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CDC Vital Signs: Asthma Prevalence, Disease Characteristics, and Self-Management Education — United States, 2001–2009

Tuesday, May 3, 2011 – 12:00pm ET

Operator: Welcome and thank you for standing by. All participants are on a listen-only mode until the question and answer session of today's conference. During that time, if would you like to ask a question, you may press star 1. Today's conference is being recorded. If you do have any objections, you may disconnect at this time. Now I would like to turn the call over to your host for today, Ms. Bernadette Burden, CDC Online Newsroom. Ma'am, you may begin.

Bernadette Burden: Thank you very much, Amy. Good day, everyone. We appreciate you taking a moment to join us for today's CDC Vital Signs telebriefing. Our topic for today will be asthma control and prevention. Today is World Asthma Day and I am happy to be joined by CDC's principal deputy director, Dr. Ileana Arias and Dr. Paul Garbe, chief of CDC's Air Pollution and Respiratory Health Branch. We will begin with information from Dr. Arias followed by a discussion from Dr. Garbe and we will continue on with questions. Dr. Arias?

Ileana Arias: Good morning and thank you for joining us. Asthma is a disease that affects the lungs. It causes repeated episodes of wheezing, restlessness, chest tightness and nighttime or early morning coughing. Asthma is a chronic disease but it can be controlled effectively by taking medicine and avoiding the triggers that can cause an attack. About 25 million people or one out of every 12 people in the U.S. has asthma and that number, unfortunately, is rising. We don't know exactly why the rate is going up, but importantly, we do know that there are measures, individuals with asthma and all of us can take, to control asthma symptoms. Asthma is chronic and cannot be cured but exacerbation and many asthma attacks can be prevented. Unfortunately, though about half the people with asthma have at least one attack every year. Asthma costs the U.S. $56 billion in medical costs, lost school and work days and early deaths in 2007, which is the year – the most recent year for which we have this data. It was also linked to 3,447 deaths, or about nine every day that same year. Providers, insurers, individuals with asthma and others can work together to promote a comprehensive approach to effectively address asthma to providing ongoing medical care for persons with asthma. This care should consist of determining the severity of asthma and the extent of control the patient has over it, prescribing inhaled corticosteroids or other medicine for individuals with persistent asthma, self-management education on proper medicine use and avoiding asthma triggers and monitoring the patient's efforts to control their asthma. Individuals with asthma need to be aware of common asthma triggers in the environment, including tobacco smoke, mold, air pollution, dust mites and pollen and then especially to limit their exposure to these. I will turn it over now to Dr. Garbe, who will talk about the specifics of the study that is being released today.

Paul Garbe: Thank you, Dr. Arias. Just to pick up briefly on the medical cause that Dr. Arias alluded to it is asthma – we estimate costs to the United States over $50 billion a year in medical costs and that translates into over $3300 per person with asthma. So, the cost to people with asthma is substantial. What we are reporting today in our article is that asthma is more prevalent among children, especially boys it is more prevalent among women, African-Americans and those reporting income below the federal poverty level. Since 2001, we have been seeing an increase in asthma prevalence across all demographic subgroups and the difference in asthma prevalence among subgroups has persisted over the years. However, in particular, we see that there is a greater rise in asthma prevalence observed for African-Americans, African-American men and women.

The health outcomes for asthma that we are summarizing in our report are asthma attacks. We see that almost half the people with asthma reported having an asthma attack in the proceeding 12 months. 20% had missed one or more school or work days. 14% of the people with asthma had visited health care facilities for urgent care because of their asthma and 22% reported poor health. Although most people with asthma had health insurance, almost 90%, more uninsured people with asthma could not afford to buy prescription medications. More than 40%, compared to 11% for those who could afford to buy their prescription medications. And fewer reported seeing or talking to a specialist or a primary care physician if they did not have insurance.

