Professional Documents
Culture Documents
District of Columbia
2009
H H H
Government of the District of Columbia Adrian M. Fenty, Mayor
District of Columbia Department of Health 825 North Capitol Street, NE Washington DC 20002 http://dchealth.dc.gov
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Table of Contents
List of Figure .........................................................................................................................................................v List of Tables....................................................................................................................................................... vii Executive Summary ............................................................................................................................................ix Key Findings................................................................................................................................................x Summary of Recommendations ............................................................................................................xiv 1.0 Introduction ................................................................................................................................................1 1.1. Cause and Triggers ...........................................................................................................................1 1.2. Public Health Significance ...............................................................................................................1 1.3. Who Is Most Affected by Asthma? .................................................................................................2 1.4. Overview of the District of Columbia ...........................................................................................2 1.4.1. DC Control Asthma Now (DC CAN) ..............................................................................4 1.4.2. DC Healthy People 2010 Asthma Objectives ..................................................................5 2.0 Asthma Burden in the District of Columbia...........................................................................................7 2.1. Measuring Asthma Prevalence .......................................................................................................7 2.2. Asthma Prevalence in the District..................................................................................................8 2.2.1. Asthma Prevalence by Gender.........................................................................................10 2.2.2. Asthma Prevalence by Race/Ethnicity ............................................................................11 2.2.3. Asthma Prevalence by Age Group ..................................................................................11 2.2.4. Asthma Prevalence by Socioeconomic Status ...............................................................12 2.2.5. Asthma Prevalence by Ward ............................................................................................14 2.2.6. Risk Factors Associated with Elevated Asthma Prevalence .........................................15 2.2.7. Asthma Prevalence among Children ..............................................................................16 3.0 Asthma Management and Quality of Life .............................................................................................19 3.1. Measuring Asthma Management and Quality of Life ...............................................................19 3.2. Asthma Severity ..............................................................................................................................19 3.2.1. Asthma Episodes (Attacks) ..............................................................................................19 3.2.2. Routine Doctor Visits .......................................................................................................21 3.2.3. Inhaler Use .........................................................................................................................23 3.3. Asthma Quality of Life ...................................................................................................................24 3.3.1. Age at First Diagnosis .......................................................................................................24 3.3.2. Limited Activity .................................................................................................................26 4.0 Asthma Morbidity ....................................................................................................................................29 4.1. Hospitalization Due to Asthma ....................................................................................................29 4.1.1. Asthma Hospitalization by Age .......................................................................................30 4.1.2. Mean Length of Stay..........................................................................................................32 4.2. Emergency Department Visit Due to Asthma ............................................................................32 4.2.1. Age-adjusted ED Visit Rates ............................................................................................32 4.2.2. ED Visits by Gender ..........................................................................................................34 4.2.3. ED Visits among Children ...............................................................................................34
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Table of Contents
4.2.4. Insurance .........................................................................................................................35 4.2.5. Disposition ......................................................................................................................36 5.0 Asthma Mortality ..................................................................................................................................39 5.1. Mortality Count by Subgroups ..................................................................................................39 5.2. Mortality Rate ..............................................................................................................................40 5.3. Mortality Rate by Sex, Race and Age Group ............................................................................40 5.4. Mortality Rate by Ward...............................................................................................................41 6.0 Work-Related Asthma ..........................................................................................................................43 6.1. Prevalence of Work-Related Asthma in The District ..............................................................44 6.1.1. WRA Study Description ................................................................................................44 6.1.2. WRA Study Results ........................................................................................................45 7.0 Air Quality and Asthma .......................................................................................................................47 7.1. Outdoor Environmental Pollutants ...........................................................................................47 7.1.1. Health Effects ..................................................................................................................48 7.2. Air Quality Standards .................................................................................................................48 7.3. The Role of Outdoor Air Pollution in the District ...................................................................49 7.3.1. Study Description ...........................................................................................................50 7.3.2. Study Results ...................................................................................................................50 8.0 Conclusions ...........................................................................................................................................53 8.1. Non-Hispanic Black Population ................................................................................................53 8.2. Populations with Low Socioeconomic Status ...........................................................................54 8.3. Children ........................................................................................................................................54 8.4. Adult and Elderly Population.....................................................................................................54 8.5. Female Population .......................................................................................................................55 8.6. Populations with Other Risk Factors.........................................................................................55 8.7. Implications on Asthma Management ......................................................................................56 8.8. Work-Related Asthma.................................................................................................................56 8.9. Asthma and Environmental Factors..........................................................................................56 9.0 Recommendations ................................................................................................................................59 9.1. Surveillance System .....................................................................................................................59 9.2. Asthma Management ..................................................................................................................60 9.3. Risk Factors and Preventable Events .........................................................................................60 9.4. Reducing Health Disparities ......................................................................................................61 10. References ..............................................................................................................................................63 Technical Notes ...............................................................................................................................................67 Acronyms ...............................................................................................................................................68 Appendix A: Work-Related Asthma Survey GWU..................................................................................69 Survey Questions...................................................................................................................................69 Appendix B: Data Tables ................................................................................................................................71 iv Burden of Asthma in the District of Columbia
List of Figures
Figure 1-1 Figure 2-1 Figure 2-2 Figure 2-3 Figure 2-4 Figure 2-5 Figure 2-6 Figure 2-7 Figure 2-8 Figure 2-9 Figure 2-10 Figure 2-11 Figure 2-12 Figure 2-13 Figure 2-14 Figure 2-15 Figure 3-1 Figure 3-2 Figure 3-3 Figure 3-4 Figure 3-5 Figure 3-6 Figure 3-7 Figure 3-8 Figure 3-9 Figure 3-10 Figure 3-11 Figure 3-12 Figure 3-13 Figure 3-14 Figure 3-15 Figure 4-1 Figure 4-2 The District of Columbia by Ward designations .................................................................3 District of Columbia asthma surveillance data sources......................................................7 Prevalence of adult asthma in District of Columbia ...........................................................9 Lifetime asthma prevalence in adults over 18, District vs. US ...........................................9 Current asthma prevalence in adults over 18, District vs. US..........................................10 Prevalence of adult (18 years) asthma by gender ............................................................10 Prevalence of adult (18 years) asthma by race/ethnicity ................................................11 Prevalence of adult (18 years) asthma by age group .......................................................12 Prevalence of adult (18 years) asthma by education level ..............................................13 Prevalence of adult (18 years) asthma by income level ..................................................13 Prevalence of current adult (18 years) asthma by ward .................................................14 Prevalence of former adult (18 years) asthma by ward ..................................................14 Prevalence of childhood (17 years) asthma .....................................................................16 Prevalence of childhood (17 years) asthma by gender ...................................................17 Prevalence of childhood (17 years) asthma by race ........................................................17 Prevalence of childhood (17 years) asthma by age group ..............................................18 Respondent answers regarding episodes of asthma ..........................................................20 Episodes of asthma by gender..............................................................................................20 Episodes of asthma by race ..................................................................................................21 Frequency of visits to a doctor for routine asthma checkups...........................................21 Frequency of visits to a doctor for routine asthma checkups by gender ................................................................................................................................22 Frequency of visits to a doctor for routine asthma doctor visit by race ..........................22 Frequency of inhaler use to stop asthma episodes ............................................................23 Frequency of inhaler use to stop asthma episodes by gender ..........................................23 Frequency of inhaler use to stop asthma episodes by race ...............................................24 Age at first diagnosis among respondents with current asthma ......................................25 Age when diagnosed with asthma by gender .....................................................................25 Age when diagnosed with asthma by race/ethnicity .........................................................26 Days of missed work or usual activities because of asthma .............................................26 Days of missed work or usual activities because of asthma by gender ................................................................................................................................27 Days of missed work or usual activities because of asthma by race ................................27 Crude asthma hospitalization rate in the District of Columbia ......................................30 Hospitalization rates due to asthma by age group in the District of Columbia ...........................................................................................................................30 Burden of Asthma in the District of Columbia v
