
Percentage
Source: District of Columbia Behavioral Risk Factor Surveillance System, 2007
Figure 2-3 shows that asthma prevalence in the District has been on an upward trend from 2000 through 2005. In 2000, the prevalence was estimated at 11% and rose steadily to 15.5% in 2006, which is a 29% increase. The prevalence increase from 2000 to 2006 is statistically significant at p<0.05. There was a drop in prevalence in 2003 in both the District and national lifetime asthma prevalence. In general, the District lifetime asthma prevalence is higher than the US lifetime asthma prevalence. However, both the District, and US lifetime asthma prevalence trends followed the same pattern from 2000-2004, but diverged in 2005. Figure 2-3 indicates a downward trend in 2005 for the US data relative to 2004, but a plateau in the DC prevalence rate. In 2006 and 2007 the District remains at about the prevalence rate, while the US increases at a faster rate. Figure 2-3: Lifetime asthma prevalence in adults over 18, District vs. US
Percentage
Source: District of Columbia Behavioral Risk Factor Surveillance System
In Figure 2-4, the current asthma prevalence trend in the District has a similar pattern as the lifetime asthma prevalence trend, with a slight peak in 2002, and slight drop in 2003. There was an approximate increase of 19% in prevalence from 2000 (7.9%) to 2007 (9.4%). Overall, current asthma prevalence is higher in the District as compared to the nation; with the highest difference of 18% occurring in 2002. Figure 2-4: Current asthma prevalence in adults over 18, District vs. US
Percentage
2.2.1. Asthma Prevalence by Gender

Approximately the same proportions of males (15.1%) and females (15.5%) have reported having lifetime asthma as seen in Figure 2-5. There is a statistically significant difference in the prevalence of current asthma among adult males (6.7%) and females (11.3%) at p<0.05, with females having a 41% higher prevalence rate than males in 2005. A higher proportion of males who have been diagnosed with asthma, but no longer have asthma is indicated in the data provided. The prevalence of former asthma is significantly higher (twice as high) among males (7.8%) as compared to their female counterparts (3.9%). Figure 2-5: Prevalence of adult (18 years) asthma by gender
Percentage
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2.2.2. Asthma Prevalence by Race/Ethnicity

Non-Hispanic black respondents have a higher prevalence of current asthma as compared to Hispanics or non-Hispanic whites as shown in Figure 2-6. There is a statistically significant difference in prevalence of 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. There was a 23% higher prevalence of lifetime asthma among non-Hispanic blacks as compared to non-Hispanic whites. The prevalence of lifetime asthma among Hispanics is 33% higher than their non-Hispanic black counterparts. The prevalence rate for former asthma by race was more than twice as high for Hispanics in comparison to non-Hispanic blacks or whites. Figure 2-6: Prevalence of adult (18 years) asthma by race/ethnicity
Percentage
2.2.3. Asthma Prevalence by Age Group

In 2007, the highest lifetime asthma prevalence was reported among 18-24 year old residents (24.8%) followed by the 25-34 year olds (18%), as shown in Figure 2-7. The lifetime asthma prevalence for both 18-24 and 25-34 year old respondents was significantly higher than their 65 year, and older counterparts. In addition, the prevalence for 18-24 year olds was approximately twice the prevalence for ages 35-44, 45-54, and 55-64; this was statistically significant.
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Figure 2-7: Prevalence of adult (18 years) asthma by age group
Percentage
Similarly, Figure 2-7 also shows that 18-24 year olds reported the highest current asthma prevalence (15.4%) and respondents 65 years old and over had the lowest current asthma rates (6.3%). The prevalence of current asthma among 18-24 year olds was more than twice that of those 65 years old and over at p<0.05. The highest former asthma prevalence was among 18-24 year olds and the lowest among 55-64 year olds. There was a significantly higher former prevalence rate among 25-34 year olds respondents as compared to their 35-44, 45-54, and 55-64 years old counterparts.
2.2.4. Asthma Prevalence by Socioeconomic Status

In this report, household income and respondents education level was used as an estimate of socioeconomic status. Education level was stratified into four categories as shown in Figure 2-8. The data revealed that the current asthma prevalence among respondents with less than a high school education was two times higher as compared to those with a college graduate education. Correspondingly, respondents reporting less than a high school education had an almost six times lower former prevalence rate than all other respondents with some level of higher education attainment. This means that respondents with asthma who had attained a high school education or greater were able to manage their asthma symptoms better than those with less than a high school education. In lifetime asthma, the asthma prevalence was slightly lower among respondents with a college graduate education as compared to all other education categories although this difference was not statistically significant.
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Figure 2-8: Prevalence of adult (18 years) asthma by education level
Percentage
Figure 2-9 shows the highest prevalence of lifetime, and current asthma among respondents reporting a household income less than $15,000. Data analysis showed no statistical significant differences between income groups for lifetime, and former asthma. However, there was a significantly higher current asthma 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 respondents reporting less than a $15,000 household income than those reporting an income above $75,000. Figure 2-9: Prevalence of adult (18 years) asthma by income level
Percentage
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2.2.5. Asthma Prevalence by Ward

Figure 2-10 and Figure 2-11 show current and former asthma prevalence by ward respectively. Confidence intervals for the ward data are very wide, and indicative of unstable data due to a small N within each category. Thus, caution should be exercised when interpreting the data. Figure 2-10 shows that Wards 2 and 8 have the highest prevalence of current adult asthma. Ward 8 has the lowest median household income and one of the highest proportions of non-Hispanic black residents in the District; both of which are risk factors for asthma. The high asthma prevalence of Ward 2 is not easily explained by socioeconomic and other risk factors since it has a higher median household income than the District as a whole, and has one of the highest proportions of non-Hispanic white residents. However, the 95% Confidence Interval for current asthma prevalence in Ward 2 is very wide, thus the data is not reliable. Figure 2-10: Prevalence of current adult (18 years) asthma by ward
Percentage
Figure 2-11: Prevalence of former adult (18 years) asthma by ward
Percentage
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Wards 3 and 4 have the lowest prevalence of current asthma, and correspondingly have the highest former adult asthma. Ward 3 and 4 both have the highest median household incomes, and the lowest number of Medicaid recipients in the District. These results are consistent with earlier findings 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 of Health (NIH) released clinical guidelines for the identification of 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% of respondents who were obese, 8% who were overweight, and another 8% of normal weight (BMI >18 and <25) had asthma. Table 2-2 showed that the odds (or likelihood) of having asthma among respondents who were obese was almost two (2) times higher than their normal weight or overweight counterparts.
Flu and Pneumonia Vaccination and Asthma

Approximately 13% of respondents over 65 years of age who received a flu shot had asthma in 2005. Approximately 12% of respondents over 65 years of age who received a pneumonia vaccination had asthma. The data presented in Table 2-2 also show that there is significantly higher asthma prevalence (almost two times higher) among residents over 65 years of age who received a flu shot, as compared to those who did not. Similarly, the odds of having asthma are 1.43 times higher among those who had a pneumonia vaccination as compared to those who did not. These findings do not necessarily indicate a causal link between pneumonia or flu vaccinations, and asthma. This observation may be due to the fact that those who have asthma are more conscious of their health, and seek to manage their asthma by reducing their chances of respiratory illness by receiving flu and pneumonia vaccinations.
Tobacco Smoking and Asthma

In 2005, 12% of current tobacco smokers had asthma. The likelihood of having asthma among tobacco smokers is almost twice as much as among non-smokers. This data suggests that an irritated and weakened respiratory system may make smokers more susceptible to asthma.
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Table 2-2: Prevalence of risk factors among BRFSS respondents with current asthma, 2005
N Weight Status Normal weight Overweight Obese Flu shot No flu shot Pneumonia No pneumonia Smokers Non Smokers 1,635 1,173 696 1,029 2,681 691 2,700 663 3,040 186,128 141,768 92,351 112,487 334,748 81,067 324,615 89,600 357,377 8.0% 7.7% 13.7% 13.2% 7.9% 11.6% 8.4% 12.4% 8.4% (5.8-10.3) (5.7-9.7) (10.5-16.9) (9.7-16.7) (6.5-9.2) (8.5-14.7) (6.9-9.9) (8.8-16.0) (7.0-9.8) 0.55 0.53 ref 1.77 ref 1.43 ref 1.54 ref (0.53, 0.56) (0.51, 0.54) < 0.001 < 0.001 Weighted N Current Asthma 95% CL Odds Ratio OR 95% CL P-Value
Immunization Age 65+ (1.74, 1.81) (1.40, 1.47) < 0.001 < 0.001
Tobacco Smoking (1.51, 1.58) < 0.001
Source: District of Columbia Behavioral Risk Factor Surveillance System % is based on weighted numbers. N is number of people interviewed. Current asthma is those respondents who have been told by a doctor or other health professional that they had asthma and who still currently have asthma. All respondents are adults age 18 years and above except for the immunization who are age 65 years and older. Weight Status: Normal weight (18 < BMI < 25), Overweight (25 < BMI < 30), Obese (BMI 30)
2.2.7. Asthma Prevalence among Children

According to the 2005 BRFSS data, 11.4% of District children under the age of 17 years were reported to currently have asthma, and 4% to have had asthma in the past, as shown in Figure 2-12. However, Figure 2-13 shows that there were no significant differences by gender for both current and former asthma prevalence among children (17 years) in the District. Figure 2-12: Prevalence of childhood (17 years) asthma
Percentage
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Figure 2-13: Prevalence of childhood (17 years) asthma by gender
Percentage
Figure 2-14 shows that children living in a household where a non-Hispanic black adult responded to the survey had higher asthma prevalence than children living in a household where the adult respondent was non-Hispanic white (13.1% vs. 9.3%). This is a 29% higher prevalence rate of asthma among nonHispanic black children as compared to their non-Hispanic white counterparts. There was negligible difference in former asthma prevalence rate by race among children. The low number of Hispanic respondents for the childhood asthma subset of questionsis not representative. Therefore, further analysis is not feasible. Figure 2-14: Prevalence of childhood (17 years) asthma by race
Percentage
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Figure 2-15 shows that approximately 8% of District children under the age of 9, and almost 16% between ages 9 to 17 had asthma in 2005. There is a 47% higher current asthma prevalence rate among 9 to 17 year old children compared to those less than 9 years of age. Figure 2-15: Prevalence of childhood (17 years) asthma by age group
Percentage
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3. Asthma Management and Quality of Life

characterizes the experience of individuals with asthma in the District by describing their asthma management, and quality of life as measured by age at first diagnosis, frequency of inhaler use, routine doctor visits, rate of asthma attack, and activity limitation due to asthma.
Appropriate disease management improves the quality of life of persons with asthma. This section
3.1. Measuring Asthma Management and Quality of Life

In 2003, the Districts BRFSS surveillance study began to include questions related to asthma management and quality of life issues that would be used to estimate the severity of symptoms in those with current asthma. These questions were administered to adult (18 years) respondents who reported having current asthma. The number sampled in this module was small because this section of the total survey only sampled persons with current asthma (a smaller segment of the population). In this section of the report, only results from data collected in 2005 were available for analysis. In future reports, data for multiple years will be combined in order to better describe the quality of life and disease management for subgroups with asthma.
3.2. Asthma Severity

