Improving Childhood Asthma Outcomes in the United States: A Blueprint for Policy Action

Sharp increases in the incidence of childhood asthma in the United States make asthma an important public health concern requiring not only therapeutic interventions but also changes in the social and physical environment in which children are growing up, according to a committee of nationally recognized experts and leaders in childhood asthma. In a special article published in the June issue of the journal Pediatrics, the committee outlined a "blueprint for policy action" with recommendations for action in 11 broad categories, including the creation of "asthma-friendly" schools.

Paradoxically, the committee noted, the asthma epidemic coincides with significant improvements in medical treatments to manage the disease. "The appropriate use of new preventive medications allows almost all children with asthma to lead normal lives without experiencing significant symptoms."

But while primary care delivered by a trained asthma professional can control the exacerbations of childhood asthma and prevent hospitalizations, the overarching problem is that we do not know how to prevent or alter the course of the disease in the first place, the committee points out. Scientific evidence suggests a variety of risk factors—genetic predisposition, environmental exposures, poverty, and inadequate health care—but the precise effect of each of these factors, and how they interact, is unknown.

And even the best medical care (patient education and access to a knowledgeable provider and the necessary medications and equipment) needs to be coupled with environmental control of the indoor exposures that have been shown to worsen asthma, including tobacco smoke, furry pets, dust mites, and cockroaches. "Thus, controlling asthma implicates local school systems, state and local housing authorities, environmental agencies, and other parts of the government and social services structure that surrounds children and their families. Alone, none of these entities has the authority or sufficient resources to institute safeguards, health education, and environmental improvements needed to reduce the risk of asthma."

To address current national gaps in childhood asthma care, the committee made policy recommendations, with implementation and financing options.

To improve the quality of care, the recommendations call for adherence by primary care providers to the National Asthma Education and Prevention Program guidelines and development of similar guidelines for teaching children and parents self-management techniques. Case management—a comprehensive set of services provided by teams of medical professionals and social work staff—is recommended for high-risk children.

To expand coverage and improve benefits, the recommendations call for continuous health insurance coverage to all uninsured children under Medicaid and SCHIP and development of a model set of services to be provided under those programs and private insurance.

In a recommendation aimed at schools, the committee noted that "Although children spend a significant amount of time in school, many barriers exist in this setting for the recognition and treatment of asthma." The committee says it is important that school-based asthma services be physician- or nurse-directed and that every school have a nurse or trained designate to deliver asthma services. It urges development of a school nurse asthma education program and programs to educate parent and professional organizations and advocacy groups about school nurse laws and successful models for school asthma policies and practices.

"Schools are a natural community hub for children and families, and thus a good base for asthma education and referral to health care and social services," the committee said.

"A school’s asthma-friendliness refers to its capacity to promote quality of life for children with asthma, through policies and facilities that support and encourage adequate knowledge, time, and commitment of school staff to meet the needs of children with asthma during school hours and in after-school activities."

Acknowledging that its recommendations are far-ranging and "utopian," the committee said that change in the current state of asthma in children requires "an ongoing commitment to continuous policy formulation and reformulation as part of a larger policy reform design."

The American Academy of Pediatrics committee cited as a basis for its report a national study by the Rand Corporation funded by the Robert Wood Johnson Foundation’s Pediatric Asthma Initiative. To request reprints of the committee’s report, "Improving Childhood Asthma Outcomes in the United States: A Blueprint for Policy Action,"contact lara@rand.org.

Jury Awards $9 Million in Asthma Death at School

A California jury that unanimously awarded a mother $9 million in damages for the death of her 11-year old son from an asthma attack at school found the school district guilty of negligence for failing to inform parents of an unwritten school policy that would have allowed the child to carry an inhaler.

Fifth grader Phillip Gonzalez had severe asthma, but pursuant to a written school policy requiring that all student medication be stored in a specific place at school, Phillip and his mother understood that he could not carry his inhaler on his person. A nebulizer was kept in the school office, where, when he had to use it, Phillip was assisted by school staff.

On the day he died, Phillip left his classroom to use the restroom and minutes later appeared in the school office exhibiting symptoms of severe asthma attack. The school secretary, who had been trained to use a nebulizer, attempted to help him, but the child collapsed. Emergency personnel were summoned, but to no avail; Phillip died later that afternoon.

At the trial, the school district contended that its policy did not preclude a student from carrying necessary medication such as an inhaler, when certified as necessary by a physician. But the district conceded that while its policy about medications being stored at school was written, the exception was not. The existence of the unwritten exemption was confirmed by the district’s two nurses, the school superintendent, and the principal of Phillip’s school, but Gonzalez and other parents of asthmatic children who had been told they could not carry inhalers testified that they were never told about the exception until after Phillip’s death.