List of Figures
Figure 4-3 Figure 4-4 Figure 4-5 Figure 4-6 Figure 4-7 Figure 4-8 Figure 4-9 Figure 4-10 Figure 5-1 Figure 5-2 Figure 5-3 Figure 5-4 Mean length of stay for asthma-related discharges and total hospital discharges ................................................................................................................32 Age-adjusted rates of emergency department visits due to asthma among all residents in the District of Columbia................................................................33 Total emergency department visits due to asthma in the District of Columbia .............................................................................................................33 Emergency department visits due to asthma by gender in the District of Columbia .............................................................................................................34 Age-adjusted rates for children in the District of Columbia ............................................35 Distribution of insurance among emergency discharge asthma patients in the District of Columbia ...................................................................................35 Disposition of emergency department visits due to asthma in the District of Columbia .............................................................................................................36 Frequency of disposition of emergency department visits due to asthma in the District of Columbia ....................................................................................37 Annual asthma mortality rate in the District of Columbia, 1999-2005 ...............................................................................................................................40 Asthma mortality rate by sex and race, District of Columbia 1999-2005 ...............................................................................................................................41 Asthma mortality rate by age group, District of Columbia 1999-2005 ...............................................................................................................................41 Crude asthma mortality rate by Ward, District of Columbia 1999-2005 ...............................................................................................................................42
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List of Tables
Table 1-1 Table 1-2 Table 2-1 Table 2-2 Table 4-1 Table 5-1 Table 7-1 District of Columbia population distribution by race and age group ..................................2 District of Columbia population, race and socio-economic distribution by ward ...................................................................................................................4 Asthma prevalence category definitions: respondent answers to BRFSS survey questions.............................................................................................................8 Prevalence of risk factors among BRFSS respondents with current asthma, 2005 .............................................................................................................................16 Number and rate of hospitalization due to asthma by age group in the District of Columbia ..........................................................................................................31 Annual asthma mortality count in the District of Columbia, 1999-2005 ..................................................................................................................................39 National Ambient Air Quality Standards ..............................................................................49
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Executive Summary Asthma is a chronic disease of the lungs bronchi (airways) characterized by airway hyper-respon-
siveness to stimuli resulting in airflow limitation, and respiratory symptoms including: breathlessness, wheezing, coughing, and chest tightness. Symptoms can vary in severity from mild intermittent to severe persistent. All levels of severity can be life threatening. According to the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey data, approximately 9% of adult residents (40,000 adults) and 11% of children (13,000 children) currently have asthma, and about 15% of adults have been diagnosed with asthma at some point in their life. Overall, the prevalence of current asthma in the District of Columbia has been consistently higher than the national rate for the past seven years. In addition, the Districts asthma prevalence was on an upward trend from 2000 to 2004, but seemed to stabilize at slightly above 15% from 2004 to 2007. Vital Records data for asthma related mortality indicate an overall decreased rate from 1999-2005, despite a rate increase in 2004. Although asthma affects all portions of the Districts population, certain subgroups are disproportionately affected. The non-Hispanic black population: very young children aged 0-4 years, especially male children of this age group, adolescent females, adults 45-50 years and the elderly (65+ years), tobacco smokers, obese and overweight populations, residents with less than or some high school education, and households with an income less than $15,000 appear to be most affected by asthma. The District of Columbia Department of Health (DOH) Asthma Control Program launched the DC Control Asthma Now (DC CAN) Program in 2001 in order to address the national Healthy People 2010 asthma objectives, and to improve the quality of life for District residents who suffer from asthma. Its mission is to develop and implement a viable, comprehensive, community-based, and consumercentered approach to asthma diagnosis and management. The objectives of DC CAN are to: Develop interventions to reduce asthma hospitalizations, deaths, and emergency department visits among high-risk populations; Identify barriers in the delivery of asthma care services, particularly to the underserved and highrisk groups; Increase education and awareness programs that are culturally sensitive, and linguistically appropriate for all racial/ethnic groups; Promote the use of guidelines from the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institutes (NHLBI) for the treatment and management of asthma;
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Educate persons with asthma, their family members/caregivers, as well as health care providers and health educators; and Develop a comprehensive asthma surveillance and data collection system to monitor trends and evaluate the effectiveness of program interventions in the reduction of asthma morbidity and mortality. The National Healthy People 2010 (HP 2010) includes seven goals for improving the health of those living with asthma. DC HP 2010 (http://doh.dc.gov/doh/site/default.asp) has adopted three (3) of these goals: Reduce asthma deaths; Reduce asthma hospitalization; and Reduce emergency department visits related to asthma.
Key Findings
Several data sources were analyzed to describe the health status of persons with asthma. The District of Columbia Behavioral Risk Factor Surveillance System (BRFSS), hospital discharge data, emergency department data, mortality records, workers compensation claims, and air quality measurements are among the data used to outline the findings in this report.
The prevalence of current asthma among 18-24 year olds was more than twice that of those 65 years and over, at p<0.05 in 2005, but was reduced by half in 2007.
Inhaler Use
In 2005, approximately 30% of BRFSS respondents with current asthma reported using an inhaler 1-4 times and 9% reported using an inhaler 5 or more times to stop an asthma attack in the past month. Almost twice as many women (10.7%) used an inhaler five or more times as compared to men (5.5%). Almost twice as many non-Hispanic black respondents (34.6%) with asthma reported using inhalers 1-4 times in the past month as compared to their non-Hispanic white counterparts (19.3%). Reports of never using an inhaler were 43% higher among non-Hispanic whites than non-Hispanic blacks.
Limited Activity
In 2005, approximately 12% of respondents with current asthma indicated that they were unable to work or carry out usual activities due to asthma lasting 1-5 days, and almost 10% indicated that their work or usual activity was restricted due to asthma lasting six or more days.
Asthma Hospitalization
There is a general decreasing trend in the crude asthma hospital discharge rate from 2002 (20.2 per 10,000 persons) to 2005 (17.1 per 10,000 persons). From 2002 to 2005 the highest rate of hospitalization occurred among children under five years old, middle aged (45-50 years) and the elderly (60-75 years). xii Burden of Asthma in the District of Columbia
Mortality
The asthma mortality rate from 1999 to 2005 was 11.6 per 100,000 persons. From year 1999 to 2005, the asthma mortality rate of non-Hispanic blacks was approximately 4 times higher than those of non-Hispanic whites. Asthma mortality rate among male District residents (12 per 100,000) was slightly higher than their female counterparts (11.2 per 100,000) from 1999 to 2005. More asthma deaths occurred among adults than children (0-17 years) and the number of deaths increased by age. Wards 7, 5 and 8 had the highest, and Ward 3 had the lowest asthma mortality rates in the District from 1999 to 2005.
Work-Related Asthma
There were 39 cases of work-related asthma (WRA) in the District from 1999 to 2005 as reported by workers compensation claims. A study was conducted to validate that all WRA cases were captured using the worker compensation claims database. The study identified 18% more cases in one year compared to the workers compensation claims database that spanned seven years.
Summary of Recommendations
Asthma represents a considerable burden on the District of Columbia. Despite some improvements in asthma prevalence nationally, the District is lagging behind. There are many opportunities for improvement as evidenced by racial, socioeconomic, and geographic disparities. Non-Hispanic blacks, low income populations, residents in Wards 6, 7 and 8, the homeless population, young children (< 5 years), school-aged children, middle aged adults (45-50), and the elderly are all subpopulations that need specific attention when considering reduction of asthma prevalence, severity, and mortality in the District. The reports findings suggest the need for improvement in asthma surveillance, management, health disparities and reduction in risk factors, and preventable events. The District of Columbia needs to maintain a consistent data collection mechanism that will capture prevalence, emergency department and hospitalization data by race, ward, and school district level as well as data on asthma management by subpopulations. There is also a significant need to develop a better data collection methodology for work-related asthma (WRA) in order to better estimate the prevalence of WRA in the District. This may mean forging partnerships with stakeholders (DC Office of Workers Compensation, physicians. employers etc.) to establish an active data collection system. Asthma intervention programs need to encourage proper asthma management by mitigating primary health care barriers for at-risk populations. DC DOH needs to continue to form partnerships with the Districts schools to improve asthma management in school-aged children. WRA is a disease that is preventable; asthma interventions need to educate health care providers, employers and employees on the diagnosis, and prevention of WRA. Obesity and tobacco smoke are risk factors that need to be integrated in asthma prevention strategies especially those targeting children. Racial and socioeconomic disparities in asthma morbidity and mortality need to be addressed by targeting resources, forming partnerships, and implementing outcome based interventions that utilize asthma data to set goals, and routinely assess improvements.
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1. Introduction Asthma is a chronic disease of the lungs bronchi (airways) characterized by airway hyper-respon-
siveness to stimuli resulting in airflow limitation and respiratory symptoms including breathlessness, wheezing, coughing, and chest tightness. Symptoms can vary in severity from mild intermittent (affecting activity levels) to severe persistent. All levels of severity can be life- threatening.
* Source: US Census Bureau, 2006 American Community Survey ** Persons of Hispanic Origin may be of any race
The Districts 63 square miles are divided into eight (8) wards on which local political representation is based and public services are administered. Figure 1-1 shows the map of the District of Columbia ward designations. Ward designations have not changed since 2000 and will remain the same until 2010. Ward boundaries are based on the population and will change with the decennial census. Groups of people, families, or clans often congregate heavily in one ward over another. There is a vast difference in the economic wealth in each ward, as well as differences in ethnic diversity. For example, in Ward 8 about 92% of the residents are non-Hispanic black and 36% of the residents live in poverty. Whereas in Ward 3, about 6% of the residents are non-Hispanic black, and some 7% of residents live in poverty.9 Figure 1-1: The District of Columbia by ward designations
African American residents are concentrated in Wards 5, 7, and 8. Wards 7 and 8 also have the largest number of youth under the age of 18. However, non-Hispanic white residents are concentrated in Wards 1, 2, and 3. Ward 1 is also the most diverse with a resident population that is a mixture of Black/ African American, white Non-Hispanic, Hispanic/Latino, Asian/Pacific Islander, and Others.
