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Pacific Southwest, Region 9

Serving: Arizona, California, Hawaii, Nevada, Pacific Islands, Tribal Nations

Children and Asthma: California

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There are approximately 9.4 million children in California, about 29% of the state's total population. Nationally, 1 in 8 children resides in California. Culturally, California is one of the most diverse states in the nation. Among children up to age 17, it is 43.8% Hispanic, 34.8% non-Hispanic White, 7.1%

non-Hispanic Black, 9.6% Asian and 0.5% American Indian/Alaska Native (2000 Census).

About 23% of children in California live in poverty. Access to health care is an integral part of successful asthma management. In California, 1.3 million children do not have health insurance or experienced gaps in coverage over the 12-month period of 2001. Latino children are the most likely to be uninsured (23.9%), followed by American Indian /Native Alaskan (16.8%). 24.8% of children in California living below the federal poverty level do not have access to health insurance.

Children and Asthma: California at a Glance

According to the 2001 California Health Interview Survey (CHIS), 9.6% of children (ages 0-17) have been diagnosed with asthma by a physician at any time (called "lifetime asthma prevalence") and reported symptoms of asthma during the preceding 12 months (called "asthma symptom prevalence") in California.

The impact of asthma is disproportionate among children of different racial and ethnic groups. African American children in California are four times more likely to be hospitalized for asthma compared to white children (NIAID, 2001). African American and Latino children living in urban areas are two to six times more likely to die from asthma than whites (NIAID, 2002).

In California, around 136,000 adolescents who experience asthma symptoms missed one or more days of school per month. Those who experienced symptoms more frequently (more than once a month) had higher rates of school absenteeism. Nearly 158,000 younger children (ages 0-11) reported that they limited their physical activities because of their asthmatic condition (CHIS, 2001).

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Asthma Strategies in California

At the national level, there are several strategic plans for addressing asthma in children. In the absence of a state-specific plan, many states opt to follow the recommendations put forth in the national strategies. In California, there is a statewide asthma strategy in place, as well as an asthma task force in San Francisco.

Strategic Plan for Asthma in California
California is the only state in Region 9 with its own asthma strategy. The California Department of Health Services (DHS) and the California Policy Research Center of the University of California held a conference in 1998 to assess the current state of knowledge about asthma and its implications for research and public policy in the state. In 1999, a framework was laid by DHS and a variety of stakeholders representing public health, medicine, community organizations, asthma experts, and individuals personally affected by asthma. These groups worked together to develop specific goals, objectives and strategies for California over the next five years. The strategy will provide a framework for evaluating current efforts and identifying priorities in asthma research, management and prevention.

Key goals of the California Asthma Strategy include:

  • Research, Epidemiology and Evaluation
    Conduct etiologic, applied and translation research including descriptive epidemiology, to develop and implement effective asthma prevention and management services.
  • Public Education
    Improve the understanding and management of asthma as both a personal and public health issue for people with asthma and their families, policy makers, and the general public.
  • Treatment and Management
    Optimize the diagnosis, treatment, and management of asthma in California by adherence to the current National Heart, Lung and Blood Institute's asthma guidelines
  • Secondary Prevention
    Identify opportunities to reduce exposure to asthma triggers (allergens and irritants) in the home, preschool, school, workplace, and outdoor environment to prevent asthma episodes or reduce their severity.
  • Policy
    Advocate and support policies that promote "asthma friendly" communities, especially those that eliminate the disproportionate burden of asthma for people living in poverty and people of color.

San Francisco Asthma Task Force Exiting EPA (disclaimer)
The Asthma Task Force was formed when community activists joined forces with the San Francisco Board of Supervisors to create a citywide response to the asthma epidemic. Signed into law in 2001, the task force is responsible for developing a citywide strategic plan to manage and prevent asthma. The task force is comprised of four committees: Environmental, Schools and Childcare, Clinical Care, and Community. A copy of the 2003 report and recommendations from each of the committees is available.