Asthma severity can be measured by the number of asthma episodes reported, the number of asthma related doctors visits, and the frequency of inhaler use. The following three sections examine each of these indicators for significant 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 of asthma or an asthma attack? As shown in Figure 3-1 for the year 2005, approximately 45% answered yes, indicating that they had an episode of asthma or an asthma attack in the past 12 months.
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Figure 3-1: Occurrence of asthma episodes
Percentage
In 2005, male respondents (50.7%) reported experiencing a higher proportion of asthma attacks in the past 12 months as compared to females (41%). However, Figure 3-2 indicates that the differences were not statistically significant by gender. Similarly, there was no significant difference in the respondents experiencing asthma attacks by race. Figure 3-3 shows that 43.5 % of non-Hispanic whites and 45.8% of non-Hispanic blacks who currently have asthma responded that they had experienced an episode of asthma or an asthma attack during the previous year. Data on Hispanics was insufficient to include in the analysis. Figure 3-2: Episodes of asthma by gender
Percentage
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Figure 3-3: Episodes of asthma by race
Percentage
3.2.2. Routine Doctor Visits

The BRFSS was also used to estimate the frequency of routine doctor visits among those reporting current asthma. These respondents were asked: During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma? Figure 3 4 shows that the majority of respondents (32%) with current asthma reported that they have routine doctor visits two to four times a year. About 30% reported either zero or one routine visit per year. The survey data shows that a significantly lower proportion of respondents (8.6%) with current asthma have five or more routine doctor visits a year. Figure 3-4: Frequency of visits to a doctor for routine asthma checkups
Percentage
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Figure 3-5 shows that men tend to visit the doctor for routine asthma checkups less frequently than women (zero or one time). Women tend to have routine checkups more often (2-4 times or 5+ times). This may be indicative of the severity of asthma problems among women as compared to men or of other factors such as differences in healthcare-seeking behaviors. However, there are no statistically significant differences between frequencies of routine doctor visits by gender. Figure 3-5: Frequency of visits to a doctor for routine asthma checkups by gender
Percentage
When stratified by race, Figure 3-6 shows that non-Hispanic whites tend to visit the doctor for routine asthma checkups less frequently (none or once per year) and non-Hispanic blacks tend to have routine checkups more often (2-4 or 5+ times per year). Black respondents indicated significantly higher frequency (more than twice) of routine doctor visits at 2-4 times than whites. Correspondingly, nonHispanic black respondents had more than twice the frequency of routine doctor visits at >5 times per year as compared to their white counterparts. This difference by race could be indicative of the severity of asthma problems among black non-Hispanics; i.e. non-Hispanic blacks are visiting the doctor more because they have asthma symptoms more often. Figure 3-6: Frequency of visits to a doctor for routine asthma doctor visit by race
Percentage
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3.2.3. Inhaler Use

Respondents with current asthma were asked: During the past 30 days how often did you take a prescription 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% indicated 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 of inhaler use to stop asthma episodes
Percentage
As illustrated in Figure 3 8, a higher percent of males (34.4%) used an inhaler 1-4 times in the past month as compared to females (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 of inhaler use to stop asthma episodes by gender
Percentage
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Figure 3-9 shows that almost twice as many non-Hispanic black respondents with asthma (34.6%) reported using inhalers 1-4 times in the past month to stop an asthma attack as compared to their non-Hispanic white counterparts (19.3%). More than twice as many non-Hispanic black respondents (12.3%) reported using an inhaler 5 or more times in the past month to stop asthma attacks as compared to non-Hispanic whites (5.1%). Figure 3-9 also shows that reports of never using an inhaler to stop asthma attacks were 43% higher among non-Hispanic whites than non-Hispanic blacks. Figure 3-9: Frequency of inhaler use to stop asthma episodes by race
Percentage
3.3. Asthma Quality of Life

Some factors which may serve as quality of life indicators among persons with asthma include age of first diagnosis, and limited activity. The following two sections examine each of these indicators for significant trends.
3.3.1. Age at First Diagnosis

To characterize the quality of life of the Districts residents with asthma, the BRFSS was used to ask questions on age of first diagnosis and limitation of usual activity due to asthma. Age at first diagnosis among respondents who currently have asthma can be used to roughly estimate the quality of life; i.e., the length of life spent with symptoms. However, limitation of usual activity is a more direct estimate of the quality of life. The BRFSS asked adult respondents with current asthma: How old were you when you were first told by a doctor or other health professional that you had asthma? In 2005, the highest percentage (22%) of respondents with current asthma reported that they were first diagnosed with asthma at the age of 19 or younger, as shown in Figure 3-10. A significantly (almost three times) higher proportion of respondents with current asthma reported first diagnosis before 19 years of age as compared to respondents 40-59 years. In addition, there is a statistically significant difference between respondents that were first diagnosed before the age of 19, and those diagnosed after sixty years of age, with almost five times 24 Burden of Asthma in the District of Columbia
higher prevalence of first diagnosis at an age younger than 19 years. There are also significantly (two times) higher proportions of respondents with current asthma reporting first diagnosis between 20-39 years of age as compared to those 40-59 years of age. Similarly, the proportion of respondents reporting first diagnosis at 20-39 years of age was four times higher than those reporting first diagnosis after 60 years of age. In summary, a significantly higher proportion of respondents with current asthma were first diagnosed with asthma below the age of 39 years. Figure 3-10: Age at first diagnosis among respondents with current asthma
Percentage
In Figure 3-11, the age in reference to first asthma diagnosis was examined by gender. Among respondents with current asthma the 25.5 % of males were first diagnosed below 19 years of age. On the other hand, the highest proportion of women reporting initial diagnosis was between ages 20-39 years. Thus, this data shows that men tend to be diagnosed earlier than women in the Districts population. Females had a three times higher first diagnosis rate between 20-39 years as compared to males and this was statistically significant at p<0.05. Figure 3-11: Age when diagnosed with asthma by gender
Percentage
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Age at first diagnosis was also stratified by race. Figure 3 12 shows that the highest proportion of nonHispanic whites reported initial diagnosis before the age of 19 years. Meanwhile, the highest proportion of non-Hispanic blacks reported initial diagnosis between 20-39 years of age. However, the differences by race were not statistically significant. Figure 3-12: Age when diagnosed with asthma by race
Percentage
3.3.2. Limited Activity

Asthma severity can also be measured by a persons inability to work or carry out usual activities of daily living. The 2005 BRFSS asked District respondents with current asthma: During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma? Approximately 12% of respondents with current asthma indicated that they were unable to work or carry out usual activities due to asthma for 1-5 days as shown in Figure 3-13. Almost 10% of respondents with current asthma indicated that their work or usual activity was restricted due to asthma for six or more days. Figure 3-13: Days of missed work or usual activities because of asthma
Percentage
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Data on limitation of usual activity was further characterized by gender. Figure 3-14 shows that in 2005, there were no significant differences by gender in respondents reports regarding days of missed work or restriction of usual activity due to asthma. Figure 3-14: Days of missed work or usual activities because of asthma by gender
Percentage
The data on limitation of usual activity was also stratified by race. Figure 3-15 shows that about twice as many non-Hispanic black respondents indicated 1-5 days of missed work or restriction in usual activity due to asthma as compared to non-Hispanic whites. The percentages by race were similar among those reporting six or more days of missed work or restriction in usual activity because of asthma. Figure 3-15: Days of missed work or usual activities because of asthma by race
Percentage
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4. Asthma Morbidity To estimate asthma morbidity, this section utilizes hospitalization, and emergency department (ED)
visit data. Hospitalization information was obtained from the District of Columbia hospital discharge data collected by the DC Hospital Association (DCHA). Emergency Department data was obtained from the eight area acute care, non-military hospitals by a project of the Childrens Research Institute, Improving Pediatric Asthma Care in The District of Columbia (IMPACT DC).
4.1. Hospitalization Due to Asthma

Asthma hospitalization was defined as primary diagnosis of asthma using the International Classification of Diseases: the 9th Revision (ICD-9) Code 493.0 through 493.9. Hospitalization is defined as an admission for 24 hours or more. It is also important to note the dataset is not measuring the number of individuals having an asthma complication, but the number of hospitalizations. Asthma is the third-ranking cause of hospitalization among children in the United States. In the District, the frequency of asthma hospital discharges for adults and children has steadily decreased from 1,525 in 1997 to 1,087 in 2005, which accounts for a 29% decrease. Similarly, Figure 4-1 shows a general decreasing trend in the crude asthma hospital discharge rate from 2002 (20.15 per 10,000 persons) to 2005 (17.1 per 10,000 persons). Thus, the hospital discharge dataset shows a decrease in the frequency of asthma hospitalization from 1997 to 2005 which may indicate a decrease in asthma severity in the population. Similarly, there has been a decrease in the frequency of hospital discharge among the Districts children from 2000 to 2005. In 2000, there were 425 children younger than 18 years of age who were discharged from DC hospitals with a primary diagnosis of asthma. By 2005 this number had decreased by 37% to 267 children.
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Figure 4-1: Crude asthma hospitalization rate in the District of Columbia
Rate (per 100,000)
Source: District of Columbia Hospital Association
4.1.1. Asthma Hospitalization by Age

The hospital discharge data was stratified into five-year age groups to identify at risk populations by age. Table 4-1 and Figure 4-2 show that from 2002 to 2005 the highest rate of hospitalization occurred among young children (under five years old), middle aged (45-49 years), and the elderly (60-74). Figure 4-2: Hospitalization rates due to asthma by age group in the District of Columbia
Rate (per 100,000)
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Table 4-1: Number and rate of hospitalization due to asthma by age group in the District of Columbia
2002 Age Group Children <5 5-9 10-14 15-17 Adults 18 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75+ Total
* per 100,000 Source: District of Columbia Hospital Association
2003 Count Rate*
2004 Count Rate*
2005 Count Rate*
Count
Rate*
158 102 63 20
466.0 324.0 202.8 127.6
122 98 68 31
358.1 333.3 220.5 205.9
119 67 40 17
328.5 238.7 129.5 110.1
121 74 52 20
315.8 266.9 171.7 121.2
48 36 53 101 121 152 112 75 89 54 65 103 1,352
72.7 66.1 101.8 223.1 288.8 390.2 298.4 248.0 374.3 297.3 395.9 303.3 201.5
41 24 51 106 128 178 143 89 88 97 64 117 1,445
65.8 42.6 99.8 246.7 316.8 475.0 397.0 292.5 371.4 523.4 407.7 349.1 221.0
24 21 38 65 77 129 124 75 75 57 58 123 1,109
41.5 36.2 75.6 154.7 191.6 350.1 348.9 239.4 309.5 298.8 387.4 368.9 171.8
23 29 42 46 87 113 115 91 59 61 47 107 1,087
44.2 48.3 86.2 109.5 220.1 309.2 329.5 281.6 241.8 314.6 322.5 321.8 171.0
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4.1.2. Mean Length of Stay