The disparity in wealth is evident in neighborhoods that exist with economic challenges. Studies show that low-income families, minorities, and children living in inner cities are at a higher risk of emergency department visits, hospitalizations, and deaths due to asthma than the general population. The income distribution for the District is outlined below in Table 1-2. Table 1-2: District of Columbia population, race and socio-economic distribution by Ward
Population a Ward 1 2 3 4 5 6 7 8 DC
a b c d
Age a, b 18 + 17% 11% 13% 21% 22% 19% 28% 37% 20% 65 + 8% 9% 14% 17% 18% 11% 14% 6% 12%
Race a Black 43% 30% 6% 78% 88% 69% 97% 92% 60% Hispanic Latino 23% 9% 7% 13% 3% 2% 1% 2% 8%
Medicaid b Number of Recipients 15,218 20,864 1,649 15,009 18,969 16,676 24,199 28,841 141,941 c
Income d Median, 1999 $36,802 $44,742 $71,875 $46,408 $34,433 $41,554 $30,533 $25,017 $40,127
Census, 2000 73,364 68,869 73,718 74,092 72,527 68,035 70,540 70,914 572,059
DC State Center for Health Statistics; Policy, Planning, and Research Administration, Vital Statistics 2004. Working Together for Health: MEDICAID Annual Report, FY 2005. DC Department of Health, Medical Assistance Admin. Total includes those missing DC Office of Planning, 1999 Median Household and Per Capita Income by Ward
Identify barriers in the delivery of asthma care services, particularly to the underserved and highrisk groups. Increase education and awareness programs that are culturally sensitive and linguistically appropriate for all races and differing socioeconomic status. Promote the use of the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) guidelines. Educate persons with asthma and their family members, as well as providers and health educators. Develop a comprehensive asthma surveillance and data collection system to monitor trends and evaluate the effectiveness of program interventions in the reduction of asthma morbidity and mortality.
As partners across the District work towards developing and implementing asthma interventions, it
BRFSS
Hospital Discharge
Emergency Department
Medicaid
Air Quality
Work-related
Workers Compensation
GWU Survey
Mortality
Vital Statistics
to determine the proportion of individuals who have asthma at a specific point in time. The estimates provided in this report reflect self-reported cases of asthma that have been diagnosed by a health care professional. Therefore, the true prevalence of asthma may be underestimated. The report has categorized prevalence of asthma into three groups: lifetime, current and former. Since the severity of asthma can vary over time, the BRFSS estimates both Lifetime and Current asthma prevalence. This was done in order to make the distinction between those that currently show symptoms of asthma, and those that do not. Current asthma prevalence is the proportion of the population that currently has asthma. Former asthma prevalence is the proportion of the population that was diagnosed with asthma but no longer show symptoms. Table 2-1 defines the prevalence categories according to the respondents answers to survey questions. Lifetime asthma prevalence is a proportion of all respondents who answered yes to the question: Did a doctor (or other health professional) ever tell you that you had asthma? Thus, lifetime asthma prevalence approximately estimates all respondents that report having asthma at some point in their lives (i.e., Lifetime Current + Former). Table 2-1: Asthma prevalence category definitions: respondent answers to BRFSS survey questions
Prevalence Category Lifetime Current Former Never 1. Has a doctor ever told you that you have asthma? YES YES YES NO 2. Do you Still have asthma? YES, NO, DONT KNOW, or REFUSED YES NO Not Applicable
In 2005, in an attempt to estimate the prevalence of asthma among children, the DC BRFSS survey asked the following two (2) questions to households with children: Has a doctor, nurse or health professional ever said that the child has asthma? Does the child still have asthma? The same interpretation of the prevalence categories applies to the survey questions related to childhood prevalence of asthma.
Percentage
Figure 2-3 shows that asthma prevalence in the District has been on an upward trend from 2000 through 2005. In 2000, the prevalence was estimated at 11% and rose steadily to 15.5% in 2006, which is a 29% increase. The prevalence increase from 2000 to 2006 is statistically significant at p<0.05. There was a drop in prevalence in 2003 in both the District and national lifetime asthma prevalence. In general, the District lifetime asthma prevalence is higher than the US lifetime asthma prevalence. However, both the District, and US lifetime asthma prevalence trends followed the same pattern from 2000-2004, but diverged in 2005. Figure 2-3 indicates a downward trend in 2005 for the US data relative to 2004, but a plateau in the DC prevalence rate. In 2006 and 2007 the District remains at about the prevalence rate, while the US increases at a faster rate. Figure 2-3: Lifetime asthma prevalence in adults over 18, District vs. US
Percentage
In Figure 2-4, the current asthma prevalence trend in the District has a similar pattern as the lifetime asthma prevalence trend, with a slight peak in 2002, and slight drop in 2003. There was an approximate increase of 19% in prevalence from 2000 (7.9%) to 2007 (9.4%). Overall, current asthma prevalence is higher in the District as compared to the nation; with the highest difference of 18% occurring in 2002. Figure 2-4: Current asthma prevalence in adults over 18, District vs. US
Percentage
Percentage
10
Percentage
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Percentage
Similarly, Figure 2-7 also shows that 18-24 year olds reported the highest current asthma prevalence (15.4%) and respondents 65 years old and over had the lowest current asthma rates (6.3%). The prevalence of current asthma among 18-24 year olds was more than twice that of those 65 years old and over at p<0.05. The highest former asthma prevalence was among 18-24 year olds and the lowest among 55-64 year olds. There was a significantly higher former prevalence rate among 25-34 year olds respondents as compared to their 35-44, 45-54, and 55-64 years old counterparts.
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Percentage
Figure 2-9 shows the highest prevalence of lifetime, and current asthma among respondents reporting a household income less than $15,000. Data analysis showed no statistical significant differences between income groups for lifetime, and former asthma. However, there was a significantly higher current asthma rate among residents reporting an income less than $15,000 as compared to those reporting an income above $75,000. Current asthma prevalence rate was more than two times higher among respondents reporting less than a $15,000 household income than those reporting an income above $75,000. Figure 2-9: Prevalence of adult (18 years) asthma by income level
Percentage
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Percentage
Percentage
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Wards 3 and 4 have the lowest prevalence of current asthma, and correspondingly have the highest former adult asthma. Ward 3 and 4 both have the highest median household incomes, and the lowest number of Medicaid recipients in the District. These results are consistent with earlier findings that respondents with higher socioeconomic status have lower current asthma prevalence.
2.2.6. Risk Factors Associated with Elevated Asthma Prevalence BMI and Asthma
In 1998, the National Institutes of Health (NIH) released clinical guidelines for the identification of overweight, and obesity based on the body mass index (BMI); an individuals weight in kilograms divided by their height in meters, squared. According to the guidelines, individuals with a BMI greater than or equal to 30 are considered to be obese, those with BMI greater than 25, but lower than 29.9 are considered overweight. In 2005, approximately 14% of respondents who were obese, 8% who were overweight, and another 8% of normal weight (BMI >18 and <25) had asthma. Table 2-2 showed that the odds (or likelihood) of having asthma among respondents who were obese was almost two (2) times higher than their normal weight or overweight counterparts.