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Schools and asthma

California High Performance Schools (CHPS)  Exiting EPA (disclaimer)
CHPS aims to increase the energy efficiency of schools in California by marketing information, services, and incentive programs directly at school districts and designers. A comprehensive site describing districts throughout the state who are already building high performance schools, training and events, and publications and resources.

California Department of Health Services Indoor Air Quality (CDHS IAQ)
A number of resources related to IAQ in California, as well as a copy of the California Portable Classroom Study.

California Division of the State Architect: Sustainable Schools
This Web site provides a diverse collection of sustainable building resources including the numerous benefits, guidelines, programs, case studies, relevant publications, and funding options/incentives. The site is geared toward those interested and involved in designing, developing, and constructing high performance schools, such as school administrators and board officials, developers, architects, planners, researchers, teachers, and parents.


Asthma research and interventions

Here is an overview of some of the current asthma projects in California. This is not an exhaustive list; rather it aims to highlight key studies and interventions related to the environment and children. There are a number of large scale, epidemiological studies underway in California where asthma is a health outcome of interest; many are related to environmental hazards such as air pollution or pesticides. In contrast, environmental studies evaluate the prevalence and character of asthma triggers and determine their potential for exposure to children. Finally, a number of studies which evaluate various types of interventions are described, as well as the environmental health data tracking effort currently underway in California.

Sources of Asthma Data

Information about asthma in children can be obtained from a number of sources. National surveys are conducted every year and provide information about asthma prevalence, hospital admissions and emergency room (ER) visits related to asthma. In California, there are additional data sources related to asthma. These sources vary in several ways: different asthma outcomes may be collected (e.g. percent diagnosed with asthma, number of ER visits, asthma medication use, etc); length of data collection; availability of data to the public and researchers. Data collected by the state can enhance national data and is often available by county, city, hospital, or school.

Listed below are sources of asthma information collected at the state level. This list is intended to highlight the primary sources of asthma data available for Californians. It is possible that other sources of data exist that are not included below. Links are provided for more detailed information about how the surveys were conducted.

Office of Statewide Health Planning and Development (OSHPD)
Since 1993, OSHPD has maintained a database of hospital discharges where asthma is listed as the primary diagnosis. All ages are included in this database, but it does not provide information about asthma prevalence in California.

Health Plan Employer Data and Information Set (HEDIS)
Data collection was initiated in 2000, but data are not collected every year. Information about asthma medication use and emergency room visits will be collected.

The California Health Interview Survey (CHIS)
A new survey of California's population to assess its health and access to health care. The first report was published in 2001 and data will collected every two years. Data is available by county, region or state and can be broken down further by race, income, gender, age, and population density. Asthma measures collected include: 1) Ever diagnosed with asthma (children and adults); 2) Taking medications (children); 3) Frequency of asthma symptoms (children) 4) Physical activity limited (children).

California Healthy Kids Survey
Information is collected about a number of environmental health issues in children. Data is available at school district and county level. Questions relevant to asthma include 1) Do you wheeze when not exercising?; 2) Have you ever been diagnosed with asthma?

California County Mortality Chart Book. 2000.
Provides asthma mortality data for California between 1990-1997. Data is available at county level and can be further divided by race, age, and gender.

California County Asthma Hospitalization Chart Book, 2003

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Asthma studies: Health Effects

Southern California Children's Health Study
The Southern California Children's Health Study is a long term study, spanning 10 years, examining the health effects (including asthma) associated with exposure to ambient air in Southern California. Four air pollutants (ozone, nitrogen dioxide, small particle particulate matter and acid vapor) were the focus of this study. 5400 children from twelve communities with varying mixtures of these pollutants were enrolled and followed from 4th to 12th grade. Pulmonary function and respiratory symptoms and illness are measured annually. The study has already yielded some important results. Children living in areas with higher concentrations of nitrogen dioxide, particulate matter and acid vapor had lower rates of lung growth. Children living in high ozone areas who spend more time outdoors exercising were shown to have an increased risk of developing asthma. Short-term rises in ozone levels were associated with increases in school absences due to respiratory illness.