The mean length of stay (LOS) for asthma hospital discharges from 1997 to 2003 had very little variability with an average LOS of 3.7 days. For all hospitalizations in the District, the mean LOS decreased from 6.7 days in 1997 to 5.8 days in 2003 as shown in Figure 4-3. Figure 4-3: Mean length of stay for asthma-related discharges and total hospital discharges
Number of Days
4.2. Emergency Department Visit Due to Asthma

Emergency department (ED) data for asthma was collected and analyzed for the years 2002 through 2006. The dataset captured all resident visits made by children (age 12 months to 17 years). Data on adult use of the emergency department were captured for the years 2005 and 2006. Data include all visits with primary, secondary or tertiary diagnosis of asthma and is collected retrospectively. The ED data were collected uniformly from all non-military District hospitals following established protocols. While some proportion of these visits are made by individuals who do not live in the District (for example, 30% of all visits and nearly 40% of pediatric visits in 2005), the data presented below include only ED visits made by District residents.
4.2.1. Age-adjusted ED Visit Rates

The 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 of ED visits increased from 2005 to 2006. However, this increase was primarily among females who had an 11% increase in their ED visit rate in the same period.
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Figure 4-4: Age-adjusted rates of emergency department visits due to asthma among all residents in the District of Columbia
Rate (per 10,000)
Source: Improving Pediatric Asthma Care in the District of Columbia, 2005 -2006
Figure 4-5 shows that in 2005 and 2006, the rate of 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 for the 1-4 year old age group should be interpreted with caution for several reasons. To begin with, it is often difficult to elicit enough cooperation from these young children to obtain accurate objective pulmonary function assessments. More importantly, these young children are prone to temporary reactive airway conditions for developmental reasons. Also, it is possible that these children may spend less time outdoors than older school-age children. Therefore, there is some debate over whether children younger than five years are always accurately diagnosed as asthmatic when in fact some of them might be suffering from a more temporary reactive airway condition that may or will disappear as they grow older.11 (This is a controversial statement and/or issue in the asthma community.) Figure 4-5: Total emergency department visits due to asthma in the District of Columbia
Rate (per 10,000)
Source: Improving Pediatric Asthma Care in the District of Columbia, 2005 -2006
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4.2.2. ED Visits by Gender

In 2006, males below the age of 15 years had a higher ED visit rate than their female counterparts. However, females surpassed the ED rate of males after the age of 15, around the age of puberty. Tucson Childrens Respiratory Study, a prospective population-based birth cohort study designed to examine respiratory health followed about 1,300 subjects, found that there is some relationship between asthma and puberty. The study reported that females who became overweight or obese between the ages of six and 11 years had an increased risk of developing new asthma symptoms during early adolescence. The results of the study found that girls, but not boys, who became overweight between six and 11 years of age were five to seven times more likely to develop new asthma symptoms at ages 11 and 13 compared to girls who were not overweight. The strongest association was between the overweight status and asthma risk among females who experienced puberty before the age of 11 years. Overweight females were associated with early menarche. Thus, there might also be a link between overweight status, puberty, and development of asthma. The biological process involved in the possible association of puberty and asthma is not clear. There have been speculations that hormones present during puberty have a role in the process, but studies have not been conclusive. Figure 4-6: Emergency department visits due to asthma by gender in the District of Columbia
Rate (per 10,000)
Source: Improving Pediatric Asthma Care in the District of Columbia, 2006
4.2.3. ED Visits among Children

In 2002, the rate of ED visits among children (1 to 17 years) was 344 per 10,000 persons, as shown in Figure 4-7. In 2006, the rate had increased by 15% to 395 per 10,000 persons. When the data were analyzed by gender, the age-adjusted rates for males were consistently higher for all five years.
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Figure 4-7: Age-adjusted rates for children in the District of Columbia
Rate (per 10,000)
Source: Improving Pediatric Asthma Care in the District of Columbia 2007 Data Report
4.2.4. Insurance
The type of patient insurance can be used as a proxy estimator of the socioeconomic status of the patient; which has already been demonstrated as an important factor in asthma prevalence. In general, patients with public insurance (Medicaid or Medicare) or no insurance tend to be of lower income strata. Studies have shown that these individuals are at a higher risk for asthma. In 2006, 70% of asthma emergency department visits in the District were covered by public insurance, 20% were private, and 7% had no insurance. This is seen in Figure 4-8. Thus, the data reveals that a majority (77%) of the ED patients diagnosed with asthma were most likely to be of a lower economic status. This finding is consistent with studies showing that low income individuals or people with no insurance were present at the ED more often with disease that had progressed, compared to those with a higher economic status. Figure 4-8: Distribution of insurance among emergency discharge asthma patients in the District of Columbia
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4.2.5. Disposition
Disposition describes the status of the person once they have received treatment at the emergency department. There are five possible categories of disposition: 1) discharge, 2) admitted to hospital, 3) left against medical advice, 4) transferred or 5) died. Figure 4-9 shows that in 2006, the highest proportion (72%) of asthma ED visits were discharged. However, approximately 17% of the ED visits were severe enough to warrant hospitalization, and the outcome for less than 0.1 percent (or 5 people) of the visits was death. Figure 4-9 also shows that out of those who were admitted into the hospital from ED, 28.1% were below the age of 20 years, 35.2% were 40 to 59 years, 18.2% were 60 to 79 years, 13.5% were 20 to 39 years, and 5% were 80 years and over. This analysis is comparable to the hospital discharge data that shows the highest rates of hospitalization was among children, followed by 40 to 50 year olds, and the elderly, respectively.
Figure 4-9: Disposition of emergency department visits due to asthma in the District of Columbia Even though the total number of ED visits among 1-4 year olds is the highest (over 1,700), the rate of hospital admittance among this age group is relatively small. Figure 4-10 shows that once the data is normalized by the total for each age category, (i.e. the sum of each of the three categories of: discharged, admitted, and died was divided by the total number of ED visits for that age group), the proportion of those admitted out of the 1,600 was less than 20% of the total ED visits for that age group. In contrast, while there was a lower frequency of ED visits (less than 100 visits) among those ages 85 years and older, the proportion of those admitted for hospitalization was about 46.7%. Therefore, Figure 4-10 suggests that there is an increase in hospital admission from ED with an increase in age. This result is also validated by hospital discharge age-specific data (Figure 4-2). One possible reason is that persons from older age groups were admitted at a higher proportion, and it may be that this population tends to suffer from other illnesses that complicate and exacerbate their asthma.
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Figure 4-10: Frequency of disposition of emergency department visits due to asthma in the District of Columbia
Percentage
37
38
5. Asthma Mortality Asthma mortality data was obtained from the District of Columbia State Center for Health Statistics,
Vital Records Division. Data on death was abstracted from death certificates. Asthma deaths were defined as the primary cause of death as coded by the Tenth Revision of the International Classification of Diseases (ICD-10), code J45 and J46.
5.1. Mortality Count by Subgroups

The annual asthma deaths in the District of Columbia from 1999 to 2005 were low (less than 15 per year). However, some patterns can be observed. From years 1999 to 2005, a total of 67 deaths were attributed to asthma. A majority of the asthma deaths occurred among non-Hispanic blacks. Meanwhile, for all the six years combined only six deaths (as compared to 61 deaths in non-Hispanic blacks) occurred among Non-Hispanic whites. Mortality data by age group reveals that more asthma deaths occurred among adults as compared to children (0-17 years), and the number of asthma deaths increased by age. There were no deaths due to asthma among 0-4 year-old children from 1999 to 2005. Table 5-1: Annual asthma mortality count in the District of Columbia, 1999-2005
1999 Sex Race/ Ethnicity Male Female White Black Other 0-4 5-17 18-44 45-64 65+ 1 2 3 4 5 6 7 8 3 8 1 10 0 0 1 2 4 4 2 2 0 1 0 0 4 2 11 2000 5 5 0 10 0 0 0 1 2 7 1 0 0 4 1 1 2 1 10 2001 5 4 0 9 0 0 0 2 4 3 1 1 0 1 2 0 3 1 9 2002 3 3 0 6 0 0 1 3 1 1 1 0 0 1 1 2 0 1 6 2003 5 4 1 8 0 0 0 1 4 4 1 1 1 0 1 1 1 3 9 2004 7 7 2 12 0 0 0 4 6 4 0 3 0 1 4 1 3 2 14 2005 4 4 2 6 0 0 0 2 2 4 1 1 0 2 2 0 2 0 8 1999-2005 32 35 6 61 0 0 2 15 23 27 7 8 1 10 11 5 15 10 67
Age
Ward
Total
Source: District of Columbia State Center for Health Statistics
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5.2. Mortality Rate

The age-adjusted mortality rate in the District of Columbia was 11.6 per 100,000 from 1999 to 2005 (Figure 5-1). Overall, deaths from asthma appear to have decreased from 2.0 per 100,000 in 1999 to 1.4 per 100,000 in 2005, with a slight decrease from 1999 to 2002 and a slight increase from 2002 to 2004. However, since less than 50 annual asthma deaths occur on average in the District of Columbia, annual mortality rates are quite variable. Therefore, annual comparisons should be made with caution. Figure 5-1: Annual asthma mortality rate in the District of Columbia, 1999 2005
Rate (per 100,000)
5.3. Mortality Rate by Sex, Race and Age Group

The asthma annual mortality data was too small to stratify by sex, race, or Ward. Thus to compensate, the 1999 to 2005 data were aggregated. Even after aggregation, rates need to be interpreted with caution since some mortality counts were less than 50. The age-adjusted asthma mortality rate for District males appears to be higher (12 per 100,000) than for females (11.2 per 100,000). Figure 5-3 shows mortality rates stratified by sex and age group. Overall, the graph shows that the asthma death rate increases with age. Through closer inspection, it appears that the asthma mortality rates for males and females follow closely and with a similar pattern. However, they diverge at four points during a life span: 30s, mid 40s, mid 50s, and 80s. Starting at the age of 30 years there is an increase in the asthma mortality rate in males and a decrease in females. However, at age 44, asthma mortality rates for females surpass those of males and again we see a reverse of this trend at age 55. At the age of 80, there is a decrease in male asthma mortality while female asthma mortality continues to increase. In order to determine the validity of this pattern, data from a greater number of years need to be aggregated to increase the sample size from which data are analyzed. The asthma mortality rate from 1999 to 2005 was 14.0 per 100,000 and 3.8 per 100,000 for non-Hispanic black and non-Hispanic white District residents, respectively (Figure 5-2). The non-Hispanic black asthma mortality rate was approximately four times higher than their non Hispanic white counterparts.
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Figure 5-2: Asthma mortality rate by sex and race, District of Columbia, 1999-2005
Rate (per 100,000)
Figure 5-3: Asthma mortality rate by age group, District of Columbia 1999-2005
Rate (per 100,000)
5.4. Mortality Rate by Ward