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Table 2-2: Prevalence of risk factors among BRFSS respondents with current asthma, 2005
N Weight Status Normal weight Overweight Obese Flu shot No flu shot Pneumonia No pneumonia Smokers Non Smokers 1,635 1,173 696 1,029 2,681 691 2,700 663 3,040 186,128 141,768 92,351 112,487 334,748 81,067 324,615 89,600 357,377 8.0% 7.7% 13.7% 13.2% 7.9% 11.6% 8.4% 12.4% 8.4% (5.8-10.3) (5.7-9.7) (10.5-16.9) (9.7-16.7) (6.5-9.2) (8.5-14.7) (6.9-9.9) (8.8-16.0) (7.0-9.8) 0.55 0.53 ref 1.77 ref 1.43 ref 1.54 ref (0.53, 0.56) (0.51, 0.54) < 0.001 < 0.001 Weighted N Current Asthma 95% CL Odds Ratio OR 95% CL P-Value
Immunization Age 65+ (1.74, 1.81) (1.40, 1.47) < 0.001 < 0.001
Source: District of Columbia Behavioral Risk Factor Surveillance System % is based on weighted numbers. N is number of people interviewed. Current asthma is those respondents who have been told by a doctor or other health professional that they had asthma and who still currently have asthma. All respondents are adults age 18 years and above except for the immunization who are age 65 years and older. Weight Status: Normal weight (18 < BMI < 25), Overweight (25 < BMI < 30), Obese (BMI 30)
Percentage
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Percentage
Figure 2-14 shows that children living in a household where a non-Hispanic black adult responded to the survey had higher asthma prevalence than children living in a household where the adult respondent was non-Hispanic white (13.1% vs. 9.3%). This is a 29% higher prevalence rate of asthma among nonHispanic black children as compared to their non-Hispanic white counterparts. There was negligible difference in former asthma prevalence rate by race among children. The low number of Hispanic respondents for the childhood asthma subset of questionsis not representative. Therefore, further analysis is not feasible. Figure 2-14: Prevalence of childhood (17 years) asthma by race
Percentage
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Figure 2-15 shows that approximately 8% of District children under the age of 9, and almost 16% between ages 9 to 17 had asthma in 2005. There is a 47% higher current asthma prevalence rate among 9 to 17 year old children compared to those less than 9 years of age. Figure 2-15: Prevalence of childhood (17 years) asthma by age group
Percentage
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Appropriate disease management improves the quality of life of persons with asthma. This section
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Percentage
In 2005, male respondents (50.7%) reported experiencing a higher proportion of asthma attacks in the past 12 months as compared to females (41%). However, Figure 3-2 indicates that the differences were not statistically significant by gender. Similarly, there was no significant difference in the respondents experiencing asthma attacks by race. Figure 3-3 shows that 43.5 % of non-Hispanic whites and 45.8% of non-Hispanic blacks who currently have asthma responded that they had experienced an episode of asthma or an asthma attack during the previous year. Data on Hispanics was insufficient to include in the analysis. Figure 3-2: Episodes of asthma by gender
Percentage
20
Percentage
Percentage
21
Figure 3-5 shows that men tend to visit the doctor for routine asthma checkups less frequently than women (zero or one time). Women tend to have routine checkups more often (2-4 times or 5+ times). This may be indicative of the severity of asthma problems among women as compared to men or of other factors such as differences in healthcare-seeking behaviors. However, there are no statistically significant differences between frequencies of routine doctor visits by gender. Figure 3-5: Frequency of visits to a doctor for routine asthma checkups by gender
Percentage
When stratified by race, Figure 3-6 shows that non-Hispanic whites tend to visit the doctor for routine asthma checkups less frequently (none or once per year) and non-Hispanic blacks tend to have routine checkups more often (2-4 or 5+ times per year). Black respondents indicated significantly higher frequency (more than twice) of routine doctor visits at 2-4 times than whites. Correspondingly, nonHispanic black respondents had more than twice the frequency of routine doctor visits at >5 times per year as compared to their white counterparts. This difference by race could be indicative of the severity of asthma problems among black non-Hispanics; i.e. non-Hispanic blacks are visiting the doctor more because they have asthma symptoms more often. Figure 3-6: Frequency of visits to a doctor for routine asthma doctor visit by race
Percentage
22
Percentage
As illustrated in Figure 3 8, a higher percent of males (34.4%) used an inhaler 1-4 times in the past month as compared to females (27.4%). However, almost twice as many women (10.7%) used an inhaler 5 or more times as compared to men (5.5%). Figure 3-8: Frequency of inhaler use to stop asthma episodes by gender
Percentage
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Figure 3-9 shows that almost twice as many non-Hispanic black respondents with asthma (34.6%) reported using inhalers 1-4 times in the past month to stop an asthma attack as compared to their non-Hispanic white counterparts (19.3%). More than twice as many non-Hispanic black respondents (12.3%) reported using an inhaler 5 or more times in the past month to stop asthma attacks as compared to non-Hispanic whites (5.1%). Figure 3-9 also shows that reports of never using an inhaler to stop asthma attacks were 43% higher among non-Hispanic whites than non-Hispanic blacks. Figure 3-9: Frequency of inhaler use to stop asthma episodes by race
Percentage
higher prevalence of first diagnosis at an age younger than 19 years. There are also significantly (two times) higher proportions of respondents with current asthma reporting first diagnosis between 20-39 years of age as compared to those 40-59 years of age. Similarly, the proportion of respondents reporting first diagnosis at 20-39 years of age was four times higher than those reporting first diagnosis after 60 years of age. In summary, a significantly higher proportion of respondents with current asthma were first diagnosed with asthma below the age of 39 years. Figure 3-10: Age at first diagnosis among respondents with current asthma
Percentage
In Figure 3-11, the age in reference to first asthma diagnosis was examined by gender. Among respondents with current asthma the 25.5 % of males were first diagnosed below 19 years of age. On the other hand, the highest proportion of women reporting initial diagnosis was between ages 20-39 years. Thus, this data shows that men tend to be diagnosed earlier than women in the Districts population. Females had a three times higher first diagnosis rate between 20-39 years as compared to males and this was statistically significant at p<0.05. Figure 3-11: Age when diagnosed with asthma by gender
Percentage
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Age at first diagnosis was also stratified by race. Figure 3 12 shows that the highest proportion of nonHispanic whites reported initial diagnosis before the age of 19 years. Meanwhile, the highest proportion of non-Hispanic blacks reported initial diagnosis between 20-39 years of age. However, the differences by race were not statistically significant. Figure 3-12: Age when diagnosed with asthma by race
Percentage
Percentage
26
Data on limitation of usual activity was further characterized by gender. Figure 3-14 shows that in 2005, there were no significant differences by gender in respondents reports regarding days of missed work or restriction of usual activity due to asthma. Figure 3-14: Days of missed work or usual activities because of asthma by gender
Percentage
The data on limitation of usual activity was also stratified by race. Figure 3-15 shows that about twice as many non-Hispanic black respondents indicated 1-5 days of missed work or restriction in usual activity due to asthma as compared to non-Hispanic whites. The percentages by race were similar among those reporting six or more days of missed work or restriction in usual activity because of asthma. Figure 3-15: Days of missed work or usual activities because of asthma by race
Percentage
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4. Asthma Morbidity To estimate asthma morbidity, this section utilizes hospitalization, and emergency department (ED)
visit data. Hospitalization information was obtained from the District of Columbia hospital discharge data collected by the DC Hospital Association (DCHA). Emergency Department data was obtained from the eight area acute care, non-military hospitals by a project of the Childrens Research Institute, Improving Pediatric Asthma Care in The District of Columbia (IMPACT DC).
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Table 4-1: Number and rate of hospitalization due to asthma by age group in the District of Columbia
2002 Age Group Children <5 5-9 10-14 15-17 Adults 18 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75+ Total
* per 100,000 Source: District of Columbia Hospital Association
Count
Rate*
158 102 63 20
122 98 68 31
119 67 40 17
121 74 52 20
72.7 66.1 101.8 223.1 288.8 390.2 298.4 248.0 374.3 297.3 395.9 303.3 201.5
65.8 42.6 99.8 246.7 316.8 475.0 397.0 292.5 371.4 523.4 407.7 349.1 221.0
41.5 36.2 75.6 154.7 191.6 350.1 348.9 239.4 309.5 298.8 387.4 368.9 171.8
44.2 48.3 86.2 109.5 220.1 309.2 329.5 281.6 241.8 314.6 322.5 321.8 171.0
31
Number of Days
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Figure 4-4: Age-adjusted rates of emergency department visits due to asthma among all residents in the District of Columbia
Source: Improving Pediatric Asthma Care in the District of Columbia, 2005 -2006
Figure 4-5 shows that in 2005 and 2006, the rate of ED visits was the highest among children 1-4 years old and adults 40 to 50 years old which is consistent with hospitalization rates presented above. However, asthma data for the 1-4 year old age group should be interpreted with caution for several reasons. To begin with, it is often difficult to elicit enough cooperation from these young children to obtain accurate objective pulmonary function assessments. More importantly, these young children are prone to temporary reactive airway conditions for developmental reasons. Also, it is possible that these children may spend less time outdoors than older school-age children. Therefore, there is some debate over whether children younger than five years are always accurately diagnosed as asthmatic when in fact some of them might be suffering from a more temporary reactive airway condition that may or will disappear as they grow older.11 (This is a controversial statement and/or issue in the asthma community.) Figure 4-5: Total emergency department visits due to asthma in the District of Columbia
Rate (per 10,000)
Source: Improving Pediatric Asthma Care in the District of Columbia, 2005 -2006
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34
Source: Improving Pediatric Asthma Care in the District of Columbia 2007 Data Report
4.2.4. Insurance
The type of patient insurance can be used as a proxy estimator of the socioeconomic status of the patient; which has already been demonstrated as an important factor in asthma prevalence. In general, patients with public insurance (Medicaid or Medicare) or no insurance tend to be of lower income strata. Studies have shown that these individuals are at a higher risk for asthma. In 2006, 70% of asthma emergency department visits in the District were covered by public insurance, 20% were private, and 7% had no insurance. This is seen in Figure 4-8. Thus, the data reveals that a majority (77%) of the ED patients diagnosed with asthma were most likely to be of a lower economic status. This finding is consistent with studies showing that low income individuals or people with no insurance were present at the ED more often with disease that had progressed, compared to those with a higher economic status. Figure 4-8: Distribution of insurance among emergency discharge asthma patients in the District of Columbia
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4.2.5. Disposition
Disposition describes the status of the person once they have received treatment at the emergency department. There are five possible categories of disposition: 1) discharge, 2) admitted to hospital, 3) left against medical advice, 4) transferred or 5) died. Figure 4-9 shows that in 2006, the highest proportion (72%) of asthma ED visits were discharged. However, approximately 17% of the ED visits were severe enough to warrant hospitalization, and the outcome for less than 0.1 percent (or 5 people) of the visits was death. Figure 4-9 also shows that out of those who were admitted into the hospital from ED, 28.1% were below the age of 20 years, 35.2% were 40 to 59 years, 18.2% were 60 to 79 years, 13.5% were 20 to 39 years, and 5% were 80 years and over. This analysis is comparable to the hospital discharge data that shows the highest rates of hospitalization was among children, followed by 40 to 50 year olds, and the elderly, respectively.
