Fighting for Air

Jalyssa Moore was three years old when she had her first asthma attack. “When she woke up that morning, she was breathing really heavy,” says her mom, Kesher Moore, who lives with her two daughters in Bridgeport, Connecticut. “She was complaining she couldn’t breathe. I ended up taking her to a doctor who sent me straight to the emergency room.”

Jalyssa is now nine years old and is on a daily regimen of inhalers to keep her severe asthma at bay. Each night, she takes one puff from Advair, a long-acting inhaler, and she has an albuterol inhaler that she takes as needed throughout the day, including before recess and gym. Lots of things can trigger Jalyssa’s asthma, including cold air, weather changes, illness and any number of allergies. Her most concerning allergy is to peanuts (her mom and the school nurse must also keep an EpiPen—injectible epinephrine—on hand in case of any accidental peanut exposure), but she’s also allergic to two different types of grass, dust mites, roaches, cats, dogs, horses, beef and corn.

The steroid-based inhalers have left Jalyssa with some muscle weakness that Kesher says has been challenging. “Riding a bike is kind of difficult for her being on the medicines,” Kesher says. “She has low upper body strength and low muscle strength in her legs.” Still, the mom says her youngest daughter is able to participate in most activities—including cheerleading and drill team—because she’s in tune with her own limitations. “She’ll know when to stop running, when to stop doing certain things so she can calm herself down,” Kesher says. “She knows when she needs her pump, when she needs to go to the nurse. At three when she got diagnosed it was hard. Because we didn’t know what was triggering her asthma, we had to find out what she was allergic to and how to control it.”

The mom says she’s seen lots of other kids and adults with asthma in her urban, largely minority neighborhood. “I don’t know what’s triggering it, but it’s becoming common,” she says.

Minority Kids and Asthma

African-American children have the highest rates of asthma in the U.S., with 21% under the age of 18 having been diagnosed according to the most recent statistics from the Centers for Disease Control and Prevention. Hispanic children are the next most impacted, with 15% diagnosed compared to 12% of white children. A family’s economic status plays a role, too—poor families are more likely to have a child diagnosed with asthma. Across the U.S., asthma rates continue to climb, with an additional 4.3 million people diagnosed between 2001 and 2009, for a total of 25 million people with asthma. Among black children, there was a 50% increase in asthma diagnoses during those years.

“We know it’s multifactorial,” says Susan Sommer, the nurse case manager for the Community Asthma Initiative at Boston Children’s Hospital. “Air pollution, genetic variations for African Americans in particular and Latinos of African descent. We’re also looking at social determinants of health, substandard housing and old housing stock. There are lots of problems with mice, cockroaches and mold in public housing.”

Boston Children’s Hospital launched the Community Asthma Initiative (CAI) in 2005 in direct response to disparities in asthma hospitalizations between black and Hispanic children and their white counterparts. “You were four to five times as likely to be hospitalized with asthma if you were African American or Latino,” Sommer says. “Our interventions include working with families both on an individual level and at a more systemic level, and working with our partners advocating for improved housing and better approaches to pest management. Also, getting inspectional services in these homes to hold the landlord’s feet to the fire.”

Staff members now routinely approach families of patients who come to the emergency room for asthma treatment and offer to enroll them. Over the course of 12 months, these staff members visit the family’s home, provide a walkthrough inspection, identify triggers such as mice droppings, cockroaches or clutter; offer integrated pest management solutions (plugging holes, covering trash cans); and provide materials where needed. And CAI staff give every family a HEPA vacuum—one with an air filter that removes 99.97% of all particles greater than 0.3 micrometers.

“Asthma is a complicated illness to manage,” Sommer says. “When a child looks well, it’s hard to understand why you have to keep giving medication. People also experience low expectations of asthma control—they accept limitations in physical activity or trips to the emergency room as ‘just the way it is.’ We try to raise people’s expectations.”

The program is working. An evaluation of the success of CAI published in Pediatrics in March 2012 noted that at the 12-month follow-up children enrolled in the program had 68% less emergency room visits and nearly 85% less hospitalizations. The kids were playing more and missing school less and parents were clocking more days at work. Boston Children’s Hospital was spending less, too—for every dollar spent on the program, the hospital saved $1.46 in expenses.

Hot Cities, Dirty Air

Kids in cities aren’t only subject to more triggers inside older apartment buildings—they are also impacted by the nitrogen dioxide and particulate matter produced by power plants and highways and by high ozone levels. Ozone is created when nitrogen oxide collides with volatile organic compounds in sunlight. This ground-level ozone frequently reaches unhealthy levels in cities on hot days and makes the air more difficult to breathe. Short-term ozone exposure also causes coughing, throat irritation, chest pain when inhaling, chest tightening, wheezing and shortness of breath, according to the U.S. Environmental Protection Agency (EPA).