This significant fact—that the policy requiring medications to be stored at school was written but the exception was not—made the district liable for negligence, the court ruled.

In her testimony, in addition to focusing on the failure of district employees to inform her about the exception and the obvious absence of any reference to the exception in the written regulation, Gonzalez pointed to the fact that the physician’s authorization form supplied by the school has no place for the doctor to insert a direction that the student should carry and/or administer his or her own medication.

In further action, the California Court of Appeal for the Fifth District May 22 found the $9 million jury award excessive and agreed to an offer from the school district to pay the mother the reduced sum of $2.225 million.

The case was Gonzalez v. Hanford Elementary School District, Nos. F033659, F034555, (Super.Ct. Nos. 0031 & 1109).

Just a Click Away: Recreational Drug Sites on the Internet

Health care providers who care for adolescents should be aware of the content of drug sites on the Internet that provide alluring information about the newest recreational drugs, information that it may be hard or impossible to find in the medical literature, according to an article in the June issue of the journal Pediatrics.

"Adolescents, who are often adept at navigating these Internet resources, may be particularly susceptible to these communications. Knowledge about what teens are viewing may help health care practitioners better understand their patients’ own informational data bank, stay informed about the latest trends in drug abuse, and position themselves as more credible resources to their patients," suggests medical technologist Dr. Paul Wax of the Good Samaritan Regional Medical Center in Phoenix, Arizona.

There has been a dramatic change in the past decade in the types of recreational drugs that are currently being used by young people in the United States, with a new generation of illicit drugs including methylenedioxymethamphetamine (MDMA: Ecstasy), hydroxybutyrate (GHB), and ketamine increasingly available to young people at low cost and perceived safety. A report of the Drug Abuse Warning Network released in December 2000 indicated that emergency department episodes related to MDMA, GHB, and ketamine increased significantly in the period from 1994 to 1999. In a 2000 survey, 8 percent of high school seniors (14 percent in the West) reported that they use or have used MDMA; and surveys from 1994 to 1999 demonstrate a sharp rise in MDMA use by college students.

Given that level of interest, it is not surprising that websites focused on recreational drug use have sprouted on the Internet, Dr. Wax notes. Some of the sites, sponsored by government entities such as the National Institute on Drug Abuse or by private groups, try to educate the public about the potential harmful effects of drug abuse, but other sites glamorize and appear to condone drug use, with frequent use of buzzwords such as "safe drug use" and "responsible drug use."

To illustrate that adolescent use of these websites can have a direct impact on drug-taking behavior, the article describes two cases in which adolescents presented to hospital emergency rooms with seizures, hallucinations, and irrational behavior after recreational drug-taking that was directed by suggestions on Internet websites, one involving a new designer drug that was unfamiliar to the regional poison control center and medical toxicologists.

It is not at all hard to find Internet sites with information about recreational drugs—anyone with Internet access can do it, by typing in the name of an address or, alternatively, simply typing in the name of a drug on a search engine such as Yahoo, which will provide connections to many sites. Dr. Wax summarizes the information that’s available on a number of the most widely used sites, including:

The Pediatrics article suggests that health care providers consider referring adolescent patients and their parents to websites provided by the medical community, such as the NIDA’s www.clubdrugs.org, for additional information on many of those drugs. Other websites that convey an anti-drug message include www.projectghb.org, www.drugs.indiana.edu/druginfo, and www.ghbkills.com.

Reprints of the article "Just a Click Away: Recreational Drug Web Sites on the Internet," by Paul M. Wax, MD, published in the June 2002 issue of Pediatrics, are available by e-mail from paulwax@bannerhealth.com.

Stepped-Up Vigilance Needed for School Food Safety

Noting that 27 million children are provided free or low-cost meals at school under the federal National School Lunch and School Breakfast programs, the General Accounting Office is urging the U.S. Department of Agriculture, which administers those programs, to take actions to better ensure the safety of the foods that are served.

Between 1990 and 1999 there were nearly 300 outbreaks of foodborne illness in schools, affecting approximately 16,000 children, the GAO noted, with the most commonly identified cause of the illnesses foods contaminated with salmonella and Norwalk-like viruses. That mirrors a rise in foodborne illness in the country as a whole in that period, the GAO concedes, and making school food safe is related to ensuring the safety of the food supply overall.