Figure 4-9: Disposition of emergency department visits due to asthma in the District of Columbia Even though the total number of ED visits among 1-4 year olds is the highest (over 1,700), the rate of hospital admittance among this age group is relatively small. Figure 4-10 shows that once the data is normalized by the total for each age category, (i.e. the sum of each of the three categories of: discharged, admitted, and died was divided by the total number of ED visits for that age group), the proportion of those admitted out of the 1,600 was less than 20% of the total ED visits for that age group. In contrast, while there was a lower frequency of ED visits (less than 100 visits) among those ages 85 years and older, the proportion of those admitted for hospitalization was about 46.7%. Therefore, Figure 4-10 suggests that there is an increase in hospital admission from ED with an increase in age. This result is also validated by hospital discharge age-specific data (Figure 4-2). One possible reason is that persons from older age groups were admitted at a higher proportion, and it may be that this population tends to suffer from other illnesses that complicate and exacerbate their asthma.
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Figure 4-10: Frequency of disposition of emergency department visits due to asthma in the District of Columbia
Percentage
37
38
5. Asthma Mortality Asthma mortality data was obtained from the District of Columbia State Center for Health Statistics,
Vital Records Division. Data on death was abstracted from death certificates. Asthma deaths were defined as the primary cause of death as coded by the Tenth Revision of the International Classification of Diseases (ICD-10), code J45 and J46.
Age
Ward
Total
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40
Figure 5-2: Asthma mortality rate by sex and race, District of Columbia, 1999-2005
Figure 5-3: Asthma mortality rate by age group, District of Columbia 1999-2005
41
Figure 5-4: Crude asthma mortality rate by ward, District of Columbia 1999-2005
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6. Work-Related Asthma Work-related asthma (WRA) is the most prevalent occupational lung disease in industrial countries.
WRA a disease that is attributable to or is made worse by environmental exposure in the workplace. It is diagnosed by confirming the cause of the diagnosis of asthma and by establishing a relationship between asthma and the workplace. WRA is suspected in every adult-onset case or asthma that is exacerbated in adult life. There are over 250 workplace agents associated with WRA. The most common include protein molecules (wood dust, grain dust, animal dander, fungal substances, and latex) or chemicals like diisocyanates. This type of asthma is partially or completely preventable and reversible, if irritants are controlled or stopped.12 Workers at an increased risk include those in professions that deal with wood or metal works, laboratory and health care workers, and drug and detergent manufacturers. Based on previous studies in other states, work-related asthma has occurred more in operators, fabricators, and laborers (32.9%), followed by managerial and professional specialties (20.2%).13 Smoking in the workplace which also contributes to the exposure to secondhand smoke is another known asthma irritant. The District of Columbia has an economic profile that includes industries in which occupational asthma is a frequent health risk. These include construction (associated with numerous triggers including di-isocyanates), the hospitality industry (solvents and cleaning agents), printing (solvents and inks), health care (latex and medications), biomedical research (latex and animal antigens), and automotive repair (solvents and epoxy compounds). Generally, WRA is underestimated. This is likely true of all occupational diseases, especially occupational respiratory disorders which are often misattributed to non-occupational etiologies such as smoking or non-occupational allergens. Furthermore, measuring the prevalence of reported WRA in the United States has been challenging due to the lack of a centralized comprehensive reporting or surveillance system. Currently, most WRA data are ascertained from workers compensation databases and the social security disability index. However, the National Institute of Occupational Safety and Health (NIOSH) has funded a state-based surveillance program. The program includes four states: New Jersey, California, Massachusetts, and Michigan which actively solicit occupational asthma reports from physicians. Data from these four states from 1993-1999 show over 2,500 cases of WRA. Alternatively, the respiratory disease surveillance system, Surveillance of Work and Occupational Respiratory Diseases (SWORD) located in the United Kingdom has proven to be an efficient and effective model to provide information on WRA incidences. This system has demonstrated that WRA is more common and involves more antigen and trigger exposures than previously estimated.
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44
45
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7. Air Quality and Asthma Asthma is associated with a variety of environmental risk factors such as indoor air pollution (smok-
ing, cockroach, dust, etc.) in addition to outdoor air pollution (ozone, particulate matter, tree pollen, weed pollen, mold, etc.). Current evidence suggests that environmental exposure is at least one of the most important causative factors that contribute to asthma aggravation. Additionally, environmental exposures may be risk factors that are more amenable to change as compared to social or psychosocial problems.15
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Secondary Standards None None Same as Primary Same as Primary Revoked 2 Same as Primary Same as Primary Same as Primary Same as Primary Same as Primary 0.5 ppm (1300 g/m3)
1-hour 1 Quarterly Average Annual (Arithmetic Mean) Annual 2 (Arithmetic Mean) 24-hour 3 Annual (Arithmetic Mean)
4
0.053 ppm (100 g/m3) Revoked 2 150 g/m3 15.0 g/m3 35 g/m3 0.08 ppm
Ozone
Sulfur Oxides
0.14 ppm
1 Not to be exceeded more than once per year. 2 Due to a lack of evidence linking health problems to long-term exposure to coarse particle pollution, the agency revoked the annual PM10 standard in 2006 (effective December 17, 2006). 3 Not to be exceeded more than once per year on average over 3 years. 4 To attain this standard, the 3-year average of the weighted annual mean PM2.5 concentrations from single or multiple community-oriented monitors must not exceed 15.0 g/m3. 5 To attain this standard, the 3-year average of the 98th percentile of 24-hour concentrations at each population-oriented monitor within an area must not exceed 35 g/m3 (effective December 17, 2006). 6 To attain this standard, the 3-year average of the fourth-highest daily maximum 8-hour average ozone concentrations measured at each monitor within an area over each year must not exceed 0.08 ppm. 7 The standard is attained when the expected number of days per calendar year with maximum hourly average concentrations above 0.12 ppm is < 1, as determined by appendix H. As of June 15, 2005 EPA revoked the 1-hour ozone standard in all areas except the fourteen 8-hour ozone nonattainment Early Action Compact (EAC) Areas. Source: US Environmental Protection Agency
The specific objectives of this program were to: Document further the relationship between environmental exposures and human health effects; Gain greater ability to undertake health impact assessment, policy development and assurance; and Generate information that would guide policy development and decision making on prevention and treatment activities, as well as resource allocation.
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Of the risk factors considered for Medicaid patient asthma exacerbations (as determined from ED and general acute care visits), ozone and tree pollen were the most significant. During the period of this study, PM10 concentrations did not pose a significant risk factor for Medicaid asthma exacerbations in DC. Listed below are some of the key findings: Of the risk factors considered for Medicaid patient asthma exacerbations (as determined from ED and general acute care visits), ozone and tree pollen were the most significant. Grass pollen effects on asthma exacerbations were strongest for the 5-12 and 13-20 year old age groups. Day-to-day temperature changes revealed that warm-temperature effects increasing asthma exacerbation rates for 5-12 year olds, but may be confounded by tree pollen, ozone, and other effects. The strongest relationship between ozone and asthma-related Medicaid patient visits was seen in the age group of 5-12 year olds. These are school-aged children whose immune systems may not be fully mature and may spend most of their time outside, where they are exposed to the greatest risk for the effects of pollutants. When data from only spring and summer seasons were used, associations of asthma-related visits with environmental data in general were stronger than when data from all seasons were used. This finding was expected because viral respiratory infections, much more prevalent in the fall and winter seasons than in spring and summer periods, are known to trigger asthma exacerbations, and covariate data to control for increases in these infections were unavailable for this study. The stronger spring/summer associations were particularly seen for ozone, which is typically at significant levels only from May through September. When data from all seasons were used, PM2.5 levels were significantly associated with visits for 5-12 year olds; although somewhat less so than were grass pollen levels. Ward 6 had the highest rates of asthma-related ED visits due to homeless Medicaid patients recording a shelter address as their residence and the larger shelters located there. Other possible factors include lack of access to health care facilities due to physical constraints, such as lack of transportation, and poor housing contributing to increased risks of indoor air quality. Wards 8, 6, and 5 showed significant ozone impacts for age groups 13-20, 21-49, and all ages, respectively. When data were further restricted to 1999 (a year with higher than average ozone and PM2.5 concentrations, as well as higher summer temperatures), the ward specific impacts of ozone and PM2.5 on 5-12 year olds were significant and strongest in Ward 7, especially when the EPA measuring site within Ward 7 was used as the source of air pollutant data.