While there is a national push to “leave no child inside” and encourage more outdoor exploration and play, for kids with asthma in high-pollution, high-ozone environments, the outdoors present a major health hazard. And the younger children are, the more susceptible they are to the damaging impacts of pollution and ozone.

The Children’s Health Study in California looked at the impacts of air pollution exposures on about 5,500 children in 12 communities for over 10 years, beginning in 1992. The study found that children exposed to the highest levels of pollutants (including particulate matter, nitrogen dioxide, acid vapor and carbon) had lungs “that developed and grew more slowly and were less able to move air through them.” By age 18, when the lungs are nearly mature, children who grew up in polluted communities had decreased lung development that was essentially irreversible, making it more likely that they would have respiratory problems in adulthood. Children living in high-ozone communities who played in several sports—and so were outside running and playing the most—“were more likely to develop asthma than children in these communities not participating in sports.”

As temperatures rise as a result of climate change, ozone levels and associated asthma rates are expected to increase. “These fluctuations that we’re experiencing that in general tend to be going toward higher temperatures really leave us all concerned,” says Kent Pinkerton, Ph.D., professor of pediatrics at the UC Davis School of Medicine and director of the UC Davis Center for Health and the Environment. “It’s not climate that’s causing an increase in asthma, but it’s the consequences of changes in climate that can precipitate and enhance problems in people that already have preexisting cases of asthma or [even] precipitate new asthma where it didn’t exist before.”

Pinkerton co-authored a paper on climate change and human health that appeared in the March 2012 issue of the Proceedings of the American Thoracic Society. That paper called attention to a series of ways that climate change would give rise to new cases of asthma—from rising ozone levels in cities to increased dust storms from desertification, to more smoke and particulate matter from wildfires. “Here in the state of California we’ve had significant problems with increasing wildfires simply due to the dry conditions,” Pinkerton says. “That’s also happening in Texas as well as the midwest, where a lot of drought-like conditions in the past year have contributed to more dust in the air as well as potential for these wildfires.”

Skyrocketing summer temperatures combined with the country’s worst drought since the Dust Bowl made 2012 a record year for wildfires. More than nine million acres burned across the country, an area the size of Massachusetts and Connecticut combined. It was only the third time such numbers have been reached since record-keeping began in the 1960s—the other two years were 2006 and 2007. Colorado was one of the worst-impacted states, as well as New Mexico and Oregon.

Global warming is not only driving more intense and frequent wildfires, but the fires themselves release large stores of carbon from forests, contributing to that warming. A report by the National Wildlife Federation notes that “In some western states a fire spanning over just a couple months can emit nearly as much carbon dioxide as its total annual fossil fuel emissions.” The environmental organization projects that overall burned areas will double by late this century across 11 western states, with Montana, Wyoming, New Mexico and Utah expected to be particularly hard hit. And, Pinkerton adds, “Even thunder storms can cause problems with asthma,” noting that the storms can release additional pollen.

The Pollen Problem

Increased pollen is another consequence of global warming contributing to allergy and asthma problems—and not just from storms. Warming due to higher levels of carbon in the atmosphere has brought earlier springs, expanding ragweed growing seasons. It’s also meant ragweed produce more pollen, triggering additional allergy and asthma symptoms, a trend that’s expected to increase as temperatures continue to rise. “The length of the season matters,” says John Balbus, senior advisor for public health with the National Institute of Environmental Health Sciences who leads agency efforts on climate change and human health. “The inflammation is cumulative—the longer the pollen season goes on the more symptomatic a person can get.”

The EPA has been studying changes in ragweed pollen seasons at 10 locations across the U.S. and Canada since 1995. At eight of the 10 locations, ragweed pollen season has increased. The greatest increases are in the northern latitudes, such as Fargo, North Dakota (increased by 24 days) and Saskatoon, Saskatchewan (increased by 26 days), consistent with global warming trends.

Ragweed pollen is potent—and about 26% of the population has a sensitivity. Children and the elderly are particularly susceptible. Researchers have long been at work on a ragweed vaccine that works by attaching a synthetic piece of DNA to the allergen. Like traditional allergy shots, these work by gradually building up a person’s immunity so the body no longer overreacts to exposures with histaminedriven itchy eyes, sneezing and shortness of breath. A study released in March 2012 reported success with a dissolvable pill form of the ragweed injections. More than 500 adults with ragweed allergy were given either the tablet or a placebo. Those taking the tablets at the highest dosage had a 17% reduction in symptoms during the peak of ragweed season.