Children's Health Study II
This study builds on an ongoing Southern California Children's Health Study and will assess whether 1) dietary intake of fruits, vegetables and antioxidants; and 2) genetic factors affect children's susceptibility for slow lung function growth and increased occurrence of respiratory illnesses from chronic exposure to ozone (O3), nitrogen dioxide (NO2), and respirable particles (PM10 and PM2.5 ). The aim of this study is to investigate the biological mechanism by which these air pollutants cause respiratory effects. An additional 3000 participants will be recruited into the study to expand the focus to studies of asthma and air pollution.

Fresno Asthmatic Children's Environment Study (FACES)
Initiated in November, 2000, FACES will evaluate how environmental factors in the community of Fresno, California influence the progression of asthma in children over time. The effects of air pollution, especially particulate matter, are emphasized in this study. Children between 6 and 10 years of age who have been diagnosed with asthma are eligible for the study. This is an ongoing effort, and children remain in the study for 4 years. Currently there are about 300 children participating. Data is collected every 6 months (capturing relevant seasonal conditions) and there are 10 additional 2 week follow-up periods during which data is collected daily. The ten period sessions occur three times per year in different seasons and will offer insight into the effect of daily pollutant levels on short-term asthma status. FACES also includes an extensive exposure assessment program relevant to children. Intensive monitoring of home and ambient air was initiated in the beginning of 2002.

Children's Respiratory Health Study
The Children's Respiratory Health Study is a cross-sectional study conducted in the San Francisco Bay area examining the relationship between traffic patterns and children's respiratory health. Respiratory health surveys were conducted in 10 schools in three East Bay communities (Oakland, San Leandro, and Hayward) and involved 1100 children between 8 and 10 years of age. The ten schools were chosen based on their proximity to major highways, with some schools being closer to highways than others. Ambient air pollutant concentrations of traffic-related pollutants (e.g. nitrogen oxide and particulate matter) were measured over several seasons. Geographic information system (GIS) methods were used to evaluate the relationship between ambient pollutant concentrations at the schools and traffic patters on nearby roadways. It was also investigated whether exposure to traffic-related air pollutants was associated with respiratory symptoms in children.

Center for the Health Assessment of Mothers and Children in Salinas (CHAMACOS)
The aim of CHAMACOS is to investigate the effects of chronic, low-level pesticide exposure to approximately 600 pregnant women on a number of health outcomes, including asthma. Salinas Valley is a predominantly agricultural area in Monterey County, California. CHAMACOS focuses on exposures during pregnancy and early life. The prevalence of asthma and respiratory symptoms is assessed at two years of age and researchers hope to determine whether exposure to allergens and endotoxins is related to respiratory symptoms and disease and whether exposure to organophosphate pesticides modifies this relationship.

University of Southern California (USC) Children's Environmental Health Center
The focus of the University of Southern California (USC) Children's Environmental Health Center is to develop a better understanding of how host susceptibility and environmental exposures contribute to children's respiratory disease. This research will provide health and environmental officials with a variety of useful intervention tools. USC intends to investigate the relationship between environmental tobacco smoke (ETS) and asthma in children. This center will determine the biological mechanisms by which ETS alters normal allergic responses in the lungs of children.

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Environmental Studies

Portable Classrooms Study
The aim of the California Portable Classrooms Study is to assess the statewide environmental health conditions in California's portable classrooms. Phase I of this study involved collection of formaldehyde data from nearly 1000 schools statewide. Phase II was recently completed and consisted of environmental data collection in 70 schools randomly selected statewide; contaminants evaluated include formaldehyde and related gases, other gaseous pollutants such as benzene and chloroform, real-time particle counts, molds and allergens, carbon monoxide, temperature, and humidity. Many of the environmental contaminants evaluated are known asthma triggers.