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8. Conclusions In the District of Columbia, approximately 9% of adult residents (40,000 people) and 11% of children
(13,000 children) currently have asthma and about 15% of adults have been diagnosed with asthma at some point in their lifetime (DC BRFSS, 2005). Overall, the prevalence of current asthma has been consistently higher than the national rate for the past six years. In addition, the Districts lifetime asthma prevalence has been on an upward trend from 2000 to 2004 but seems to be stabilizing at 15.2% in 2007. Although asthma affects all segments of the District population, certain subgroups are disproportionately affected by asthma including: Non-Hispanic black population, Very young children aged 0-4 years, especially male children of this age group, Females after puberty (starting from the early teens); Adults aged 45-50 years, The elderly (over 65 years), Tobacco smokers, Obese and overweight residents, Residents with less than or some high school education, and Residents with household incomes less than $15,000.
(6.6%) in the District. However, there is an almost fourfold difference in the mortality rate between the two races. There are multifaceted factors that may be causing the increased severity among non-Hispanic blacks: poor asthma management, complications with other respiratory diseases and environmental triggers. However, all these factors are interconnected and linked to poor socioeconomic status. For example, poor asthma management can be due to lack of knowledge and access to care, which in turn can lead to poor overall health outcomes and possible complications with asthma and poor housing situations can lead to high indoor pollution and exposure to indoor asthma triggers.
8.3. Children
The National Health Interview Survey 2005 reported that 6.5 million or 9% of US children (<18 years) currently have asthma.21 A higher proportion of the Districts children (11% or 13,000 children) currently have asthma. Children, especially 0-4 year olds, are vulnerable due to their susceptibility to environmental pollutants and other agents that trigger or exacerbate asthma. Children four years and younger have the highest asthma emergency department (ED) visit rates and one of the highest inpatient hospitalization rates among all age groups. Male children in this age group have higher health care utilization for asthma than females. The highest childhood asthma prevalence rate is among 9-17 year olds (16%) according to BRFSS DC in 2005. Despite children experiencing high asthma prevalence and severity, they have the lowest asthma mortality rate in the District, with two deaths among children 17 years from 1999 to 2005.
positive correlations with general acute care visits) are very similar to those of other asthma studies in the scientific literature (Weisel et al. 1995,26 Tolbert et al.. 2000,27 Galan et al.. 200328). Kimes et al. (2004)29 observed seasonal variations in ED visits that were almost identical to what was observed in this study. Thus, this study highlights the complexity of risk factors for asthma and the need for employing multifaceted interventions that congruently address socioeconomic and environmental risk factors in the District. A significant proportion of school-aged children, 5-12 years old, with asthma experience exasperations due to grass pollen, warm-temperature, ozone and PM2.5. Children 5-12 years spend a lot of time outdoors which increases their exposure to ambient air and outdoor pollution. School and other asthma intervention programs will have to consider these findings when planning asthma reduction strategies in this age group.
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9. Recommendations Asthma represents a considerable burden on the District of Columbia. Despite some improvements
in asthma prevalence nationally, the District lags behind. There are many opportunities for improvement, as evidenced by racial, socioeconomic, geographic disparities. Non-Hispanic blacks, low income populations, the homeless population, residents in Wards 7, 8, and 6, young children (< 5 years), schoolaged children, middle aged adults (45-50), and the elderly subpopulations need specific attention when considering the reduction of asthma prevalence, severity and mortality. The reports findings suggest recommendations for improvement in asthma surveillance, management, health disparities and reduction of risk factors and preventable events as outlined below.
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Asthma management in children, Access to care for people with asthma, Impact of asthma on quality of life for people with asthma and their caregivers, or Pharmacy usage among people with asthma. The District needs to address the above issues by incorporating data fields and/or data sources that will capture these data in order to provide a better understanding of asthma management in children and adults.
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DC DOH should fund and conduct outreach programs to educate employers and employees on the work place triggers of asthma. This report found that a high proportion of obese residents also suffer from asthma. Although the causal relationship between asthma and obesity is not clear, there is enough research to suggest that obesity is a risk factor linked to asthma. Therefore, asthma reduction interventions need to have a comprehensive focus on improving the overall health of residents, and specifically reducing the obesity epidemic among children and adults as part of the asthma intervention strategy. Prevention of smoking around children should be another component of the asthma primary prevention strategy. DC DOH and other asthma stakeholders should continue to educate parents (especially those with a history of asthma), day care providers, and others who routinely deal with young children on the dangers of second hand smoke.
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10. References
1
American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Trends in Asthma Morbidity and Mortality; November 2007. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma, October 2007.
Centers for Disease Control and Prevention (CDC), 2003. < www.cdc.gov. > Akinbami LJ. The State of Childhood Asthma, United States: 1980-2005, Advance Data from Vital and Health Statistics: no 381, Revised December 29, 2006. Hyattsville, MD: National Center for Health Statistics, 2006. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute; Data Fact Sheet: Asthma Statistics; January 1999. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute Data Fact Sheet: Asthma Statistics; January 1999. American Lung Association; Trends in Asthma Morbidity and Mortality; August 2007. National Institutes of Health. News Release; NHLBI Reports New Asthma data for World Asthma Day; 2001. District of Columbia Office of Planning. Census 2000 Data. National Center for Health Statistics, Centers for Disease Control and Prevention, Morbidity and Mortality Report. 2003. Wright, A. Epidemiology of Asthma and Recurrent Wheeze in Childhood. Clinical Reviews in Allergy and Immunology: 2002; 22:33-44. Friedman-Jimnez G, Beckett WS, Szeinuk J, Petsonk EL, Clinical Evaluation, Management, and Prevention of Work-Related Asthma, American Journal of Industrial Medicine. 2000; 37:121-141. Department of Health and Human Services, Centers for Disease Control and Prevention, National
10
11
12
13
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Institute for Occupational Safety and Health: Work-Related Lung Disease Surveillance Report, 2002.
14
Breedlove, J., Occupational Asthma is More Common in the District of Columbia than Represented in Compensation Statistics, George Washington University Masters Thesis, 2006. Eggleston PA, Buckley TJ, Breysse PN, Wills-Karp M, Kleeberger SR, Jaakkola JJK, The Environmental and Asthma in U.S. Inner Cities. Environmental Health Perspectives Supplements, Vol. 107, S3, June 1999. Diaz-Sanchez A, Tsien A, Casillas A, Dotson AR, Saxon A, Enhanced nasal cytokine production in human beings after in vivo challenge with diesel exhaust particles, Journal of Allergy and Clinical Immunology, 1996; 98:114-123. Rosenstreich DL, Eggleston P, Kattan M, Baker D, Slavin RG, Gergen P, Mitchell H, McNiff-Mortimer K, Lynn H, Ownby D, et al. The role of cockroach allergy and exposure to cockroach allegen in causing morbidity among inner-city children with asthma, New England Journal of Medicine, 1997;336:1356-1363. Department of Health and Human Services: National Asthma Education Program Expert Panel Report: Guidelines for Diagnosis and Management of Asthma DHHS Publ. No 91-3042. Bethesda, MD: 1991.
15
16
17
18
19
US Environmental Protection Agency, < www.epa.gov > Babin SM, Burkom HS, Tabernero N, Holtry R S, Ambient Air Quality and Medicaid Patient Asthma Data Summary Report for the Investigation of the Linkage between Ambient Air Quality and Medicaid Patient Asthma Exacerbations in Washington, DC, The Johns Hopkins University Applied Physics Laboratory Report, 2006. Ross M and Patrick K, The Brookings Institute: A Policy Brief for the Medical Homes DC Area Health Education Center Leaders Among Us: Developing a Community Health Worker Program in Washington, DC, October 2006. Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyper responsiveness, Journal of Allergy and Clinical Immunology, 2005; 115:925- 927. Strachan DP, Butland BK, Anderson HR, Incidence and prognosis of wheezing illness from early childhood to age 33 in a national British cohort. British Medical Journal, 1996; 312:1195 -1199. Piipari R, Jaakkola JJk, Jaakkola N, Jaakkola MS., Smoking and asthma in adults, European Respiratory Journal. 2004: 24: 734-739.
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21
22
23
24
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25
Ross, M and K Patrick, The Brookings Institute Leaders Among Us: Developing a Community Health Worker Program in Washington DC October 2006. Weisel CP, RP Cody, and PJ Lioy, Relationship between summertime ambient ozone levels and emergency department visits for asthma in central New Jersey. Environmental Health Perspectives, 1995: 103, 2: pp 97-102. Tolbert, PE, Mulholland JA, Macintosh DL, Xu F, Daniels D, Devine OW, Carlin BP, Klein M, Dorley J, Butler AJ, Nordenberg DF, Frumkin H, Ryan PB, and White, MC: Air quality and pediatric emergency room visits for asthma in Atlanta, Georgia, American Journal of Epidemiology, 2000:151, 8:798-810. Galan I, Tobias A, Banegas JR, and Aranguez E, Short-term effects of air pollution on daily asthma emergency room admissions, European Respiratory Journal, 2000; 22: 802-808. Kimes D, Levine E, Timmins S, Weiss SR, Bollinger ME, and Blaisdell C, Temporal dynamics of emergency department and hospital admissions of pediatric asthmatics. Environmental Research, 2004; 94:7-17.