These mitigation strategies cannot come soon enough for asthma sufferers. A 2006 report on the increase in pollen production expected from rising CO2 levels that appeared in Environmental Health Perspectives, noted that pollen allergens act together with particulate matter from car and truck exhaust to make asthma conditions worse. And these pollen levels are leading to increased emergency room visits for asthmatics. A study looking at pollen levels and emergency room visits between 1993 and 2004 in Atlanta found there was a 10% to 15% increase in asthma-related emergency room visits on the highestpollen concentration days.

While Balbus says climate change is already impacting asthma sufferers—particularly in regard to increased pollen — he stresses that it’s one of many drivers. “Triggers vary by individual,” Balbus says. “Many people are triggered by outdoor pollens, many are triggered by dust and mold, and we see spikes in asthma that go along with winter respiratory infections.”

Triggers, Triggers Everywhere

Other environmental exposures are impacting asthma rates, too. Exposure to phthalates, chemicals used to soften plastic that are in children’s toys and PVC flooring and build up in household dust, was found to have an association with asthma and allergies in children. And in March 2013, researchers from Columbia University released findings that postnatal exposure to bisphenol A (BPA), a chemical used in plastic bottles and food containers and in the epoxy resins lining food cans, was associated with a risk of wheeze and asthma. This increased risk was seen at “fairly routine, low doses of exposure to BPA,” said lead author Kathleen Donohue in a related release.

Spray cleaners, including glass cleaners, furniture cleaners and air fresheners, are creating toxic indoor environments that trigger asthma, too. These sprays emit volatile organic compounds (VOCs) and certain of these chemicals—particularly benzene, ethylbenzene and toluene—have been strongly associated with asthma in kids in an Australian study. The researchers report that “Domestic exposure to VOCs at levels [even] below currently accepted recommendations may increase the risk of childhood asthma.”

Add indoor allergy triggers like dust mites and mold, and there are few places children with asthma can retreat to breathe easy. Asthma management needs to begin at home, says Balbus, before tackling the looming issue of global warming. “Household dust exposure is important,” he says. “Especially for kids in poorer quality housing, interventions like plastic on mattresses and HEPA vacuums make a big difference.”

Asthma is one of a host of health consequences from climate change, Balbus says. “If you look at the science, increases in temperature and sea level rise are expected to speed up over time and the consequences become more alarming” he says. “There’s an urgent need to limit climate change not just for asthma but for the overall health and well-being of a growing population over the long term.” That said, he adds that burning less fossil fuels would not only reduce global warming-causing emissions, but also bring immediate benefits in the form of cleaner air for asthma sufferers.

Pinkerton was one of many experts who contributed to a report by The American Thoracic Society on strategies for mitigating climate change and improving the outlook for people with asthma. Recommendations ranged from constructing energy-efficient buildings to educating clinicians about the impacts of climate change, to developing more effective alerts for air quality, weather events and pollen. And people can better use technology to alert them to health threats. The report concluded: “There needs to be an emphasis on public recognition and early warning response to severe climate-related events with the awareness that these effects are likely to have the most impact on susceptible populations: the elderly, infants and children, those with existing respiratory/cardiovascular disease…and those living in low-resource countries.”

People can stay abreast of air quality in their region via the EPA’s air quality index called AirNow. The rankings—from zero to 500—reflect how clean or unhealthy the air is based on the presence of five major pollutants: ground-level ozone, particle pollution (or particulate matter), carbon monoxide, sulfur dioxide and nitrogen dioxide. A ranking of 100 represents the level established by the EPA as acceptable for public health—so rankings below 100 are good, while above 100 are unhealthy. The rankings are also color-coded: green (0-50) for good; yellow (51-100) for moderate; orange (101-150) for unhealthy for sensitive groups; red (151-200) for unhealthy; purple (201-300) for very unhealthy and maroon (301-500) for hazardous.

The agency notes that air quality values above 300 are “extremely rare” adding that “they generally occur only during events such as forest fires,” a particular worry as climate change increases the frequency of such fires. They add that ozone is worst in warmer months and carbon monoxide is likely to be a problem during morning and evening rush hours. People can stay updated with real time air quality information on the website airnow.gov or download the free AirNow app. The site enviroflash.info allows people to register for these air quality updates to be sent to their inboxes. On poor air quality days, the EPA advises people to protect their health by limiting very prolonged or very active outdoor activity such as yard work or running.

It’s the type of health vigilance that’s second nature to Kesher Moore. Now able to recognize triggers and enlist her daughter’s help in managing her symptoms, Kesher has kept emergency room visits to a minimum. Jalyssa did have to travel from her school by ambulance one day because of a high temperature and rapid heartbeat combined with an asthma attack. But her mother says, “They did the same things I would have done at home. They gave her Tylenol until the temperature went down; and then gave her albuterol and had her wait in there until everything was OK.”

Mostly, the mom says, she’s learned not to panic. “Since we’ve found out how to control the asthma, she’s fine,” Kesher says. “It’s scary, but you know what to do.”