School Bus Study
Investigators will measure in-bus and near-bus pollutant levels during normal bus operations across a full range of activities, conditions and fuels. Conditions include different roadway types, varying traffic densities and various ventilation rates during travel, loading and unloading at schools. Fuels that will be studied include diesel, gasoline and natural gas, and buses that have been retrofitted with diesel particulate traps will also be included in the busy. This study will assist in quantifying children's exposure to air pollution during their school bus commutes.

Asthma Interventions in California

Community Intervention Project on Childhood Asthma
The major goal of this study is to determine whether a comprehensive environmental health education program, enhanced by least toxic integrated pest management for cockroach control, will result in reduction in concentrations of antigens in household dust and/or improvement in clinical status among these children. The study population will consist of 300 children with chronic persistent asthma randomly selected from the 3,000 asthmatics identified by the school-based Breathmobile program. Children will be randomized into three groups: (1) 100 children will continue to receive usual care from the Breathmobile; (2) 100 children will receive usual care plus a standardized antigen reduction strategy (STARS), a community based, family oriented environmental health training program; and (3) 100 children will receive usual Breathmobile care plus STARS, enhanced by professional pest control and home cleaning. Exposure to environmental asthma triggers in the home will be assessed by measuring concentrations of dust mite antigen, and cockroach antigen, in house dust. Outcomes of interest include change in knowledge, change in concentrations of antigen in house dust, school absence, clinical assessment of asthma severity, and medication use. Covariates to be considered include exposure to environmental tobacco smoke, indoor and outdoor air pollutants, housing characteristics (such as molds, mildew, air conditioning) and demographics (such as family size, gender, ethnicity).

Asthma Feasibility Study
California Office of Binational Border Health (COBBH) assists in the coordination of the Division of Environmental and Occupational Disease Control project which partners with Baja California health professionals at the Colegio de la Frontera Norte (Colef), and Mexico's National Institute of Public Health (INSP) to study the prevalence of childhood asthma in Imperial County and Mexicali and develop improved community education for its control.

Open Airways for Schools
This program was developed by the American Lung Association and helps children ages 8-11 take the steps necessary to help prevent asthma episodes by recognizing asthma symptoms when they occur and carrying out the appropriate management steps. Open Airways consists of six 40-minute group lessons for children held during the day, with take home assignments. School participation in Open Airways varies by state; contact the local ALA chapter for more information.

Kicks Asthma LA
A collaborative effort designed to empower a community on the eastside of Los Angeles to protect it's children from environmentally-related diseases, particularly asthma. Ultimately, KICK asthma could serve as model program that could be replicated in other Latino communities around the country.

Oakland Kicks Asthma
A pilot program with the goal of developing a comprehensive asthma intervention program for teens in Oakland. Some components of this program include initiating an asthma surveillance system, media advocacy and public awareness, implementing EPA's Tools for Schools program, asthma education for school personnel, peer education, asthma case management and clinical improvement.

Environmental Health Tracking in California

California Environmental Health Tracking Program - Alameda pilot project
The California Environmental Health Tracking Program (CEHTP) was created in response to a state legislative mandate, Senate Bill 702. The focus of this effort is improving collection, integration and analysis of both environmental hazards and health outcomes in the State of California. Improving the quality of data about asthma is a priority. A pilot program is underway in Alameda County that includes asthma indicators currently in use (such as hospitalizations and, and in some cases, emergency room visits) as well as new indicators (outpatient visits and prescription purchasing). If successful, this pilot project may be expanded to the state level.

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Additional asthma resources in California

Statewide Resources

California Environmental Protection Agency: Office of Environmental Health Hazard Assessment (OEHHA)
OEHHA is involved in a number of children’s health efforts throughout the state. Information is available on OEHHA projects involving children and air pollution, risk assessment and school safety. Additional resources and fact sheets are also available.