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Technical Notes Prevalence: the proportion of individuals who have a disease at a particular point in time or duration
Prevalence = Rate: the number of health events (in this report, asthma related events) in a given population divided by the number of people who are at risk for that event within a specified time. Crude Rate: the number of events that occur in a group divided by the population of that particular group. In this report, age specific rates are crude rates for that specific age group. When rates for all ages are presented, rates are age-adjusted. Age-adjusted Rate: the rate of an event adjusted by the age composition of the population studied to minimize the effects played by age when comparing rates between two different populations. In this report, the direct standardization method was used to age adjust rates. The direct method of age adjusting averages the age specific rates of the study population and uses the weights of the distribution of a specific standard population. The directly standardized rate represents what the crude rate would have been in the study population if that population had the same distribution as the standard population with respects to the variable (in this case age) for which the adjustment was carried out. In this report, the 2000 US census population was used as the standard population. Odds Ratio (OR): the odds of two ratios. The odds of a disease (asthma) among those exposed (to obesity, smoking etc.) to the odds of a disease among the unexposed (normal weight, non-smoker etc.) Confidence Interval (CI): The purpose of the confidence interval is to measure the precision of an estimate, indicating that the wider the interval, the less precise the estimate. The 95% confidence interval is interpreted as a 95% chance that the true value of the estimate lays within the confidence interval.
of a period.
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The confidence interval formula for an estimate of prevalence is based on the binomial distribution. Prevalence CI = Where p = prevalence proportion n = sample size Determination of Statistical Significance: In this report the words significant or significantly were used to indicate statistical significance at p<0.05. Data in this report were stated as statistically significant based on non-overlapping 95% confidence intervals. Although this is not strictly speaking a statistical test, it is a commonly accepted way to compare estimates. It has been noted to be more conservative than formal statistical testing (Schenker and Gentleman, 2001).
Acronyms
BRFSS DC DC CAN DCHA DOH ED IMPACT WRA Behavioral Risk Factor Surveillance System District of Columbia District of Columbia Control Asthma Now District of Columbia Hospital Association Department of Health Emergency Department Improving Pediatric Asthma Care in the District of Columbia Work Related Asthma
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The following questionnaire, developed by the George Washington University, was sent to 220
Survey Questions
1. In the past year (2005) how many asthma cases per gender of work-related/occupational asthma have you diagnosed in patients who live or work in the District of Columbia? 2. What is the average age of patients you have diagnosed with work-related/occupational asthma? 3. In how many of the total cases were you the first physician to diagnose the case(s) as occupational/work-related asthma? 4. Do you counsel patients with occupational/work-related asthma to: a. Request a permanent work station change? b. Use personal protective equipment (PPE) on the job? c. Request environmental changes in the workplace to eliminate triggers? d. Ask for a transfer to a work site with no knows exposures? e. Other 5. Have any of your patients ever submitted a workers-compensation claim for work related/occupational asthma against their employers?
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70
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+ Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8
Income
Ward
Source: DC BRFSS
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Table B-2: Lifetime asthma by demographics Have you ever been told by a doctor or other health professional that you had asthma?
Lifetime N Total Gender Male Female 18-24 25-34 Age 35-44 45-54 55-64 65+ White Non-Hispanic Race/ Ethnicity Black Non-Hispanic Hispanic Other Non-Hispanic Less than High School Education High School Graduate Some College College Graduate Less than $15,000 $15,000-$24,999 Income $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Source: DC BRFSS
% 15.3 15.1 15.5 24.8 18.0 12.2 12.0 13.8 11.3 12.1 15.8 21.1 10.0 16.3 16.8 17.0 13.8 20.7 16.4 18.6 11.7 15.7 12.7
95% CI (+/-) 1.8 3.0 1.9 8.2 3.7 3.0 2.9 3.2 2.8 2.2 2.4 9.0 5.4 5.4 4.1 4.9 2.0 7.2 5.7 6.2 3.8 4.2 2.5
3,736 1,503 2,233 203 721 746 656 646 698 1,790 1,547 125 133 248 603 618 2,256 289 384 330 452 537 1,322
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Table B-3: Prevalence of childhood asthma by demographics and by ward Has a doctor, nurse, or other health professional ever said that the child has asthma? and Does the child still have asthma?
Current N Total Childs Gender Childs Age Parents Race/ Ethnicity Male Female 8 or Under 9 to 17 White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 790 400 383 395 342 266 428 31 49 61 181 157 391 67 94 73 80 101 321 50 45 92 110 81 62 88 98 % 11.4 12.3 10.2 8.4 15.9 9.3 13.1 * * 14.4 11.2 12.4 10.0 19.3 15.9 8.2 12.5 12.5 8.7 20.8 * 6.9 15.4 11.2 13.1 8.2 16.4 95% CI (+/-) 2.6 3.9 3.4 3.0 4.8 4.0 3.6 * * 9.4 5.5 5.3 3.8 10.4 8.1 5.6 8.4 8.0 3.6 15.3 * 6.4 8.8 7.3 8.8 5.4 8.0 % 4.0 4.3 3.8 1.8 7.3 3.2 4.3 * * 1.2 4.6 7.3 2.2 6.5 0.8 0.0 1.8 9.6 3.6 5.3 * 2.7 5.8 1.2 2.9 1.5 11.0 Former 95% CI (+/-) 2.4 2.3 4.1 1.3 5.1 2.4 3.5 * * 1.9 3.0 7.8 1.5 6.5 1.0 0.0 2.2 11.6 2.4 6.4 * 3.4 6.0 1.8 3.6 1.8 11.8 % 84.6 83.4 85.9 89.8 76.8 87.5 82.6 * * 84.3 84.2 80.3 87.7 74.2 83.3 91.8 85.7 77.9 87.7 73.8 * 90.3 78.7 87.6 84.0 90.3 72.5 Never 95% CI (+/-) 3.3 4.4 5.2 3.2 6.4 4.5 4.7 * * 9.8 6.1 9.1 4.0 11.7 8.2 5.6 8.7 14.0 4.2 16.0 * 7.4 10.1 7.7 9.6 5.8 13.1
Less than High School High School Graduate Parents Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+ Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8
Parents Income
Ward
Source: DC BRFSS
73
74 Table B-4: Age when diagnosed with asthma by demographics How old were you when you were first told by a doctor or other health professional that you had asthma?
<=19 N 447 158 289 25.5 19.2 11.1 5.9 8.2 28.0 4.3 6.3 6.0 10.3 3.4 4.1 3.9 5.5 2.8 2.7 22.0 6.0 19.0 4.3 8.4 2.8 4.7 1.9 % 95% CI (+/-) % % % 95% CI (+/-) 95% CI (+/-) 95% CI (+/-) % 45.9 56.4 37.1 20-39 40-59 60+ Dont Know 95% CI (+/-) 6.8 11.6 7.5 34 100 82 71 78 74 192 200 18 30 33 77 72 263 * 17.8 21.6 24.8 * 10.8 16.1 8.2 * 15.4 16.0 21.5 * 8.6 9.8 6.0 24.6 13.7 * * 9.4 5.8 * * 17.9 18.3 * * 5.8 5.8 * * 7.5 10.4 * * * 12.9 7.6 5.6 3.4 4.3 * * * 8.2 6.2 2.4 * 30.3 18.9 15.8 8.7 1.7 * 10.7 11.3 10.1 6.2 2.0 * 17.2 42.7 28.0 18.0 10.0 * 8.4 13.0 11.2 11.2 6.8 * * 1.9 15.4 34.7 24.7 * * 2.3 9.1 13.5 13.4 * * * * 1.6 39.5 4.6 6.5 * * * 8.8 1.1 3.9 * * * * 2.4 13.6 2.7 3.4 * * * 6.3 1.2 2.1 * 52.5 36.5 40.8 37.0 24.1 45.4 51.1 * * * 45.0 53.7 44.3 * 11.8 12.8 14.2 13.0 12.9 10.4 8.9 * * * 15.4 17.2 8.5 44 53 43 49 73 138 * 20.6 * * 11.7 17.3 * 15.4 * * 10.2 8.2 * 23.8 * * 24.0 25.3 * 14.0 * * 12.6 8.8 * 8.1 * * 17.3 6.5 * 6.9 * * 11.1 3.4 * 6.1 * * 8.7 1.9 * 6.5 * * 6.4 2.0 * 41.4 * * 38.2 48.9 * 21.7 * * 14.1 11.4
Total
Gender
Male Female
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate
Income
Source: DC BRFSS
Table B-5: Frequency of visits to a doctor for routine asthma checkups by demographics During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?
