1. April 6 -8, 2004 Asthma in California: Challenges in Assessment and Intervention Shanghai-California Environmental Health Conference Richard Kreutzer, M.D. California – China Environmental Health Training Program

2. April 6 -8, 2004 Asthma in California Asthma in California-Lifetime Prevalence

3. April 6 -8, 2004 Asthma in California-Cohort Analysis

4. April 6 -8, 2004 Definition of Asthma A chronic inflammatory disorder of the airway Infiltration of mast cells, eosinophils and lymphocytes Recurrent episodes of wheezing, coughing and shortness of breath Widespread, variable and often reversible airflow limitation Airway hyperresponsiveness Slide 1

5. April 6 -8, 2004 Magnitude of the Problem 150 million asthmatics world wide Prevalence increasing in most countries (20 to 50% every 10 years) Significant cause of school/work absence Health care expenditures very high 1 million unnecessary deaths each decade Slide 3

6. April 6 -8, 2004 Cost of Illness Hospital Stay Intensive Care Emergency Department Primary Care Medications Direct Medical Care Social Security Lost work output Lost school days Impact on individual/family/soci ety Indirect Costs Slide 5

7. April 6 -8, 2004 What is the cause of asthma?

8. April 6 -8, 2004 Mechanisms Underlying the Definition of Asthma Risk Factors (for development of asthma) Airway Hyperresponsiveness Airflow Limitation Symptoms Risk Factors (for exacerbation) Slide 2

9. April 6 -8, 2004 Risk Factors for Asthma Asthma occurs in families Atopy: The strongest identifiable risk factor for the development of asthma Allergen and chemical sensitizer exposures Contributing factors may increase susceptibility to development of asthma in predisposed individuals Slide 6

10. April 6 -8, 2004 Risk Factors that Lead to Asthma Development Atopy Family history Predisposing Factors Indoor Allergens – Domestic Mites and cockroach – Animal Allergens – Tobacco smoke – Fungi Outdoor Pollution/Allergens – Ozone – Pollens Occupational Sensitizers Causal Factors Respiratory Infections Small Size at Birth Diet Exercise Cold air Air Pollution/allergens – Outdoor Pollutants – Indoor Pollutants Smoking – Passive Smoking – Active Smoking Contributing Factors Slide 7

11. April 6 -8, 2004 Factors Influencing the Rise in Asthma Lifestyle Changes Immune System Changes Slide 8

12. April 6 -8, 2004 Role of “Western” Lifestyle Increase in indoor furnishings Humidity and indoor temperature Decreased ventilation Increased time indoors Reduction in physical activity can result in allergic sensitization and “priming” for asthma development Hygiene hypothesis Slide 10

13. April 6 -8, 2004 Factors Influencing Atopy Slide 9

14. April 6 -8, 2004 Immune System Balance in Asthma Development Slide 11

15. April 6 -8, 2004 Influences on the Developing Immune Response Inheritance of a genetic susceptibility to atopy Effect of the in utero environment created by the mother (diet, allergen exposure, etc.) Maternally directed development of the fetal immune response to common environmental antigens Actions of early infections, gut microbial flora colonization and allergen exposures of the infant on the developing immune response after birth Development of a normal or allergic immune response (and symptoms) to common environmental antigens 1 st trimester of pregnancy 2 nd and 3 rd trimester of pregnancy Birth 1 st year of life British Medical Bulletin 2000;56(No.4) Slide 12

16. April 6 -8, 2004 Slide 13

17. April 6 -8, 2004 Slide 14

18. April 6 -8, 2004 Asthma Management Issues Disease management model versus addressing the ecology of the disease Clinical approach versus a population-based approach What are the places in the community where changes can influence the course of asthma?

19. April 6 -8, 2004 Management by Patient Family Involvement Clinical Expertise Work/School Support Community Awareness, Support & Action Community-Wide Environmental Control Measures Conducive Policies Noreen Clark

20. April 6 -8, 2004 PlacePlace LocationLocation PurposePurpose Physical Infrastructure Policies/PracticesPolicies/Practices Multiplicity of Users Governance and Enforcement 16

21. April 6 -8, 2004

23. Social Environment Stressors Physical Environment Stressors Health Outcomes Intervening Factors Amy Schulz, et.al. Stress Process Model

24. April 6 -8, 2004 Potential Places for Intervention Clinics and health care institutions Home Preschool School Workplace Community- e.g. energy, agriculture, transportation, planning and zoning

25. April 6 -8, 2004 Strategic Plan for Asthma in California

26. April 6 -8, 2004 Strategic Plan for Asthma in California – Five Goals Research, epidemiology, and evaluation Public education Treatment and management Secondary prevention Policy

27. April 6 -8, 2004 Overcoming barriers: Integration across organizations

28. April 6 -8, 2004 To conclude: Integration is a powerful tool to extend current resources and develop new ones. Integration doesn’t come easily but there are effective strategies to help get there. Paths to integration will vary by community and must fit the local landscape.