California Department of Health Services: Environmental Health Investigations Branch (EHIB): Asthma
EHIB has a number of projects related to asthma and the environment. Links to publications and fact sheets are available, as well as information about the prevalence and incidence of asthma in California. The “California Breathing” project within EHIB is a comprehensive public health plan intended to “operationalize” California’s Strategic Plan for Asthma (2003). The plan addresses four major areas: asthma surveillance, asthma disparities, asthma and schools and asthma partnerships. An “asthma best picks” site is also available and lists governmental, non-governmental, and academic resources.

Center for Chronic Disease Prevention and Health Promotion
A description of some of the main asthma-related projects from the CDCB, including the California Asthma Public Health Initiative. An excellent source of information on asthma in California, a comprehensive resource list, and links to the Strategic Plan for Asthma in California, the California Interagency Work Group, and World Asthma Day resources.

California Department of Health Services: Indoor Air Quality (IAQ)
The IAQ web site contains information about asthma triggers related to indoor air environments. Meeting minutes from the California Interagency Working Group on IAQ are available. There are links to a variety of resources related to IAQ in the home and schools as well as specific agents such as environmental tobacco smoke, VOCs, mold and indoor ozone. The California Portable Classrooms Study can also be directly accessed from this site.

Children’s Environmental Health Network (CEHN) The California Project
CEHN is a national organization devoted to protecting children from environmental hazards. CEHN has a California-specific page which includes information about a number of children’s health issues, including asthma. This site has an extensive list of resources on many health topics, fact sheets, descriptions of key projects in California and interim findings.

California Air Resources Board (CARB): Children’s Environmental Health Protection Program
CARB is involved in a number of projects related to air pollution. Many of the current efforts at CARB are related to Senate Bill 25, which established a mandate to study the impact of air pollution on children’s health throughout California. Links to more information about this program, SB25, air quality standards and air monitoring networks in California are available.

American Lung Association (ALA) California
There are 15 local ALA offices throughout California; contact information is available at this site. Listings of programs and events are searchable by either location or category. The primary focus of these resources is asthma education and management.

Community Action to Fight Asthma (CAFA)
CAFA is an initiative which aims to address the multiple environmental triggers of asthma among school aged children. As part of a 3 year program, CAFA supports and coordinates the efforts of 12 community based partnerships across California. Information about funding opportunities, legislative activities, articles, and links to additional resources are available at CAFA’s web site.

California Asthma Among the School Aged (CAASA) Project
A primary focus of CAASA is to improve clinical management of asthma in children by assessing new processes and systems at the clinic/community level and creating linkages between health care providers, parents, schools and the community. There are 7 CAASA clinics in California.

Pediatric Environmental Health Specialty Unit (PEHSU) - University of California
PEHSU is a federally funded clinical and educational center that provides clinical and public health evaluations of children and communities with environmental health problems. A description of the program’s services and partners as well as some general information about the relationship between the environment and asthma.

California Asthma Resources List (CARL)
Asthma services are listed by county. A description of the programs and services and contact information are available. This site is maintained by the California Department of Health Services.

California County and City Health Departments
Many county and city health departments have their own asthma programs and comprehensive lists of local contacts and resources. This site contains links to county and city health departments in California.

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Northern California

Regional Asthma Management and Prevention Initiative (RAMP)
RAMP focuses primarily on Alameda, Contra Costa, San Francisco, San Mateo, and Solano counties in California. This an excellent site that provides a comprehensive list of resources related to asthma and clinical management, research, legislation and funding, the environment and data collection. Links to local programs, partnerships and outreach programs are available for each county. Regional asthma statistics from a variety of data sources are also compiled by RAMP.

Contra County Health Services: Asthma Program
Contra Costa Health Services has a page devoted to asthma that includes some of the major regional asthma projects underway, and well as links to additional asthma resources.