None N 286 Male Female 87 199 32.8 27.7 13.3 7.8 33.8 27.3 18.0 8.3 27.0 35.1 15.8 9.0 29.5 6.8 29.6 8.5 32.2 8.1 8.6 6.4 9.9 % 95% CI (+/-) % % % 95% CI (+/-) 95% CI (+/-) Once 2 - 4 Times 5+ Times 95% CI (+/-) 3.4 5.0 4.4
Total
Gender
Age
18-24 25-34 35-44 45-54 55-64 65+ 22 56 58 48 60 38 111 141 8 21 27 53 53 153 * 23.7 27.8 38.7 * 14.1 15.5 10.1 * 11.4 26.5 43.5 42.5 25.0 * * 11.6 8.3 * * 35.7 21.0 * * 12.4 9.7 * * * 11.0 22.1 11.5 16.8 43.4 * * * 57.9 42.1 12.5 * 40.4 39.4 * 15.5 * * 14.7 15.5 * 9.6 * * 40.4 29.6 * 12.1 * * 15.5 14.1 * 7.9 * * 19.2 24.5 * 48.9 * White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate
Income
* * * * * 7.1
* * * * * 5.2
Source: DC BRFSS
75
Table B-6: Episodes of asthma or asthma episodes (attacks) by demographics During the past 12 months, have you had an episode of asthma or an asthma attack?
Yes N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 90 206 22 56 59 52 62 41 114 148 8 21 33 52 55 156 39 35 26 31 44 81 % 44.8 50.7 41.5 * 46.2 58.4 48.8 46.7 * 43.5 45.8 * * * 39.3 43.2 47.7 * * * * * 41.3 95% CI (+/-) 8.1 16.4 8.7 * 15.3 14.9 16.1 15.5 * 11.7 10.8 * * * 18.1 18.8 11.0 * * * * * 13.6 % 55.2 49.3 58.5 * 53.8 41.6 51.2 53.3 * 56.5 54.2 * * * 60.7 56.8 52.3 * * * * * 58.7 No 95% CI (+/-) 8.1 16.4 8.7 * 15.3 14.9 16.1 15.5 * 11.7 10.8 * * * 18.1 18.8 11.0 * * * * * 13.6
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
76
Table B-7: Frequency of days missed work or usual activities because of asthma by demographics During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?
0 N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 293 91 202 22 56 59 51 60 41 114 146 8 20 31 52 54 156 37 34 26 31 44 81 % 78.4 77.3 79.0 * 85.9 76.0 65.2 73.8 * 81.9 76.3 * * * 70.9 81.4 81.9 * * * * * 84.7 95% CI (+/-) 6.4 13.0 6.8 * 9.7 12.0 15.8 14.5 * 10.2 9.2 * * * 18.0 11.9 7.4 * * * * * 9.1 % 11.9 12.6 11.5 * 8.1 11.4 21.2 15.5 * 7.5 14.3 * * * 17.8 11.9 8.1 * * * * * 7.7 1-5 95% CI (+/-) 5.5 11.7 5.4 * 7.4 8.5 14.7 13.1 * 6.7 8.4 * * * 17.1 10.1 4.7 * * * * * 6.9 6 or more % 9.7 10.1 9.4 * 5.9 12.6 13.6 10.7 * 10.6 9.4 * * * 11.4 6.6 10.0 * * * * * 7.6 95% CI (+/-) 3.9 7.0 4.7 * 6.3 9.4 9.8 9.1 * 8.6 5.0 * * * 10.0 5.8 6.0 * * * * * 6.3
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
77
Table B-8: Frequency of medication use to prevent asthma episodes by demographics During the past 30 days how often did you take a prescription asthma medication to prevent an asthma attack from occurring?
Every Day or Almost Every Day N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 91 205 22 55 59 52 63 41 114 148 8 21 33 52 55 156 39 35 26 31 44 81 % 41.0 41.4 40.8 * 27.2 32.8 49.2 61.8 * 38.0 43.1 * * * 48.8 32.6 37.3 * * * * * 27.8 95% CI (+/-) 7.9 15.9 8.4 * 14.2 14.0 16.0 14.1 * 10.6 10.8 * * * 18.7 15.8 10.7 * * * * * 10.8
Less Often 95% CI (+/-) 7.5 13.1 8.9 * 13.1 13.7 14.9 10.5 * 12.7 10.4 * * * 18.1 16.2 10.5 * * * * * 15.3
Never 95% CI (+/-) 7.9 16.1 8.1 * 15.3 15.4 14.6 11.1 * 11.3 9.0 * * * 14.7 20.6 9.9 * * * * * 13.1
% 25.2 19.3 28.5 * 26.7 23.6 21.9 15.7 * 21.1 27.8 * * * 22.3 21.2 26.0 * * * * * 35.7
% 33.8 39.3 30.7 * 46.1 43.6 28.9 22.6 * 40.8 29.1 * * * 28.9 46.2 36.7 * * * * * 36.5
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
78
Table B-9: Frequency of inhaler use to stop asthma episodes by demographics During the past 30 days how often did you take a prescription asthma inhaler during an asthma attack to stop it?
Never N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 271 87 184 20 52 57 47 56 35 109 131 6 20 28 46 49 148 35 32 22 27 42 78 % 61.3 60.1 61.9 * 62.3 62.2 0.0 51.5 * 75.7 53.1 * * * * * 68.3 * * * * * 75.6 95% CI (+/-) 8.5 16.6 9.4 * 15.5 15.3 0.0 16.4 * 9.7 11.7 * * * * * 11.3 * * * * * 11.9 1 - 4 Times % 29.9 34.4 27.4 * 32.0 27.6 0.0 29.8 * 19.3 34.6 * * * * * 28.7 * * * * * 22.5 95% CI (+/-) 8.3 16.5 9.0 * 15.0 13.3 0.0 15.8 * 9.0 12.0 * * * * * 11.4 * * * * * 11.7 5 or More Times % 8.8 5.5 10.7 * 5.7 10.2 0.0 18.7 * 5.1 12.3 * * * * * 3.0 * * * * * 2.0 95% CI (+/-) 3.8 5.0 5.2 * 6.6 10.8 0.0 12.8 * 4.3 6.2 * * * * * 2.2 * * * * * 2.4
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
79
Table B-10: Told by doctor that asthma was job related by demographics Were you ever told by a doctor, nurse, or other health professional that your asthma was related to any job you ever had?
Never Worked Outside Home % * * * * * * * * * * * * * * * * * * * * * * * 95% CI (+/-) * * * * * * * * * * * * * * * * * * * * * * *
Yes 95% CI (+/-) 1.8 1.7 2.6 * 2.5 2.5 3.3 7.4 * 2.7 2.9 * * * * 6.9 1.1 * * * * * 2.0
No 95% CI (+/-) 1.8 1.7 2.6 * 2.5 2.5 3.3 7.4 * 2.7 2.9 * * * 0.0 6.9 1.1 * * * * * 2.0
N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 296 90 206 22 56 59 52 62 41 114 149 8 20 33 53 55 155 39 35 27 31 44 81
% 2.6 1.5 3.3 * 2.0 1.7 2.2 6.4 * 2.6 3.5 * * * * 8.2 0.8 * * * * * 1.5
% 97.4 98.5 96.7 * 98.0 98.3 97.8 93.6 * 97.4 96.5 * * * 100.0 91.8 99.2 * * * * * 98.5
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
80
Table B-11: Respondent told doctor that asthma was job related by demographics Did you ever tell a doctor, nurse, or other health professional that your asthma was related to any job you ever had?
Yes N Total Gender Male Female 18-24 25-34 35-44 45-54 55-64 65+ White Non-Hispanic Black Non-Hispanic Hispanic Other Non-Hispanic 294 90 204 22 56 59 51 62 40 113 148 8 20 33 53 53 155 39 35 27 31 44 80 % 4.5 2.1 5.9 * 5.3 3.6 12.3 8.4 * 3.1 6.1 * * * 3.5 7.0 2.3 * * * * * 2.4 95% CI (+/-) 2.8 2.1 4.2 * 6.1 3.9 12.9 8.5 * 3.1 4.6 * * * 4.8 6.5 2.1 * * * * * 2.6 % 95.5 97.9 94.1 * 94.7 96.4 87.7 91.6 * 96.9 93.9 * * * 96.5 93.0 97.7 * * * * * 97.6 No 95% CI (+/-) 2.8 2.1 4.2 * 6.1 3.9 12.9 8.5 * 3.1 4.6 * * * 4.8 6.5 2.1 * * * * * 2.6
Age
Race/ Ethnicity
Less than High School High School Graduate Education Some College College Graduate Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
Income
Source: DC BRFSS
81
82
H H H
Government of the District of Columbia Adrian M. Fenty, Mayor
District of Columbia Department of Health 825 North Capitol Street, NE Washington DC 20002 http://dchealth.dc.gov