Dr. Arias mentioned some of the features about asthma control. We know a great deal about how asthma control can be controlled, thanks in great part to the efforts of our colleagues at the National Heart, Lung and Blood Institute with the National Asthma Education and Prevention Program. And we have been very active in working with our state health departments to take this knowledge from the NIH guidelines and put that into practice in states. And I would like to give you some examples of some of the successes that some of our state programs have had. And in particular, focusing on patient education around self-management. We think self-management is an important – very important component of what patients can do. Our Connecticut asthma program was seeking to reduce the burden of asthma on children and adults who rely on emergency rooms as their primary source of health care due to either low socioeconomic status or not having insurance. So, they implemented a program to include in-home asthma education and environmental assessment to help residents find out what makes their asthma worse. A certified asthma educator would visit the home. An environmental health specialist would accompany the educator. They would do an assessment of environmental triggers in the home, and they would provide education on how to manage asthma in the home. And what the program found in implementing this work was that there was a dramatic reduction in the average number of physician visits after the home visit. In the months preceeding that home visit, participants averaged almost three visits to the doctor for urgent care compared to fewer than one visit following — in the six months following that — that program. Another success has been with our state program in Rhode Island, where they have implemented a team approach for asthma care, where they involve primary care managers, looking at both asthma and other chronic conditions. They have implemented quality improvement methods, electronic patient tracking and they are coordinating these efforts across federally funded community health centers as well as hospital-based health centers, which largely serve people of low income in Rhode Island. And finally, a third program in New York State, the state program there has developed tools for primary care providers to provide the guidelines in an easily used format. They provide booklets and videos for primary care providers to use to learn how to implement the guidelines in their practices and they have been carrying out a quality improvement assessment among Medicare managed – Medicaid managed care plans in New York State. So, each of these programs we think has been very successful. We have many other state programs that have had equal success in reducing asthma in some of their population subgroups. Time does not allow me to go into details in describing other programs. I wish I could describe all the other programs.

Bernadette Burden: All right, thank you Dr. Garbe and thank you, Dr. Arias. Amy, we are ready for questions.

Operator: Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star 1. You will be announced by name and affiliation prior to asking your question. Once again to ask a question, please ask star 1. One moment, please. To withdraw your question, please press star 2. Our first question comes from Roni Rabin with The New York Times, your line is open.

Roni Rabin: Hi, thank you. I'm just wondering, is this a sudden increase or is this a continuing increase from what we saw, say, in the 1990s or was the prevalence fairly stable then? And how does this increase compare with the increases of, say the previous decade or two? And in addition, I know you say you don't know why there's been an increase. Is it somewhat surprising that this comes when there has been a reduction in smoking and, you know, improvements in air quality and what is being done to try to figure out why — why this continues to increase?

Paul Garbe: The trend has been gradually rising over this decade. Some of our assessment of the trend in this decade compared to previous years is related to changes in questions that are asked. The data source we used is the National Health Interview Survey and they did change some of their questions. So, it makes it difficult to compare trends in the '90s to current trends. But the reasons for why we have a continuing rise in asthma prevalence are something that we are exploring. We have investigators in our program that are looking at that trying to get some understanding and certainly it is a very active research question among many of the academic researchers and our federal partners that are working on asthma control.

Roni Rabin: So, what is the difference in the questions that were asked now as opposed to before? Would they be capturing more – likely be capturing more cases?

Paul Garbe: That's good question. And I have to ask one of my colleagues to describe that for me. It was a matter of adding – a second question added. I could certainly get back to you with the detail on that.

Roni Rabin: Yeah, that would be great. I mean it does mention two questions. Gosh, where do I have that?

Paul Garbe: For this assessment, we used two questions. First someone is asked have you ever been told by a health care provider you have asthma?

Roni Rabin: Right.

Paul Garbe: Say yes to that, then we ask, do you still have asthma? So, to be counted as having asthma for this study, a person needed to have answered either for themselves or for their child yes to both questions. And in the '90s, we only had one of those questions was available.

Bernadette Burden: All right. Thank you very much. Amy, our next question?

Operator: Our next question is from Tom Maugh with the Los Angeles Times, your line is open.

Tom Maugh: Well, considering all the cutbacks, budgetary problems in both states and the federal government, are we going to be able to keep doing these programs to help the asthma victims?

Paul Garbe: That's a really good question. Not being a budget person, I'm – you know, the budget for the United States is certainly in the hands of people who know more about that than me. We have enormously dedicated people in our state programs and local health departments and they work hard and my observation and experience is many of them will continue working very hard. We hope that resources are available for it — for us to do as much as we are able to do, but certainly the level of commitment that we have among all of our health partners, both health departments as well as advocacy organizations that are involved in the national picture on asthma. I think people are very committed to reducing asthma.