But some features of the school food program are of special concern, including that, while the federal government buys and contributes about 17 percent of the food that goes into school lunches and breakfasts, state and local school food authorities purchase the other 83 percent. Currently, those local authorities have no access to federal inspection and compliance records that might help them weigh the reliability or safety of potential suppliers. And though the Food and Nutrition Service has an established procedure for holding and recalling USDA-donated foods when safety concerns arise, those hold-and-recall procedures don’t apply to school-purchased foods.

The Agriculture Department and the Food and Drug Administration have not developed specific security provisions to protect food served in the school meal programs from potential deliberate contamination as an act of bioterrorism, but it’s believed that any actions that are taken to safeguard the food supply as a whole will apply to school food, as well. The two agencies are currently in the process of conducting risk assessments to determine where in the farm-to-table continuum the food supply may be most vulnerable, and they are issuing voluntary guidelines to the food industry to enhance the physical security of processing and storage facilities.

But the basic fact, the GAO points out, is that no federal agency specifically monitors the safety of school meals, and responsibility for even the federally donated foods is divided. The USDA’s Agricultural Marketing Service buys meat, poultry, fish, and vegetables for donation; the Farm Service Agency purchases grains, oils, peanut products, dairy products, and other foods. USDA contracts for the purchase of these products with manufacturers who are selected through a formally advertised competitive bidding process. The Food and Nutrition Service, through its Food Distribution Division, provides the donated foods to state agencies for distribution to schools. Schools then purchase the remainder of food for school meals independently, using their own procurement practices, either purchasing directly from manufacturers or distributors or contracting with food service management companies that procure the foods for them.

The U.S. Agriculture Department "provides little guidance to promote safety in school food procurements," the report concludes. The Food and Nutrition Service guidance to schools emphasizes safe food handling, not procurement, because according to USDA officials, most cases of foodborne illness at school are due to poor food storage, handling, and serving practices. For example, FNS provides manuals that address appropriate temperatures for reheating ready-to-eat foods and for hot-holding potentially hazardous foods, and information on employee personal hygiene—handwashing, for instance—and how it relates to cross-contamination of foods.

Some of the problems the General Accounting Office sees in school food procurement reflect the "patchwork structure" of the existing food safety system as a whole, the report concedes. As an example: under existing law, the Food and Drug Administration and the Agriculture Department can’t compel a company to pull a suspect food off the market and can only ask the producer or manufacturer to recall the product voluntarily. If the supplier does not comply, the USDA can detain the product for only up to 20 days; and the FDA would have to seek a court order to seize the food.

Summing up, the GAO said: "Continued vigilance is necessary to determine the true extent and cause of the problems [in school food procurement], to ensure that schools obtain the safest food possible for our children and also to ensure that unsafe foods are promptly and effectively withdrawn from schools when illnesses occur."

The report, "Continued Vigilance Needed to Ensure Safety of School Meals," GAO 02—669T, published April 20, 2002, is available on the Internet at www.gao.gov Acrobat Reader is required.

CDC Sees School Health Role in Skin Cancer Prevention

School health services can promote practices that reduce the risk of skin cancer, according to a report by the Centers for Disease Control and Prevention, by providing sun screen free or at minimum cost, encouraging children to wear protective clothing out-of-doors, and seeing to it that either natural or man-made shade is available on playgrounds and athletic fields.

Skin cancer is the most common type of cancer in the United States, and new cases of the most serious form—melanoma—have increased 150 percent since 1973. Since the vast majority of melanomas are caused by ultraviolet radiation, and more than half of a person’s lifetime exposure to UV occurs in childhood, protecting children from undue exposure to the sun is a valid public health objective and schools have a role in teaching and modeling protective behaviors, the CDC believes.

In "Guidelines for School Programs to Prevent Skin Cancer," the most recent in a series of guidelines produced by the CDC to help schools promote the health of young persons, the agency recommends the development of overall policies to educate students and parents about the risk of skin cancer and to maximize protection during school activities.

For school health services, the guidelines suggest that:

Unlike many diseases, the CDC points out, skin cancer is primarily preventable. "Schools can play a substantial role in protecting students from unnecessary exposure to UV, thereby reducing their future risk for skin cancer."

The full text of "Guidelines for School Programs to Prevent Skin Cancer," Morbidity and Mortality Weekly Report Recommendations and Reports, April 26, 2002, Vol. 51, No. RR-4, is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5104a1.htm.

Elementary School Intervention Seen Affecting Sexual Behavior at 21

The Seattle Social Development Project, a controlled intervention begun in elementary school to promote bonding of children to school and family, has been found to affect the sexual behavior of participants at age 21. Compared with young adults who did not have the intervention, participants had fewer sexual partners, were more apt to use condoms, had fewer sexually transmitted diseases, and, for females, were significantly less likely to become pregnant. These outcomes occurred, researchers pointed out, although the project had no sex education component.