The Districts asthma mortality rate was stratified by Ward in order to determine the geographical differences. Wards 7, 5 and 8 had the highest asthma mortality rates and Ward 3 had the lowest asthma mortality rates in the District from 1999 to 2005. The data revealed that most asthma deaths occurred amongst non-Hispanic black individuals. Wards 7, 5 and 8 have the highest proportion of non-Hispanic black residents in the District, while Ward 3 has the lowest (see Table 1-2).
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Figure 5-4: Crude asthma mortality rate by ward, District of Columbia 1999-2005
Rate (per 100,000)
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6. Work-Related Asthma 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 confirming the cause of the diagnosis of asthma and by establishing a relationship between asthma and the workplace. WRA is suspected in every adult-onset case or asthma that is exacerbated in adult life. There are over 250 workplace agents associated with WRA. The most common include protein molecules (wood dust, grain dust, animal dander, fungal substances, and latex) or chemicals like diisocyanates. This type of asthma is partially or completely preventable and reversible, if irritants are controlled or stopped.12 Workers at an increased risk include those in professions that deal with wood or metal works, laboratory and health care workers, and drug and detergent manufacturers. Based on previous studies in other states, work-related asthma has occurred more in operators, fabricators, and laborers (32.9%), followed by managerial and professional specialties (20.2%).13 Smoking in the workplace which also contributes to the exposure to secondhand smoke is another known asthma irritant. The District of Columbia has an economic profile that includes industries in which occupational asthma is a frequent health risk. These 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. This is likely true of all occupational diseases, especially occupational respiratory disorders which are often misattributed to non-occupational etiologies such as smoking or non-occupational allergens. Furthermore, measuring the prevalence of reported WRA in the United States has been challenging due to the lack of a centralized comprehensive reporting or surveillance system. Currently, most WRA data are ascertained from workers compensation databases and the social security disability index. However, the National Institute of Occupational Safety and Health (NIOSH) has funded a state-based surveillance program. The program includes four states: New Jersey, California, Massachusetts, and Michigan which actively solicit occupational asthma reports from physicians. Data from these four states from 1993-1999 show over 2,500 cases of WRA. Alternatively, the respiratory disease surveillance system, Surveillance of Work and Occupational Respiratory Diseases (SWORD) located in the United Kingdom has proven to be an efficient and effective model to provide information on WRA incidences. This 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 of Work-Related Asthma in the District

Data on work related asthma were acquired by DC CAN from the DC Office of Workers Compensation. From 1999-2005, thirty nine (39) claims were filed by District employers whose employees worked in the District of Columbia. This equates to 5.6 per year for the seven-year period. This is an exceptionally low figure and most likely an undercount. The majority of individuals with work-related illnesses however, do not file Workers Compensation Claims. Many self-employed workers such as independent contractors, federal employees, or railroad workers are not covered by the state compensation claims office. In addition, hospital discharge data was reviewed to identify claims paid by workers compensation. However, these efforts yielded minimal results. Because there are no parallel reporting mechanisms or surveillance systems, it is difficult to obtain an accurate estimate of WRA. To ascertain a better estimation of WRA prevalence in the District; in 2006, the DC CAN partnered with the George Washington University Department of Environmental and Occupational Health School of Public Health and Health Services to conduct a WRA study.14 The two objectives of this study were: To determine if cases of WRA are undercounted in the District of Columbia; and To determine the feasibility of a simple active reporting system to monitor WRA cases. The following 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 of Columbia. The survey population that was chosen consisted of a broad range of disciplines including occupational medicine, pulmonary disease, internal medicine, family practice, and general practice. Each specialty was chosen for an increased probability of capturing practicing physicians who were specialists in lung disease, working in a large academic hospital or family practice physicians at a free clinic who would potentially diagnose occupational asthma cases. The survey was administered via internet and US mail. It contained seven questions that took five to seven minutes to complete. The details of this survey are summarized in Appendix A. It consisted of both open ended and restricted choice answers. The survey questions were designed to ascertain: The number of WRA cases diagnosed in 2005; If patients with WRA had submitted a workers compensation claim against their employer; and Which occupations were most likely to be performed by those with WRA. A third party, Medical Marketing Service (MMS), distributed the link to physicians asking them to complete this free-internet survey. After having the internet version of the survey open for three weeks, an additional step was taken to increase the response rate. A mass mailing was sent to all physicians in the District of 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

The response rate for both the internet and mail survey was 16.8%. The study found 46 work related asthma cases in 2005 alone (29 males and 17 females). The average age for those being diagnosed with occupational asthma was 38.6 years old. The most common occupations among patients with WRA reported by physicians in the study were construction laborers and workers in the public administration field (guards, police officers, environmental quality, and housing inspectors). The study resulted in the identification of 18% more cases in one year compared to the Workers Compensation Claims database that spanned seven years. This result confirms the hypothesis that work related asthma is underreported in the District of Columbia. The studys low response rate and relative insensitivity suggests that there are more cases than captured by the study. In order to measure an accurate prevalence of WRA, a more sophisticated survey system with strict case definitions and incentives to solicit increased physician response would be necessary. Alternatively, a surveillance system similar to the GWU WRA Survey and SWORD would efficiently 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 of asthma.
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7. Air Quality and Asthma Asthma is associated with a variety of environmental risk factors 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 of the most important causative factors that contribute to asthma aggravation. Additionally, environmental exposures may be risk factors that are more amenable to change as compared to social or psychosocial problems.15
7.1. Outdoor Environmental Pollutants

There are a variety of outdoor environmental pollutants such as ozone (O ) and particulate matter (PM) that have been found to have an adverse impact on health. Ozone is a gas that is present in two layers of the atmosphere and forms and reacts under the action of sunlight. Higher up in the atmosphere, ozone acts as a protective layer that shields the earth from high levels of Ultra-Violet (UV) radiation. However, ozone at ground-level is considered a major air pollutant. Particulate matter is the sum of all solid and liquid particles suspended in air, many of which are hazardous. This complex mixture contains organic and inorganic particles such as dust, pollen, soot, smoke, and liquid droplets. These particles vary in size, composition and origin. Based on size, particulate matter is divided into two main groups: The coarse fraction contains the larger particles with sizes ranging from 2.5 to 10m (PM10 PM2.5). The fine fraction contains the smaller ones with sizes up to 2.5 m (PM2.5). The particles in the fine fraction which are smaller than 0.1 m are called ultrafine particles. When particulate matter is combined with other air pollutants, the individual health effects of each pollutant are cumulative. In certain cases, especially for combinations of particulate matter with ozone or allergens, harmful effects were shown to be even greater than the sum of the individual effects.
3
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7.1.1. Health Effects

Certain groups of people are more susceptible to suffer adverse health effects due to ambient air pollution. These include elderly people, children, people with pre-existing heart and lung disease, asthmatics, and socially disadvantaged and poorly educated populations. Pollutants, O 16, 17 and PM,18 have been directly linked to airway inflammation and obstruction that leads to respiratory morbidity. Inner cities in the United States, including the District, have social and economic influences (e.g. psychosocial stress, high smoking rates, inappropriate medication use, inadequate resources, and poor access to quality health care) that increase their vulnerability to outdoor environmental exposures.15
3
7.2. Air Quality Standards

In response to adverse health effects of outdoor air pollutants, the Environmental Protection Agency (EPA) has legislated standards for air quality. The Clean Air Act, which was last amended in 1990, requires EPA to set National Ambient Air Quality Standards (40 CFR part 50) for pollutants considered harmful to public health and the environment. The 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 The EPA Office of Air Quality Planning and Standards (OAQPS) has set National Ambient Air Quality Standards for six principal pollutants, which are called criteria pollutants. Table 7-1 lists national ambient air quality standards. Units of measure for the standards are parts per million (ppm) by volume, milligrams per cubic meter of air (mg/m3), and micrograms per cubic meter of air (g/m3).
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Table 7-1: National ambient air quality standards

Pollutant Carbon Monoxide Lead Nitrogen Dioxide Particulate Matter (PM10) Particulate Matter (PM2.5) Primary Standards 9 ppm (10 mg/m )
3
Averaging Times 8-hour

1
Secondary Standards None None Same as Primary Same as Primary Revoked 2 Same as Primary Same as Primary Same as Primary Same as Primary Same as Primary 0.5 ppm (1300 g/m3)
35 ppm (40 mg/m3) 1.5 g/m

3
1-hour 1 Quarterly Average Annual (Arithmetic Mean) Annual 2 (Arithmetic Mean) 24-hour 3 Annual (Arithmetic Mean)
4
0.053 ppm (100 g/m3) Revoked 2 150 g/m3 15.0 g/m3 35 g/m3 0.08 ppm
24-hour 5 8-hour 6 1-hour (limited areas)

7
Ozone
0.12 ppm 0.03 ppm
Sulfur Oxides
Annual (Arithmetic Mean) 24-hour 1 3-hour

1
0.14 ppm
1 Not to be exceeded more than once per year. 2 Due to a lack of evidence linking health problems to long-term exposure to coarse particle pollution, the agency revoked the annual PM10 standard in 2006 (effective December 17, 2006). 3 Not to be exceeded more than once per year on average over 3 years. 4 To attain this standard, the 3-year average of the weighted annual mean PM2.5 concentrations from single or multiple community-oriented monitors must not exceed 15.0 g/m3. 5 To attain this standard, the 3-year average of the 98th percentile of 24-hour concentrations at each population-oriented monitor within an area must not exceed 35 g/m3 (effective December 17, 2006). 6 To attain this standard, the 3-year average of the fourth-highest daily maximum 8-hour average ozone concentrations measured at each monitor within an area over each year must not exceed 0.08 ppm. 7 The standard is attained when the expected number of days per calendar year with maximum hourly average concentrations above 0.12 ppm is < 1, as determined by appendix H. As of June 15, 2005 EPA revoked the 1-hour ozone standard in all areas except the fourteen 8-hour ozone nonattainment Early Action Compact (EAC) Areas. Source: US Environmental Protection Agency
7.3. The Role of Outdoor Air Pollution in the District

In order to develop a comprehensive understanding of the risk factors for asthma, and their complex relationships in the District, it is vital to examine the role of outdoor air pollutants. In 2003, in response to this need, the DC Department of Health partnered with the Johns Hopkins University Applied Physics Laboratory and conducted a study on the relationship between ambient air quality and asthma exacerbations in the District of Columbia. The purpose of the study was to investigate and quantify any correlations between ambient air quality and Medicaid patient asthma exacerbations within the District of Columbia between October 1994 and November 2005. This study was funded as part of a cooperative agreement between the Centers for Disease Control and Prevention and the DOH to develop the District of Columbia Environmental Public Health Tracking Program (DC EPHTP). Burden of Asthma in the District of Columbia 49
The specific objectives of this program were to: Document further the relationship between environmental exposures and human health effects; Gain greater ability to undertake health impact assessment, policy development and assurance; and Generate information that would guide policy development and decision making on prevention and treatment activities, as well as resource allocation.
7.3.1. Study Description

The study employed three sources of data: Daily asthma-related Medicaid patient visits for all ages covering 135 months from October 1994 to December 2005; Air quality data from DC monitoring stations, including aero-allergen data for mold spores and tree, weed, and grass pollen from the US Army Centralized Allergen Extract Laboratory at the Walter Reed Army Medical Center; and Weather data from the National Weather Service data from Reagan National Airport. Case definitions were developed for both asthma-related emergency department (ED) and general acute care visits among Medicaid patients. Asthma-related Medicaid patient ED visits were defined as hospital ED visits of Medicaid patients with asthma-related discharge ICD-9 codes in one of the first three positions of their record. These data are subsets of the data in the next case definition. Asthma-related Medicaid patient general acute care visits were defined as records included in the case definition above plus Medicaid records designated as physician services, outpatient services, nurse practitioner services, federally-qualified health center services, clinic services, emergency ambulance services, Mental Retardation and Developmental Disabilities Administration waiver services, and ambulance services (representing about 63% of the overall Medicaid database). These additional records were also restricted to those with asthma-related ICD-9 codes in one of the first three diagnosis code positions.
7.3.2. Study Results