Ileana Arias: This is Ileana Arias. Other thing that I think becomes very helpful is that there has been an emphasis on taking a holistic approach to health, especially when it comes to addressing home environment and the immediate environment in the home so that addressing asthma then becomes part and parcel of what is done generally to address other environmental health hazards that may have a significant negative impact on the health of adults and children. So, either dollars that are specifically devoted to asthma but then our effort is also to incorporate it into broader programs so that regardless of the resource situation, the issue is being addressed.

Bernadette Burden: Thank you. Our next question, please?

Operator: Our next question comes from Mike Stobbe of the Associated Press.

Mike Stobbe: Hi, thanks for taking the question. Um, did you all say that 90% of the people in this survey who had asthma had insurance? I wanted to check that figure and I wanted to ask, how does that compare to the general population and what percent are insured? I was wondering if asthmatics tend to be insured more often than other people and why that may be.

Paul Garbe: What we reported was that 89% of the participants in the survey who had asthma also had health insurance and compared to the general population with health insurance, it's about the same.

Mike Stobbe: Okay. Thank you.

Bernadette Burden: Thank you very much. Next question, please.

Operator: Our next question is from Bill Hendrick with WebMD.

Bill Hendrick: Hello. I'm wondering what the best kinds of medications are, the most effective medications are, for asthma? And I'm somewhat familiar with the medications for asthma and COPD and so forth.

Paul Garbe: Well, we are not in a postition to recommend any particular brand.

Bill Hendrick: I don't want a brand.

Paul Garbe: Two classes of medications are important for asthma management and asthma control. There is the quick-relief medication that you take when you are having symptoms or if you are having an asthma attack. These fall into the general category called beta-agonists. And then there are long-term controller medications. Principally, these will be inhaled corticosteroids. These should be recommended for people who have persistent asthma. Not everyone with asthma has persistent asthma. About a third of the population has what we would call intermittent asthma, but for the two-thirds that have persistent asthma, inhaled corticosteroids are the recommended primary treatment. They come in a variety of forms. Some of them are combined with other medications, long-acting beta-agonists, but it really is really up to the — a person's primary care provider which — to determine which medication would be appropriate for a person with asthma.

Bill Hendrick: Are the same medications used for asthma as for emphysema, COPD, so forth?

Paul Garbe: Some of the long-acting beta-agonist medications can be prescribed for both asthma and COPD. Now, there are some formulations that are long-acting beta-agonists only and currently, I believe none of those are recommended for use in a person with asthma. So, a physician who wants to include a long-acting beta-agonist for asthma treatment should be using a combined medication that includes inhaled corticosteroid.

Bernadette Burden: All right. Thank you very much. Our next question, please.

Operator: Our next question is from Lisa Schnirring with CIDRAP News.

Lisa Schnirring: Hi, thanks for all the great info today. It seems that asthma is a risk factor for flu complications, became an issue during the H1N1 pandemic and I'm wondering if that presents any take home messages as to how to better manage that during regular flu seasons, if there were any surprises about that. Any thoughts you can share on that would be definitely helpful.

Paul Garbe: That is a great point to bring up. We recommend influenza and pneumonia vaccinations for people with asthma. Importantly, people with asthma should have the injectable flu vaccine. They should not be given the inhaled flu vaccine but the flu — influenza vaccination is important for everyone, especially people with asthma.

Bernadette Burden: Thank you very much. Our next question, please.

Operator: Our next question from Tom Corwin with the Augusta Chronicle.

Tom Corwin: Hi, thanks for taking my call. Some of the people that I've talked to who regularly treat children with asthma are convinced that asthma is almost exacerbated by poverty, by some of the conditions that the children live in. To what extent when you are looking at the underlying causes do you look at socioeconomic factors and how much does that play into the increase, do you think?

Paul Garbe: We have a paper that is going to be published very soon that looks exactly at that question. And what we are finding, that even in some of the race ethnicity subgroups, asthma prevalence is still high with high income so, there are some factors it is a very complicated relationship, poverty and SES status that play into asthma exacerbations.

Tom Corwin: Thank you.

Bernadette Burden: Thank you very much. Our next question?

Operator: Our next question is from John Gever from MedPage Today.

John Gever: Hi, thanks for taking my question. Now, could you talk a little bit about vitamin D and also exposure to fine particulate pollution, pm 2.5s as potential explanations for the rising prevalence?