"The study demonstrates that the promotion of academic success, social competence, and bonding to school during elementary grades can prevent risky sexual practices and adverse health consequences in early adulthood," according to a report on the project in the May issue of Archives of Pediatrics and Adolescent Medicine. "The program’s broad focus on youth development provides evidence that strengthening social and psychological skills, rather than targeting specific risk behaviors, can protect against an array of health risks, including STDs, human immunodeficiency virus infection, and pregnancy in adolescents and young adults."

The Seattle project, like other youth development programs that have gained attention in recent years, operates on the theory that strengthening the protective factors in children’s lives—such as social connectedness, positive family relationships, a future orientation, school achievement, and timely and regular health care—reduces the effects of risk factors in their lives. Multilevel interventions in the Seattle program included training teachers in proactive classroom management and cooperative learning, training parents in child management and skills to support their children’s educational development, and providing the children with cognitive and social skills training. Participants were African-American children in grades 1 through 6. Ninety-three percent of the participants in the intervention and control groups were successfully interviewed at age 21.

Reprints of the Archives report on the Seattle Social Development Project are available at e-mail jdh@u.washington.edu.

WORTH NOTING

Making It Hard to Buy Cigarettes Doesn’t Curb Youth Smoking

It seems logical that if it’s difficult for teenagers to obtain cigarettes, they are more likely not to smoke, an argument that has led to widespread enactment of "youth access" laws making it illegal to sell cigarettes to minors. But a study published in the June issue of the journal Pediatrics reports that the strategy isn’t working, partly because the laws are hard to enforce and partly because many teens who smoke don’t even try to buy cigarettes commercially but rely on older friends and family members to keep them supplied. "Given the limited resources available for tobacco control, as well as the expense of conducting youth access programs, tobacco control advocates should abandon this strategy and devote the limited resources that are available for tobacco control toward other interventions with proven effectiveness," such as media campaigns, smoke-free workplaces and homes, and education on the effects of secondhand smoke, researchers said.

NIH Reports on HIV Vaccines

Prevention efforts over the past decade have slowed the spread of HIV, and new therapies have reduced deaths due to AIDS in countries where the therapies are available, but a critical element in the fight against HIV/AIDS—development of a vaccine—is still in the trial stages, the National Institute of Health reported in May. Results from the world’s first two large-scale efficacy trials will be available within the next year, said Anthony Fauci, head of NIH’s Institute of Allergy and Infectious Diseases. Over the next two years, NIH expects to test more than a dozen potential new vaccines, an effort requiring more than 20 clinical trials of various sizes. "We are confident that research will lead to an HIV vaccine, perhaps not in a year or two, or even three years. However, we will get there," Fauci said.

Vegetarian Adolescents Meet Dietary Objectives

Vegetarian adolescents were significantly more likely than their nonvegetarian counterparts to meet Healthy People 2010 dietary objectives, eating less total fat and saturated fat and being more likely to have five or more servings a day of fruits and vegetables, according to a study reported in the May issue of Archives of Pediatrics and Adolescent Medicine. Vegetarians were also less likely to eat fast food or drink regular soda and fruit drinks. Though the vegetarians had a healthier overall diet pattern, neither they nor their nonvegetarian peers met the recommended intake for calcium, an important element of adolescent diets. The study included vegans (who eat no animal products), lactovegetarians (who use dairy products), ovovegetarians (who eat eggs), and semivegetarians (who eat some meat, particularly fish and chicken).

Kits to Reach Families with Uninsured Children

The Covering Kids coalition is offering Back to School Action Kits to help reach out to families with the message that uninsured children should be enrolled in either Medicaid or SCHIP. The kits include tips on staging a successful media campaign and enrollment effort and partnering with businesses and organizations to reach families. To request the kit, e-mail your name, organization, address, and phone number to coveringkids@gmmb.com.

May 2002 News Alerts

The following information appeared during the month of May in the News Alerts section of this website.

Satellite Broadcast - The Immunization Encounter: Critical Issues

CDC will host a broadcast on "The Immunization Encounter: Critical Issues," June 27, 2002 from 12:00 to 2:30 p.m. EST. This satellite broadcast will address issues related to a routine immunization clinic encounter, exemplifying recommended standards of practice for patient intake and screening, vaccine administration, vaccine management, documentation, vaccine adverse events management and reporting, and resources for staff orientation and development. The broadcast is targeted toward immunization clinic managers, staff supervisors and staff who administer vaccines including nurses, nurse practitioners, pharmacists, medical and physician assistants. For more information go to http://www.phppo.cdc.gov/phtn/imm-encounter.