When seasonal trends of asthma-related visits were examined, the investigators found two annual peaks in both ED and general acute care Medicaid patient visits. The highest peak fell during September 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 of 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 reacts with automobile emissions to produce ozone. Therefore, 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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Of the risk factors considered for Medicaid patient asthma exacerbations (as determined from ED and general acute care visits), ozone and tree pollen were the most significant. During the period of this study, PM10 concentrations did not pose a significant risk factor for Medicaid asthma exacerbations in DC. Listed below are some of the key findings: Of the risk factors considered for Medicaid patient asthma exacerbations (as determined from ED and general acute care visits), ozone and tree pollen were the most significant. Grass pollen effects on asthma exacerbations were strongest for the 5-12 and 13-20 year old age groups. Day-to-day temperature changes revealed that warm-temperature effects increasing asthma exacerbation rates for 5-12 year olds, but may be confounded by tree pollen, ozone, and other effects. The strongest relationship between ozone and asthma-related Medicaid patient visits was seen in the age group of 5-12 year olds. These are school-aged children whose immune systems may not be fully mature and may spend most of their time outside, where they are exposed to the greatest risk for the effects of pollutants. When data from only spring and summer seasons were used, associations of asthma-related visits with environmental data in general were stronger than when data from all seasons were used. This finding was expected because viral respiratory infections, much more prevalent in the fall and winter seasons than in spring and summer periods, are known to trigger asthma exacerbations, and covariate data to control for increases in these infections were unavailable for this study. The stronger spring/summer associations were particularly seen for ozone, which is typically at significant levels only from May through September. When data from all seasons were used, PM2.5 levels were significantly associated with visits for 5-12 year olds; although somewhat less so than were grass pollen levels. Ward 6 had the highest rates of asthma-related ED visits due to homeless Medicaid patients recording a shelter address as their residence and the larger shelters located there. Other possible factors include lack of access to health care facilities due to physical constraints, such as lack of transportation, and poor housing contributing to increased risks of indoor air quality. Wards 8, 6, and 5 showed significant ozone impacts for age groups 13-20, 21-49, and all ages, respectively. When data were further restricted to 1999 (a year with higher than average ozone and PM2.5 concentrations, as well as higher summer temperatures), the ward specific impacts of ozone and PM2.5 on 5-12 year olds were significant and strongest in Ward 7, especially when the EPA measuring site within Ward 7 was used as the source of air pollutant data.
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8. Conclusions In the District of Columbia, approximately 9% of adult residents (40,000 people) and 11% of children
(13,000 children) currently have asthma and about 15% of adults have been diagnosed with asthma at some point in their lifetime (DC BRFSS, 2005). Overall, the prevalence of current asthma has been consistently higher than the national rate for the past six years. In addition, the Districts lifetime asthma prevalence has been on an upward trend from 2000 to 2004 but seems to be stabilizing at 15.2% in 2007. Although asthma affects all segments of the District population, certain subgroups are disproportionately affected by asthma including: Non-Hispanic black population, Very young children aged 0-4 years, especially male children of this age group, Females after puberty (starting from the early teens); Adults aged 45-50 years, The elderly (over 65 years), Tobacco smokers, Obese and overweight residents, Residents with less than or some high school education, and Residents with household incomes less than $15,000.
8.1. Non-Hispanic Black Population

Asthma disparities continue to be an issue in the District, with the non-Hispanic black population being affected most severely. Non-Hispanic black adults have the highest current and lifetime 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 frequency of doctor visits and inhaler use than their non-Hispanic white counterparts. The majority of asthma deaths occur in this population, accounting for 91% of asthma deaths from 1999 to 2005. Similarly, Wards 7, 5 and 8, which are predominantly (over 88%) non-Hispanic black, have the highest District-wide asthma mortality rates. The significant difference in morality rates among non-Hispanic blacks and whites may be an indication of the increased severity among the black population. There is an approximately two fold difference in prevalence (according to the 2005 BRFSS) of asthma among non-Hispanic blacks (10.4%) and whites Burden of Asthma in the District of Columbia 53
(6.6%) in the District. However, there is an almost fourfold difference in the mortality rate between the two races. There are multifaceted factors 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 factors are interconnected and linked to poor socioeconomic status. For example, poor asthma management can be due to lack of 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 Status

In addition to black Non-Hispanics, populations with low socioeconomic status (populations with a low household income and low education attainment) appear to be disproportionately affected by asthma. The 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 the highest unemployment rate, highest Medicaid recipients, and lowest median income in the District, also have the highest mortality rates.
8.3. Children
The National Health Interview Survey 2005 reported that 6.5 million or 9% of US children (<18 years) currently have asthma.21 A higher proportion of the Districts children (11% or 13,000 children) currently have asthma. Children, especially 0-4 year olds, are vulnerable due to their susceptibility to environmental pollutants and other agents that trigger or exacerbate asthma. Children four years and younger have the highest asthma emergency department (ED) visit rates and one of the highest inpatient hospitalization rates among all age groups. Male children in this age group have higher health care utilization for asthma than females. The highest childhood asthma prevalence rate is among 9-17 year olds (16%) according to BRFSS DC in 2005. Despite children experiencing high asthma prevalence and severity, they have the lowest asthma mortality rate in the District, with two deaths among children 17 years from 1999 to 2005.
8.4. Adult and Elderly Population

The Districts middle aged (45-50 years) and elderly (65+ years) populations have the highest hospitalization rate among the adult population. This is also consistent with the increased proportion of hospital admissions from ED among these age groups. In addition, the Districts elderly population had the highest asthma deaths among all age groups. However, both lifetime and current asthma prevalence was significantly higher among 18-24 year olds as compared to the middle aged and elderly populations. Increased asthma severity among the middle aged and elderly may be due to complications from other morbidities, such as pulmonary illnesses that may occur with increasing age. 54 Burden of Asthma in the District of Columbia
8.5. Female Population

District females (11%), 18 years, have a higher current asthma prevalence rate than males (7%). Females, after puberty, have a higher hospital ED visit rate than males. Among District adults with current asthma, females appear to receive the first diagnosis of asthma at a later age (20-39 years) than males, who are diagnosed at an earlier age (19 years). This data suggests that asthma intervention programs need to target teenage and adult females.
8.6. Populations with Other Risk Factors

Fourteen percent (14%) of the Districts residents who are obese (BMI30) and 8% who are overweight (25<BMI<30) have asthma (DC BRFSS, 2005). Populations who are obese appear to have higher risk of asthma than people who have a lower BMI. However, the BRFSS dataset does not allow us to conclude on causality, that is, whether obesity causes asthma or visa versa. This relationship that was found between obesity and asthma in the Districts population is consistent with other studies. A study from the Harvard School of Public Health found that obese patients with severe asthma account for 75 % of ED visits for asthma. On the other hand, when morbidly obese asthma patients lose weight, there is a decrease in asthma symptoms and severity.22 This study reinforced the fact that obesity is a strong predictor of adult asthma and the persistence of childhood asthma into adolescence. The biological processes linking asthma and obesity are not clearly understood. According to the Harvard group, increased abdominal and chest wall mass in obese people results in an under-expansion of the lung which causes the size of breath to be smaller. These factors make it more likely that their airway will narrow. In addition, there is chronic low grade systemic inflammation in the obese originating from fat tissues. There is a higher leptin, a pro-inflammatory hormone derived from fat tissues, level in obese individuals than lean individuals. In contrast, blood levels of adiponectin, a hormone with anti-inflammatory properties, are actually lower among obese individuals. All these factors possibly lead to an increased risk in developing asthma. There are also other speculations that genetic factors may play a role in the relationship between obesity and asthma. Tobacco smoking is another risk factor that increases the likelihood of asthma development among the Districts residents. Twelve percent (12%) of current tobacco smokers have asthma (DC BRFSS, 2005). The proportion of people with asthma was two times higher among tobacco smokers as compared to nonsmokers. This is consistent with other studies that have found an increase in bronchial hyperresponsivness and a decline in lung function among smokers.23 However, scientific evidence of the influence of smoking on asthma development is mixed and controversial. Nevertheless, a prospective population study by Piipari et al. suggests smoking to be an underestimated contributing factor to asthma development.24 Approximately 13% of residents over the age 65 years who received influenza vaccines have asthma, and about 12% of those within the same age group who received pneumonia vaccinations also have asthma. The odds of having asthma appear to be significantly higher among those flu and pneumonia vaccinations. These findings do not necessarily indicate a causal linkage between these vaccinations and asthma. This observation is more likely due to the fact that those who have asthma are more conscious of their health and seek to manage their asthma by reducing their chances of acquiring respiratory illnesses by receiving influenza and pneumonia vaccinations. Burden of Asthma in the District of Columbia 55
8.7. Implications for Asthma Management

Among District adults with current asthma, it appears that asthma management can be improved. Of 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 five or more times in the past month to stop asthma episodes (DC BRFSS, 2005). In addition, 22% of the Districts adult residents with current asthma reported having at least one day in the past twelve months when they were unable to carry out normal activities because of their asthma. Approximately 30% of adults with current asthma reported not visiting the doctor for a routine asthma checkup in the past twelve months thus, not managing their asthma through their primary care giver. This is according to the 2007 Asthma National Asthma Education and Prevention Program (NAEPP) guidelines. There are many obstacles that may impede residents with asthma from managing their asthma efficiently. As indicated by this report, a majority of the Districts residents who are affected by asthma are at-risk, i.e., the poor, children, and the elderly. In 2006, a study targeting these populations conducted focus groups in Wards 7 and 8 on health care and barriers to health care in the District.25 While not specifically related to asthma, the results can be translated to the asthma situation. Findings from the focus groups echo what other research shows i.e., that many complex, interrelated barriers deter residents from accessing health care in general and from receiving primary or preventive care. These barriers include: Lack of insurance, limited finances, and scheduling conflicts; Fear and mistrust of the medical system from lack of understanding of the importance of primary care; Negative experiences with the medical system; and Lack of knowledge of the health care system and need for care.
8.8. Work-Related Asthma

Work-related asthma has proven difficult to estimate in the District due to the lack of an active surveillance system that is designed to capture WRA. The George Washington University study has shown that using worker compensation claims dataset alone underestimates the prevalence of work-related asthma.
8.9. Asthma and Environmental Factors