Paul Garbe: I'm not knowledgeable on vitamin D. I have people in my program working on that, but I would be doing them a disservice if I tried to summarize their work without having them here to advise me. Fine particulate matter, on the other hand, is an important question. It certainly is an asthma exacerbater. The health burden from fine particulate matter is complicated in that it appears to play a greater role in cardiovascular disease than respiratory disease. That said, addressing fine particulate matter as a public health issue is a priority for Dr. Freiden and our program, and we will be looking at how to address that closely with our colleagues from the Environmental Protection Agency.

John Gever: Okay. Thanks.

Bernadette Burden: Thank you very much. Next question, please.

Operator: Our next question is from Allison McCook with MedScape.

Allison McCook: Hi. Thanks for taking my question. Given our right for doctors, I was interested to see how these findings could, you know, how doctors could take this and apply this in their practice and one of the things I noticed was that so few people with asthma have a written action plan and that means something that, like, genuinely people are saying is a good idea. So, why do you think that is so uncommon for people?

Paul Garbe: Good question. Tough to answer without doing a lot of additional research. However, my thought is that the amount of time that is needed to for a primary care provider to develop a good asthma action plan would possibly prevent them from providing care to other patients that day. So, for a physician who's busy, finding that right balance of the amount of time they need to treat an individual with the time they need to treat all of the other patients is always a delicate task each day. Nonetheless, a written asthma action plan as well as physician education on how to manage asthma that's directed to the patient with asthma are both very important and that is one of the efforts that our state programs do place a great emphasis on, working with care providers in their states to help them provide that education in the clinical setting so that people learn how to manage their disease and physicians are better able to work with patients to manage asthma.

Bernadette Burden: Thank you very much. Next question, please.

Operator: Once again, if you would like to ask a question from the phone, please press star 1. One moment, please. Our next question from Tom Maugh with the Los Angeles Times.

Tom Maugh: You say you can't make direct comparisons between the '90s and the 2000s, but can you place this in any kind of context historically, you know, say 20, 30 years ago? What can you say about overall trends?

Paul Garbe: Well, overall trends have been going up. When you look at the number of people with asthma, the trend has been going up. Now, one trend that has changed, in the '80s and '90s there was a fairly dramatic increase in the number of people who died from asthma and that trend has been going down. Now, we still see almost 3500 people die each year with asthma, which is 3500 people more than should be. So, that's — be that's the one bright spot we haven't transited. The trend in death is going down, but the overall trend in the number of people with asthma has been rising pretty consistently over the last few – the last 10 to 20 years.

Tom Maugh: Can you say how much the deaths have gone down? Like, what was it in the '80s?

Paul Garbe: I don't that with me but we could certainly get back to you with an answer on that.

Bernadette Burden: Thank you very much. Do we have any additional questions, Amy?

Operator: Not at this time.

Bernadette Burden: Thank you, everyone, for joining us. I now would like to get some concluding words from both Dr. Arias as well as Dr. Garbe and provide some follow-up information to you as well. Dr. Arias?

Ileana Arias: Thank you so much for joining us today to talk about what we consider a very important and significant health issue. I think what's most important for us to convey through you is that asthma attacks are not inevitable. Asthma can be controlled and we know that developing and sticking to a written asthma action plan allows for the control of asthma instead of being controlled by asthma. So, one of the things we are very committed to doing, whether it is through education of patients or professionals and other tools that we can make available, is providing people the possiblity that they are going to maximize their quality of life and basically control a chronic condition that doesn't have to control them.

Bernadette Burden: Thank you very much. Dr. Garbe?

Paul Garbe: I second what Dr. Arias has just said and remind everyone that we do have guidelines on how to control asthma and the guidelines call for both physician participation as well as patient participation in managing their own care. Important elements of that is education. Physicians should provide education. The patient should act on education. Environmental control is also an important component. There are numerous environmental triggers in homes that people can learn to avoid and we certainly encourage people to be active in controlling their asthma.

Bernadette Burden: Thank you both. Just a couple of notes to those on the phone. If you do have follow-up questions for our experts or any additional information that you will need from CDC, please contact the CDC Division of News Media. Our phone number is 404-639-3286 or you can use our e-mail box, which is available on our press release today. I would like to also make you aware that in coming months, with our Vital Signs program, for the month of June, our focus will be food safety. For the month of July, we will focus on cancer prevention. We look forward to your participation and welcome you to join us for those two briefings, as well as others. That will conclude our conference for today. Amy, let me turn it back over to you.

Operator: Thank you for participating in today's conference. You may disconnect at this time.

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