CDC Issues New STD Treatment Guidelines

New guidelines for preventing and treating sexually transmitted diseases issued May 10 by the Centers for Disease Control and Prevention include sections addressed specifically to STDs in children and adolescents. The guidelines were published in the CDC’s Morbidity and Mortality Weekly Report Recommendations and Reports, Volume 51, Number RR-6, and are available in both PDF and HTML formats. To download the guidelines in PDF format, requiring Adobe Acrobat Reader, click on www.cdc.gov/mmwr/PDF/rr/rr5106.pdf. To download in HTML (web) format, click on www.cdc.gov/mmwr/preview/mmwrhtml/rr5106al.htm.

CDC Reports Downward Trend in Youth Smoking

Analysis of data from the national Youth Risk Behavior Survey by the Office on Smoking and Health in the Centers for Disease Control and Prevention shows the incidence of smoking by male students increased significantly from 1991 to 1997, but declined significantly by 2001. For female students, smoking prevalence peaked in 1999 and declined significantly by 2001. Despite the declines, 28.5 percent of high school students are current smokers, and 13.8 percent smoke frequently. Noting that the data are consistent with other national surveys that suggest smoking levels by high school students are declining, the CDC said factors that may be contributing to the decline are increases in cigarette prices, increased school-based efforts to prevent tobacco use, and increased exposure of teenagers to mass media smoking prevention campaigns. The report can be read and downloaded at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5119a1.htm.

HHS Awards $16.1 Million to 28 Health Centers

Health and Human Services Secretary Tommy Thompson May 17 announced 28 grants totaling almost $16.1 million to expand access to health care services for Americans in rural and inner-city areas, as part of the Consolidated Health Center Program, which funds a national network of community health centers, migrant health centers, health care for the homeless centers, public housing primary care centers, and school-based health centers. Community health centers, the largest part of the program, received 21 of the grants. Other awards include two Health Care for the Homeless grants; two Public Housing Primary Care Program grants; and three Healthy Schools, Healthy Communities Program grants to support full-service school-based health centers that provide access to comprehensive primary health care services, including mental and oral health services, to students and their families. The list of grant recipients is available at http://newsroom.hrsa.gov/releases/2002releases/thirdround.htm.

Health Care Quality Information Site

A new government website sponsored in part by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid is intended to help organizations educate consumers about the quality of their health care. The site will offer tips on how to collect and analyze data and present and disseminate information in order to develop a quality measurement and reporting project, such as a health plan report card. A downloadable Planning Workbook is designed to help develop customized plans for presenting health care information. The website is www.talkingquality.gov.

Urban School Health Leadership Grants

Applications will be accepted through July 3 for the National Cancer Society’s National Urban School Health Leadership Institute, a new initiative funded in part through a cooperative agreement with the Centers for Disease Control and Prevention, Division of Adolescent and School Health, to help school districts develop a systematic and coordinated approach to addressing health and safety issues that interfere with student success. Six to 10 districts will be selected to send teams for three annual training sessions and three booster sessions in leadership training, team development, and technical assistance activities. A three-year commitment is required for participation. Applications are available by e-mail at ntolbert@cancer.org.

Effects of the World Trade Center Attack on NYC Public School Students

Effects of the World Trade Center Attack on NYC Public School Students - An Initial Report to the New York City Board of Education is available on the New York City Board of Education web site. The study was conducted six months after the attack by Applied Research and Consulting LLC, the Columbia University Mailman School of Public Health, and the New York Psychiatric Institute. Summary of the results is posted at http://www.nycenet.edu/offices/spss/wtc_needs/coping.htm.

NCHS Announces 2002 Data Users Conference

The National Center for Health Statistics (NCHS), the federal government's principal vital and health statistics agency, will hold its 2002 Data Users Conference in Washington, D.C., July 15-17. Health data users will have the opportunity to meet and to discuss data collection, analysis, and dissemination activities at NCHS. There is no registration fee but participants must register before May 15. Further information and online registration is at http://www.cdc.gov/nchs/events/2002duc/invitation.htm.

$2.8 Million Available to Fund Youth Violence Prevention

The Substance Abuse and Mental Health Services Administration (SAMHSA) has announce the availability of funds for grants to develop and enhance youth violence prevention activities in communities and schools. Approximately $2.8 million in funding will be available to fund 12 to 16 projects for community-based organizations and schools. SAMHSA's Center for Mental Health Services (CMHS) will administer these grants. Application due date is June 19, 2002. To read complete release, go to http://www.samhsa.gov/news/newsreleases/020503ma_youthviol.htm.