There is an association between socioeconomic risk factors and environmental factors, as determined by the Johns Hopkins University Ambient Air Study. The wards with poorer socioeconomic status (Wards 5, 6, 7, & 8) and higher Medicaid enrollment tend to show the most significant association with air quality on asthma-related general acute care visits. Therefore, the socioeconomically disadvantaged residents appear to be more susceptible to air pollutants which increase their asthma symptomology. Although the study had limitations and further research needs to be done, the results were consistent with similar studies of asthma and air quality. The results of this study (i.e., that ambient ozone has 56 Burden of Asthma in the District of Columbia
positive correlations with general acute care visits) are very similar to those of other asthma studies in the scientific literature (Weisel et al. 1995,26 Tolbert et al.. 2000,27 Galan et al.. 200328). Kimes et al. (2004)29 observed seasonal variations in ED visits that were almost identical to what was observed in this study. Thus, this study highlights the complexity of risk factors for asthma and the need for employing multifaceted interventions that congruently address socioeconomic and environmental risk factors in the District. A significant proportion of school-aged children, 5-12 years old, with asthma experience exasperations due to grass pollen, warm-temperature, ozone and PM2.5. Children 5-12 years spend a lot of time outdoors which increases their exposure to ambient air and outdoor pollution. School and other asthma intervention programs will have to consider these findings when planning asthma reduction strategies in this age group.
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9. Recommendations Asthma represents a considerable burden on the District of Columbia. Despite some improvements
in asthma prevalence nationally, the District lags behind. There are many opportunities for improvement, 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), schoolaged children, middle aged adults (45-50), and the elderly subpopulations need specific attention when considering the reduction of asthma prevalence, severity and mortality. The reports findings suggest recommendations for improvement in asthma surveillance, management, health disparities and reduction of risk factors and preventable events as outlined below.
9.1. Surveillance System

The District of Columbia needs to improve its ability to collect information on the number of people with asthma in all District populations. The District is an ethnically diverse population with a large group of immigrants. However, data on the number of people with asthma for all subgroups (for example, immigrants, Hispanics, Asians etc.) are not available. Data on emergency department (ED) visits are currently not available by race. Sufficient data are also not available at the level of geographic detail that would aid in planning effective asthma interventions (e.g. wards, districts, school district levels etc.). Smoking is the only asthma trigger information collected by the BRFSS. Triggers in the work place, homes, and schools have not yet been developed into a questionnaire that can be distributed nor captured routinely by any other data system. The District has many aging homes and schools that may be sources of allergens. Data is needed on home, work and school environments, and their health effects on the population. This data can be used to aid patients, health care providers, and asthma project programmers who may be able to effectively target asthma reduction plans. The District lacks adequate work-related asthma data. Currently, the District relies on the DC Office of Workers Compensation database to estimate work-related asthma. However, many selfemployed workers including independent contractors, federal employees, or railroad workers are not covered by the state compensation claims office. This underscores the need for developing a better data collection methodology for work-related asthma in order to better estimate the prevalence of WRA in the District. This may mean forging partnerships with stakeholders (DC Office of Workers Compensation, physicians, employers etc.) to establish an active data collection system. Our knowledge of asthma management completely relies on self-reported survey data for adults. There is limited information readily available in the District related to:
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Asthma management in children, Access to care for people with asthma, Impact of asthma on quality of life for people with asthma and their caregivers, or Pharmacy usage among people with asthma. The District needs to address the above issues by incorporating data fields and/or data sources that will capture these data in order to provide a better understanding of asthma management in children and adults.
9.2. Asthma Management

Although asthma cannot be cured, symptoms can be controlled by appropriate medical care and through the reduction of asthma triggers. To decrease the number of complications due to acute asthma exacerbations as well as the need for ED care and hospitalizations, proper asthma management through the development of asthma action plans should be encouraged. Asthma patient and health care provider awareness of basic aspects of asthma management should be increased. Language and cultural barriers impede some populations of the District (e.g. minorities and immigrants) from navigating and accessing a cumbersome health care system, understanding treatment descriptions, comprehending and/or proper medication use and communicating concerns to health care providers. Asthma reeducation programs targeting minorities and immigrant populations need to be culturally competent with language accessible services. District of Columbia Department of Health (DC DOH) should continue to work toward improving asthma management in schools. DC DOH should partner with the DC school system to implement programs that will: Raise awareness of asthma as a serious disease in schools and among school staff; Train school staff on asthma management and to recognize asthma triggers; Help schools implement procedures for managing asthma episodes in school settings; and Support case management activities and education for children with diagnosed asthma that is affecting their school performance.
9.3. Risk Factors and Preventable Events

The work place environment is a setting where prevention of asthma is possible. Therefore: Interventions should ensure that health care providers are aware of the proper diagnosis and management of WRA and
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DC DOH should fund and conduct outreach programs to educate employers and employees on the work place triggers of asthma. This report found that a high proportion of obese residents also suffer from asthma. Although the causal relationship between asthma and obesity is not clear, there is enough research to suggest that obesity is a risk factor linked to asthma. Therefore, asthma reduction interventions need to have a comprehensive focus on improving the overall health of residents, and specifically reducing the obesity epidemic among children and adults as part of the asthma intervention strategy. Prevention of smoking around children should be another component of the asthma primary prevention strategy. DC DOH and other asthma stakeholders should continue to educate parents (especially those with a history of asthma), day care providers, and others who routinely deal with young children on the dangers of second hand smoke.
9.4. Reducing Health Disparities

There are vast racial and socioeconomic disparities in asthma prevalence, emergency department visits, and mortality rates in the District. Efforts to reduce the burden of asthma in the District must address this issue. Therefore: DC DOH should identify and target resources including programs and activities to geographic areas and populations that are experiencing the highest burden of asthma. Partnerships and strategic alliances should be forged among agencies and organizations addressing asthma in order to access these populations. For example, racial and ethnic minorities constitute more than half of those who get their health care through Medicaid. Therefore, Medicaid should be an active partner in addressing asthma in the District of Columbia. Coalitions and asthma stakeholders need to evaluate their current programs to ensure they are accessing and reaching these populations effectively. Programs should utilize available DC DOH data to target activities, set measurable program goals, and routinely assess improvements.
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10. References
1
American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Trends in Asthma Morbidity and Mortality; November 2007. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma, October 2007.
Centers for Disease Control and Prevention (CDC), 2003. < www.cdc.gov. > Akinbami LJ. The State of Childhood Asthma, United States: 1980-2005, Advance Data from Vital and Health Statistics: no 381, Revised December 29, 2006. Hyattsville, MD: National Center for Health Statistics, 2006. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute; Data Fact Sheet: Asthma Statistics; January 1999. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute Data Fact Sheet: Asthma Statistics; January 1999. American Lung Association; Trends in Asthma Morbidity and Mortality; August 2007. National Institutes of Health. News Release; NHLBI Reports New Asthma data for World Asthma Day; 2001. District of Columbia Office of Planning. Census 2000 Data. National Center for Health Statistics, Centers for Disease Control and Prevention, Morbidity and Mortality Report. 2003. Wright, A. Epidemiology of Asthma and Recurrent Wheeze in Childhood. Clinical Reviews in Allergy and Immunology: 2002; 22:33-44. Friedman-Jimnez G, Beckett WS, Szeinuk J, Petsonk EL, Clinical Evaluation, Management, and Prevention of Work-Related Asthma, American Journal of Industrial Medicine. 2000; 37:121-141. Department of Health and Human Services, Centers for Disease Control and Prevention, National
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11
12
13
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Institute for Occupational Safety and Health: Work-Related Lung Disease Surveillance Report, 2002.
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Breedlove, J., Occupational Asthma is More Common in the District of Columbia than Represented in Compensation Statistics, George Washington University Masters Thesis, 2006. Eggleston PA, Buckley TJ, Breysse PN, Wills-Karp M, Kleeberger SR, Jaakkola JJK, The Environmental and Asthma in U.S. Inner Cities. Environmental Health Perspectives Supplements, Vol. 107, S3, June 1999. Diaz-Sanchez A, Tsien A, Casillas A, Dotson AR, Saxon A, Enhanced nasal cytokine production in human beings after in vivo challenge with diesel exhaust particles, Journal of Allergy and Clinical Immunology, 1996; 98:114-123. Rosenstreich DL, Eggleston P, Kattan M, Baker D, Slavin RG, Gergen P, Mitchell H, McNiff-Mortimer K, Lynn H, Ownby D, et al. The role of 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. Department of Health and Human Services: National Asthma Education Program Expert Panel Report: Guidelines for Diagnosis and Management of Asthma DHHS Publ. No 91-3042. Bethesda, MD: 1991.
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US Environmental Protection Agency, < www.epa.gov > Babin SM, Burkom HS, Tabernero N, Holtry R S, Ambient Air Quality and Medicaid Patient Asthma Data Summary Report for the Investigation of the Linkage between Ambient Air Quality and Medicaid Patient Asthma Exacerbations in Washington, DC, The Johns Hopkins University Applied Physics Laboratory Report, 2006. Ross M and Patrick K, The Brookings Institute: A Policy Brief for the Medical Homes DC Area Health Education Center Leaders Among Us: Developing a Community Health Worker Program in Washington, DC, October 2006. Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyper responsiveness, Journal of Allergy and Clinical Immunology, 2005; 115:925- 927. Strachan DP, Butland BK, Anderson HR, Incidence and prognosis of wheezing illness from early childhood to age 33 in a national British cohort. British Medical Journal, 1996; 312:1195 -1199. Piipari R, Jaakkola JJk, Jaakkola N, Jaakkola MS., Smoking and asthma in adults, European Respiratory Journal. 2004: 24: 734-739.
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Ross, M and K Patrick, The Brookings Institute Leaders Among Us: Developing a Community Health Worker Program in Washington DC October 2006. Weisel CP, RP Cody, and PJ Lioy, Relationship between summertime ambient ozone levels and emergency department visits for asthma in central New Jersey. Environmental Health Perspectives, 1995: 103, 2: pp 97-102. Tolbert, PE, Mulholland JA, Macintosh DL, Xu F, Daniels D, Devine OW, Carlin BP, Klein M, Dorley J, Butler AJ, Nordenberg DF, Frumkin H, Ryan PB, and White, MC: Air quality and pediatric emergency room visits for asthma in Atlanta, Georgia, American Journal of Epidemiology, 2000:151, 8:798-810. Galan I, Tobias A, Banegas JR, and Aranguez E, Short-term effects of air pollution on daily asthma emergency room admissions, European Respiratory Journal, 2000; 22: 802-808. Kimes D, Levine E, Timmins S, Weiss SR, Bollinger ME, and Blaisdell C, Temporal dynamics of emergency department and hospital admissions of pediatric asthmatics. Environmental Research, 2004; 94:7-17.
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Technical Notes Prevalence: the proportion of individuals who have a disease at a particular point in time or duration
Prevalence = Rate: the number of health events (in this report, asthma related events) in a given population divided by the number of people who are at risk for that event within a specified time. Crude Rate: the number of events that occur in a group divided by the population of that particular group. In this report, age specific rates are crude rates for that specific age group. When rates for all ages are presented, rates are age-adjusted. Age-adjusted Rate: the rate of an event adjusted by the age composition of the population studied to minimize the effects played by age when comparing rates between two different populations. In this report, the direct standardization method was used to age adjust rates. The direct method of age adjusting averages the age specific rates of the study population and uses the weights of the distribution of a specific standard population. The directly standardized rate represents what the crude rate would have been in the study population if that population had the same distribution as the standard population with respects to the variable (in this case age) for which the adjustment was carried out. In this report, the 2000 US census population was used as the standard population. Odds Ratio (OR): the odds of two ratios. The odds of a disease (asthma) among those exposed (to obesity, smoking etc.) to the odds of a disease among the unexposed (normal weight, non-smoker etc.) Confidence Interval (CI): The purpose of the confidence interval is to measure the precision of an estimate, indicating that the wider the interval, the less precise the estimate. The 95% confidence interval is interpreted as a 95% chance that the true value of the estimate lays within the confidence interval.
of a period.
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The confidence interval formula for an estimate of prevalence is based on the binomial distribution. Prevalence CI = Where p = prevalence proportion n = sample size Determination of Statistical Significance: In this report the words significant or significantly were used to indicate statistical significance at p<0.05. Data in this report were stated as statistically significant based on non-overlapping 95% confidence intervals. Although this is not strictly speaking a statistical test, it is a commonly accepted way to compare estimates. It has been noted to be more conservative than formal statistical testing (Schenker and Gentleman, 2001).
Acronyms
BRFSS DC DC CAN DCHA DOH ED IMPACT WRA Behavioral Risk Factor Surveillance System District of Columbia District of Columbia Control Asthma Now District of Columbia Hospital Association Department of Health Emergency Department Improving Pediatric Asthma Care in the District of Columbia Work Related Asthma
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Appendix A: Work-Related Asthma Survey GWU