Bay Area Air Quality Management District (BAAQMD)
Contains information about a number of issues related to overall air quality such as regional compliance with ambient air standards, air incident reports, advisories, permit public notices and facility reviews.

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Central California

San Joaquin Valley Health Consortium
The Central California Asthma Project (CCAP) was formed from community-based partners as a forum to exchange information and resources to control asthma among individuals and groups in the counties of Fresno, Kern, Kings, Madera, Mariposa, Merced, and Tulare. Descriptions of asthma programs available for health professionals and school officials. A number of asthma education and management programs are available for children and adults.

Palo Alto Medical Foundation Research Institute
Event information and some general asthma resources. Several scientific paper citations related to exercise-induced asthma.

Central California Asthma Project
The goal of this project is to create self-sustaining asthma coalitions that increase asthma awareness and provide education and outreach in Central California. This page also contains statistics about mortality, health care providers, HMO/hospital resources, demographics, education and employment in Fresno, Kern, Kings, Merced, Mariposa, and Tulare counties.

Community Medical Centers Asthma Education Program
Provides information and support for Tulare, Kings, Madera, Fresno and parts of Mariposa County. [Web site not up and running yet]

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Southern California

South Coast Air Quality Management District
Air pollution control agency for Orange County and major portions of Los Angeles, San Bernadino, and Riverside counties in Southern California. Information about air quality; smog, and ozone level forecasts available.

"The Health Effects of Air Pollution on Children"
An article by Michael Kleinman, PhD, describing how air pollutants can cause health effects.

San Diego Asthma Coalition
The American Lung Association led the development of this coalition in 1999; today it is a collaboration of around 50 agencies to develop and coordinate resources to prevent asthma. The coalition has published a San Diego County Asthma Resource Directory for Consumers. It is intended to assist parents find the resources needed to manage asthma in their children and can be accessed via the Web site.

Children’s Environmental Health Center (CEHC)
CEHC combines clinical and basic research of respiratory environmental health problems in children with community grassroots and outreach efforts. University of Southern California (USC) and University of California, Los Angeles (UCLA) faculty collaborate on a number of projects, including several major health studies in Southern California.

Community Education and Outreach Program (COEP)
COEP attempts to connect USC and UCLA researchers with local community-based organizations to form interdisciplinary teams to improve environmental health in children. This site contains links to many of the community-based groups involved in this effort.

Southern California Environmental Health Sciences Center (SCEHSC)
The SCEHSC consists of five research cores (respiratory effects, childhood cancer, adult cancer, study design and statistical methodology, and exposure assessment), three facility cores (molecular biology and sample processing, biostatistics, and analytical chemistry), an administrative core, and community outreach and education core. The overarching goal of this Center is to expand opportunities to conduct large scale research studies, develop models for community outreach and school programs, and educate the public on environmental health. Descriptions of current efforts in all these areas are available on the web site.

USC Keck School of Medicine Division of Occupational and Environmental Health
A description of studies relevant to children’s health; some studies focus on asthma.

Kick Asthma LA
Description of this program, which is a collaborative effort designed to empower a community on the eastside of Los Angeles to protect it’s children from environmentally related disease, particularly asthma.

Asthma and Allergy Foundation of America (AAFA) Southern California Chapter
A number of resources are available at this site: Breathmobile programs in Los Angeles area, professional and community workshops, information about children’s programs such as Asthma Camp, educational materials and resources, publications and some statistics.

National Latino Resource Center (NLRC)
NLRC serves as one of four regional centers for the Community Action to Fight Asthma (CAFA) initiative and provides technical assistance to the San Diego Regional Asthma Coalition and the Imperial Valley Asthma Coalition. NLRC specializes in applied research, training, technical assistance and research-based services related to the U.S. Latino population. Details of NLRC and it’s role in CAFA are available at this site.

Physicians for Social Responsibility
Regional center associated with the Community Action Fighting Asthma (CAFA) project.

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