physicians who practice occupational medicine, pulmonary disease, internal medicine, family practice, and general practice in the District of Columbia. The survey population chosen consisted of a broad range of disciplines, each specialty chosen for an increased probability of capturing practicing physicians who were specialists in lung disease and working in either a large academic hospital or a family practice physician at a free clinic who would potentially diagnose occupational asthma cases. The survey was administered via internet and US mail, by a third party agency (Medical Marketing Service), and had a response rate of 16.8%.
The following questionnaire, developed by the George Washington University, was sent to 220
Survey Questions
1. In the past year (2005) how many asthma cases per gender of work-related/occupational asthma have you diagnosed in patients who live or work in the District of Columbia? 2. What is the average age of patients you have diagnosed with work-related/occupational asthma? 3. In how many of the total cases were you the first physician to diagnose the case(s) as occupational/work-related asthma? 4. Do you counsel patients with occupational/work-related asthma to: a. Request a permanent work station change? b. Use personal protective equipment (PPE) on the job? c. Request environmental changes in the workplace to eliminate triggers? d. Ask for a transfer to a work site with no knows exposures? e. Other 5. Have any of your patients ever submitted a workers-compensation claim for work related/occupational asthma against their employers?
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Appendix B: Data Tables

Table B-1: Prevalence of adult asthma by demographics and by ward Have you ever been told by a doctor or other health professional that you had asthma? and Do you still have asthma?
Current N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 3,720 1,495 2,225 203 716 745 655 644 692 1,782 1,541 125 192 246 601 618 2,244 288 382 329 451 533 1,315 241 305 480 378 294 325 278 228 % 9.2 6.7 11.3 15.4 8.4 8.3 8.3 10.4 6.3 6.6 10.4 8.0 10.5 14.0 10.0 11.3 7.3 16.5 8.1 10.6 6.9 8.2 6.8 10.9 13.9 6.6 6.7 9.8 9.4 9.3 13.8 95% CI (+/-) 1.3 2.0 1.8 6.8 2.4 2.4 2.4 2.8 2.3 1.5 2.0 5.4 5.1 4.9 3.3 3.9 1.5 7.0 3.1 4.5 3.2 3.1 1.8 5.1 8.1 3.1 3.1 5.0 4.1 5.2 5.3 % 5.7 7.8 3.9 9.4 8.7 3.8 3.5 3.3 4.5 5.1 5.0 13.1 10.1 1.0 6.7 5.8 6.0 3.2 8.1 7.8 4.7 6.9 5.2 6.7 5.5 7.5 9.2 5.7 1.4 3.9 6.7 Former 95% CI (+/-) 1.2 2.4 0.9 5.9 3.0 1.9 1.8 1.6 1.8 1.7 1.4 8.0 7.7 1.3 2.9 3.5 1.5 2.1 5.2 5.0 2.2 3.2 1.9 5.1 4.5 4.0 4.4 4.4 1.1 2.8 6.4 % 85.1 85.4 84.8 75.2 82.9 87.9 88.2 86.4 89.2 88.3 84.6 78.9 79.4 85.0 83.3 83.0 86.7 80.3 83.8 81.6 88.4 84.9 87.9 82.4 80.6 85.9 84.1 84.5 89.1 86.8 79.5 Never 95% CI (+/-) 1.7 3.0 1.9 8.2 3.6 2.9 2.9 3.2 2.8 2.2 2.4 9.0 8.5 5.1 4.2 4.9 2.0 7.1 5.7 6.3 3.8 4.2 2.5 6.7 8.7 4.8 5.1 6.3 4.2 5.7 7.6
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+ Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8
Income
Ward
Source: DC BRFSS
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Table B-2: Lifetime asthma by demographics Have you ever been told by a doctor or other health professional that you had asthma?
Lifetime N Total Gender Male Female 18-24 25-34 Age 35-44 45-54 55-64 65+ White Non-Hispanic Race/ Ethnicity Black Non-Hispanic Hispanic Other Non-Hispanic Less than High School Education High School Graduate Some College College Graduate Less than $15,000 $15,000-$24,999 Income $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Source: DC BRFSS
% 15.3 15.1 15.5 24.8 18.0 12.2 12.0 13.8 11.3 12.1 15.8 21.1 10.0 16.3 16.8 17.0 13.8 20.7 16.4 18.6 11.7 15.7 12.7
95% CI (+/-) 1.8 3.0 1.9 8.2 3.7 3.0 2.9 3.2 2.8 2.2 2.4 9.0 5.4 5.4 4.1 4.9 2.0 7.2 5.7 6.2 3.8 4.2 2.5
3,736 1,503 2,233 203 721 746 656 646 698 1,790 1,547 125 133 248 603 618 2,256 289 384 330 452 537 1,322
Small numbers prohibit the display of the data by ward.
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Table B-3: Prevalence of childhood asthma by demographics and by ward Has a doctor, nurse, or other health professional ever said that the child has asthma? and Does the child still have asthma?
Current N Total Childs Gender Childs Age Parents Race/ Ethnicity Male Female 8 or Under 9 to 17 White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 790 400 383 395 342 266 428 31 49 61 181 157 391 67 94 73 80 101 321 50 45 92 110 81 62 88 98 % 11.4 12.3 10.2 8.4 15.9 9.3 13.1 * * 14.4 11.2 12.4 10.0 19.3 15.9 8.2 12.5 12.5 8.7 20.8 * 6.9 15.4 11.2 13.1 8.2 16.4 95% CI (+/-) 2.6 3.9 3.4 3.0 4.8 4.0 3.6 * * 9.4 5.5 5.3 3.8 10.4 8.1 5.6 8.4 8.0 3.6 15.3 * 6.4 8.8 7.3 8.8 5.4 8.0 % 4.0 4.3 3.8 1.8 7.3 3.2 4.3 * * 1.2 4.6 7.3 2.2 6.5 0.8 0.0 1.8 9.6 3.6 5.3 * 2.7 5.8 1.2 2.9 1.5 11.0 Former 95% CI (+/-) 2.4 2.3 4.1 1.3 5.1 2.4 3.5 * * 1.9 3.0 7.8 1.5 6.5 1.0 0.0 2.2 11.6 2.4 6.4 * 3.4 6.0 1.8 3.6 1.8 11.8 % 84.6 83.4 85.9 89.8 76.8 87.5 82.6 * * 84.3 84.2 80.3 87.7 74.2 83.3 91.8 85.7 77.9 87.7 73.8 * 90.3 78.7 87.6 84.0 90.3 72.5 Never 95% CI (+/-) 3.3 4.4 5.2 3.2 6.4 4.5 4.7 * * 9.8 6.1 9.1 4.0 11.7 8.2 5.6 8.7 14.0 4.2 16.0 * 7.4 10.1 7.7 9.6 5.8 13.1
Less than High School High School Graduate Parents Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+ Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8
Parents Income
Ward
Source: DC BRFSS
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74 Table B-4: Age when diagnosed with asthma by demographics How old were you when you were first told by a doctor or other health professional that you had asthma?
<=19 N 447 158 289 25.5 19.2 11.1 5.9 8.2 28.0 4.3 6.3 6.0 10.3 3.4 4.1 3.9 5.5 2.8 2.7 22.0 6.0 19.0 4.3 8.4 2.8 4.7 1.9 % 95% CI (+/-) % % % 95% CI (+/-) 95% CI (+/-) 95% CI (+/-) % 45.9 56.4 37.1 20-39 40-59 60+ Dont Know 95% CI (+/-) 6.8 11.6 7.5 34 100 82 71 78 74 192 200 18 30 33 77 72 263 * 17.8 21.6 24.8 * 10.8 16.1 8.2 * 15.4 16.0 21.5 * 8.6 9.8 6.0 24.6 13.7 * * 9.4 5.8 * * 17.9 18.3 * * 5.8 5.8 * * 7.5 10.4 * * * 12.9 7.6 5.6 3.4 4.3 * * * 8.2 6.2 2.4 * 30.3 18.9 15.8 8.7 1.7 * 10.7 11.3 10.1 6.2 2.0 * 17.2 42.7 28.0 18.0 10.0 * 8.4 13.0 11.2 11.2 6.8 * * 1.9 15.4 34.7 24.7 * * 2.3 9.1 13.5 13.4 * * * * 1.6 39.5 4.6 6.5 * * * 8.8 1.1 3.9 * * * * 2.4 13.6 2.7 3.4 * * * 6.3 1.2 2.1 * 52.5 36.5 40.8 37.0 24.1 45.4 51.1 * * * 45.0 53.7 44.3 * 11.8 12.8 14.2 13.0 12.9 10.4 8.9 * * * 15.4 17.2 8.5 44 53 43 49 73 138 * 20.6 * * 11.7 17.3 * 15.4 * * 10.2 8.2 * 23.8 * * 24.0 25.3 * 14.0 * * 12.6 8.8 * 8.1 * * 17.3 6.5 * 6.9 * * 11.1 3.4 * 6.1 * * 8.7 1.9 * 6.5 * * 6.4 2.0 * 41.4 * * 38.2 48.9 * 21.7 * * 14.1 11.4
Total
Gender
Male Female
Age
18-24 25-34 35-44 45-54 55-64 65+
Race/ Ethnicity
White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic
Less than High School High School Graduate Education Some College College Graduate
Income
Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Source: DC BRFSS
Table B-5: Frequency of visits to a doctor for routine asthma checkups by demographics During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?
None N 286 Male Female 87 199 32.8 27.7 13.3 7.8 33.8 27.3 18.0 8.3 27.0 35.1 15.8 9.0 29.5 6.8 29.6 8.5 32.2 8.1 8.6 6.4 9.9 % 95% CI (+/-) % % % 95% CI (+/-) 95% CI (+/-) Once 2 - 4 Times 5+ Times 95% CI (+/-) 3.4 5.0 4.4
Total
Gender
Age
18-24 25-34 35-44 45-54 55-64 65+ 22 56 58 48 60 38 111 141 8 21 27 53 53 153 * 23.7 27.8 38.7 * 14.1 15.5 10.1 * 11.4 26.5 43.5 42.5 25.0 * * 11.6 8.3 * * 35.7 21.0 * * 12.4 9.7 * * * 11.0 22.1 11.5 16.8 43.4 * * * 57.9 42.1 12.5 * 40.4 39.4 * 15.5 * * 14.7 15.5 * 9.6 * * 40.4 29.6 * 12.1 * * 15.5 14.1 * 7.9 * * 19.2 24.5 * 48.9 * White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic
* 11.7 12.4 * 15.8 * 7.8 11.5 * * * 17.4 19.8 5.3
* * 6.5 * 23.4 * 5.1 10.7 * * * 7.1 3.5 5.2
* * 6.6 * 12.9 * 3.8 5.2 * * * 6.2 3.8 3.3

Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+ 36 34 26 30 44 80 * * * * * 42.8 * * * * * 13.6 * * * * * 42.6 * * * * * 14.8 * * * * * 7.6 * * * * * 5.0
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate
Income
* * * * * 7.1
* * * * * 5.2
Source: DC BRFSS
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Table B-6: Episodes of asthma or asthma episodes (attacks) by demographics During the past 12 months, have you had an episode of asthma or an asthma attack?
Yes N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 90 206 22 56 59 52 62 41 114 148 8 21 33 52 55 156 39 35 26 31 44 81 % 44.8 50.7 41.5 * 46.2 58.4 48.8 46.7 * 43.5 45.8 * * * 39.3 43.2 47.7 * * * * * 41.3 95% CI (+/-) 8.1 16.4 8.7 * 15.3 14.9 16.1 15.5 * 11.7 10.8 * * * 18.1 18.8 11.0 * * * * * 13.6 % 55.2 49.3 58.5 * 53.8 41.6 51.2 53.3 * 56.5 54.2 * * * 60.7 56.8 52.3 * * * * * 58.7 No 95% CI (+/-) 8.1 16.4 8.7 * 15.3 14.9 16.1 15.5 * 11.7 10.8 * * * 18.1 18.8 11.0 * * * * * 13.6
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
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Table B-7: Frequency of days missed work or usual activities because of asthma by demographics During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?
0 N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 293 91 202 22 56 59 51 60 41 114 146 8 20 31 52 54 156 37 34 26 31 44 81 % 78.4 77.3 79.0 * 85.9 76.0 65.2 73.8 * 81.9 76.3 * * * 70.9 81.4 81.9 * * * * * 84.7 95% CI (+/-) 6.4 13.0 6.8 * 9.7 12.0 15.8 14.5 * 10.2 9.2 * * * 18.0 11.9 7.4 * * * * * 9.1 % 11.9 12.6 11.5 * 8.1 11.4 21.2 15.5 * 7.5 14.3 * * * 17.8 11.9 8.1 * * * * * 7.7 1-5 95% CI (+/-) 5.5 11.7 5.4 * 7.4 8.5 14.7 13.1 * 6.7 8.4 * * * 17.1 10.1 4.7 * * * * * 6.9 6 or more % 9.7 10.1 9.4 * 5.9 12.6 13.6 10.7 * 10.6 9.4 * * * 11.4 6.6 10.0 * * * * * 7.6 95% CI (+/-) 3.9 7.0 4.7 * 6.3 9.4 9.8 9.1 * 8.6 5.0 * * * 10.0 5.8 6.0 * * * * * 6.3
Age
Race/ Ethnicity
Income
Source: DC BRFSS
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Table B-8: Frequency of medication use to prevent asthma episodes by demographics During the past 30 days how often did you take a prescription asthma medication to prevent an asthma attack from occurring?
Every Day or Almost Every Day N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 91 205 22 55 59 52 63 41 114 148 8 21 33 52 55 156 39 35 26 31 44 81 % 41.0 41.4 40.8 * 27.2 32.8 49.2 61.8 * 38.0 43.1 * * * 48.8 32.6 37.3 * * * * * 27.8 95% CI (+/-) 7.9 15.9 8.4 * 14.2 14.0 16.0 14.1 * 10.6 10.8 * * * 18.7 15.8 10.7 * * * * * 10.8
Less Often 95% CI (+/-) 7.5 13.1 8.9 * 13.1 13.7 14.9 10.5 * 12.7 10.4 * * * 18.1 16.2 10.5 * * * * * 15.3
Never 95% CI (+/-) 7.9 16.1 8.1 * 15.3 15.4 14.6 11.1 * 11.3 9.0 * * * 14.7 20.6 9.9 * * * * * 13.1
% 25.2 19.3 28.5 * 26.7 23.6 21.9 15.7 * 21.1 27.8 * * * 22.3 21.2 26.0 * * * * * 35.7
% 33.8 39.3 30.7 * 46.1 43.6 28.9 22.6 * 40.8 29.1 * * * 28.9 46.2 36.7 * * * * * 36.5
Age
Race/ Ethnicity
Income
Source: DC BRFSS
78
Table B-9: Frequency of inhaler use to stop asthma episodes by demographics During the past 30 days how often did you take a prescription asthma inhaler during an asthma attack to stop it?
Never N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 271 87 184 20 52 57 47 56 35 109 131 6 20 28 46 49 148 35 32 22 27 42 78 % 61.3 60.1 61.9 * 62.3 62.2 0.0 51.5 * 75.7 53.1 * * * * * 68.3 * * * * * 75.6 95% CI (+/-) 8.5 16.6 9.4 * 15.5 15.3 0.0 16.4 * 9.7 11.7 * * * * * 11.3 * * * * * 11.9 1 - 4 Times % 29.9 34.4 27.4 * 32.0 27.6 0.0 29.8 * 19.3 34.6 * * * * * 28.7 * * * * * 22.5 95% CI (+/-) 8.3 16.5 9.0 * 15.0 13.3 0.0 15.8 * 9.0 12.0 * * * * * 11.4 * * * * * 11.7 5 or More Times % 8.8 5.5 10.7 * 5.7 10.2 0.0 18.7 * 5.1 12.3 * * * * * 3.0 * * * * * 2.0 95% CI (+/-) 3.8 5.0 5.2 * 6.6 10.8 0.0 12.8 * 4.3 6.2 * * * * * 2.2 * * * * * 2.4
Age
Race/ Ethnicity
Income
Source: DC BRFSS
79
Table B-10: Told by doctor that asthma was job related by demographics Were you ever told by a doctor, nurse, or other health professional that your asthma was related to any job you ever had?
Never Worked Outside Home % * * * * * * * * * * * * * * * * * * * * * * * 95% CI (+/-) * * * * * * * * * * * * * * * * * * * * * * *
Yes 95% CI (+/-) 1.8 1.7 2.6 * 2.5 2.5 3.3 7.4 * 2.7 2.9 * * * * 6.9 1.1 * * * * * 2.0
No 95% CI (+/-) 1.8 1.7 2.6 * 2.5 2.5 3.3 7.4 * 2.7 2.9 * * * 0.0 6.9 1.1 * * * * * 2.0
N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 90 206 22 56 59 52 62 41 114 149 8 20 33 53 55 155 39 35 27 31 44 81
% 2.6 1.5 3.3 * 2.0 1.7 2.2 6.4 * 2.6 3.5 * * * * 8.2 0.8 * * * * * 1.5
% 97.4 98.5 96.7 * 98.0 98.3 97.8 93.6 * 97.4 96.5 * * * 100.0 91.8 99.2 * * * * * 98.5
Age
Race/ Ethnicity
Income
Source: DC BRFSS
80
Table B-11: Respondent told doctor that asthma was job related by demographics Did you ever tell a doctor, nurse, or other health professional that your asthma was related to any job you ever had?
Yes N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 294 90 204 22 56 59 51 62 40 113 148 8 20 33 53 53 155 39 35 27 31 44 80 % 4.5 2.1 5.9 * 5.3 3.6 12.3 8.4 * 3.1 6.1 * * * 3.5 7.0 2.3 * * * * * 2.4 95% CI (+/-) 2.8 2.1 4.2 * 6.1 3.9 12.9 8.5 * 3.1 4.6 * * * 4.8 6.5 2.1 * * * * * 2.6 % 95.5 97.9 94.1 * 94.7 96.4 87.7 91.6 * 96.9 93.9 * * * 96.5 93.0 97.7 * * * * * 97.6 No 95% CI (+/-) 2.8 2.1 4.2 * 6.1 3.9 12.9 8.5 * 3.1 4.6 * * * 4.8 6.5 2.1 * * * * * 2.6
Age
Race/ Ethnicity
Income
Source: DC BRFSS
81
82
H H H
Government of the District of Columbia Adrian M. Fenty, Mayor
District of Columbia Department of Health 825 North Capitol Street, NE Washington DC 20002 http://dchealth.dc.gov

District of Columbia Burden of Asthma Report

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Burden of Asthma in the

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

Adult Asthma Prevalence

Asthma Prevalence by Gender

Asthma Prevalence by Race/Ethnicity

Asthma Prevalence by Age

Asthma Prevalence by Education

Asthma Prevalence by Household Income

Asthma Prevalence by Ward

Asthma Prevalence by Risk Factors

Childhood Asthma Prevalence

Asthma Episode Prevalence

Asthma Doctor Visits

Age at First Diagnosis

Emergency Department (ED) Visits

Outdoor Air Quality and Asthma

Burden of Asthma in the District of Columbia

1.1. Cause and Triggers

1.2. Public Health Significance

1.3. Who is Most Affected by Asthma?

1.4. Overview of Asthma Trends in the District of Columbia

Burden of Asthma in the District of Columbia

Source: Department of Health, Community Health Administration

Burden of Asthma in the District of Columbia

Unemployed d Percent 5% 6% 7% 4% 8% 6% 7% 12% 7%

1.4.1. Control Asthma Now (DC CAN)

1.4.2. DC Healthy People 2010

Burden of Asthma in the District of Columbia

Burden of Asthma in the District of Columbia

2. Asthma Burden in the District of Columbia

DC CAN Surveillance Data

2.1. Measuring Asthma Prevalence

2.2. Asthma Prevalence in the District

Burden of Asthma in the District of Columbia

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

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

Source: District of Columbia Behavioral Risk Factor Surveillance System

Burden of Asthma in the District of Columbia

Source: District of Columbia Behavioral Risk Factor Surveillance System, 2005

2.2.1. Asthma Prevalence by Gender

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

Burden of Asthma in the District of Columbia

2.2.2. Asthma Prevalence by Race/Ethnicity

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

2.2.3. Asthma Prevalence by Age Group

Burden of Asthma in the District of Columbia

Figure 2-7: Prevalence of adult (18 years) asthma by age group

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

2.2.4. Asthma Prevalence by Socioeconomic Status

Burden of Asthma in the District of Columbia

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

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

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

Burden of Asthma in the District of Columbia

2.2.5. Asthma Prevalence by Ward

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

Figure 2-11: Prevalence of former adult (18 years) asthma by ward