Pennsylvania's Asthma School Project and descriptive pilot investigation: a focus on environmental health tracking.Introduction According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ), asthma is the most common chronic disease of childhood, and prevalence has been increasing over time (CDC, 2000). Asthma-tracking efforts at the state and local levels have, however, been limited (Boss et al., 2001). The Pew PEW. A seat in a church separated from all others, with a convenient space to stand therein. 2. It is an incorporeal interest in the real property. And, although a man has the exclusive right to it, yet, it seems, he cannot maintain trespass against a person Environmental Health Commission has designated asthma as a health outcome that is a top priority for tracking in states (Pew Environmental Health Commission [PEHC], 2000). In 2003, the Environmental Council of the States and the Association of State and Territorial Health Officials released the report Catching Your Breath (2003). The report identified steps states could take to address asthma in children in indoor home environments, schools and child care facilities, and outdoor environments, identifying six areas of opportunity for state action: 1) enhancing coordination and joint action of health and environmental agencies; 2) reducing environmental asthma factors in homes; 3) reducing environmental asthma factors in schools and child care centers; 4) reducing outdoor environmental asthma factors; 5) collecting, using, and integrating health and environmental data; and 6) continuing research into causes, triggers, and effective asthma control strategies. There are a number of examples of recent environmental health projects focusing on school-based and community-based pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. asthma surveillance. In 2002, the Massachusetts Department of Public Health The Massachusetts Department of Public Health is a governmental agency of the Commonwealth of Massachusetts with various responsibilities related to public health within that state. received funds from CDC to conduct demonstration projects as part of the National Environmental Public Health Tracking (EPHT EPHT Environmental Public Health Tracking (CDC) ) Program, including a project on pediatric asthma (Knorr, Condon, Dwyer, & Hoffman, 2004). The Children's Health Children's Health Definition Children's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence. Study, started in 1993 in California California (kăl'ĭfôr`nyə), most populous state in the United States, located in the Far West; bordered by Oregon (N), Nevada and, across the Colorado River, Arizona (E), Mexico (S), and the Pacific Ocean (W). , investigates the long-term Long-term Three or more years. In the context of accounting, more than 1 year. long-term 1. Of or relating to a gain or loss in the value of a security that has been held over a specific length of time. Compare short-term. consequences of air pollution for the respiratory health of children (Kunzli et al., 2003). In 1997, researchers conducted a study of environmental hazards 'Environmental hazard' is a generic term for any situation or state of events which poses a threat to the surrounding environment. This term incorporates topics like pollution and Natural Hazards such as storms and earthquakes. and asthma triggers in 60 elementary schools elementary school: see school. in Texas as part of the Partners in School Asthma Management Program (Tortolero et al., 2002). The efforts by Massachusetts Massachusetts (măsəch  `sĭts), most populous of the New England states of the NE United States. , California, and Texas, as well as other states,
suggest that school-based and school-nurse-reported asthma surveillance
and tracking are reliable. The authors of this article evaluated whether
the Commonwealth of Pennsylvania Pennsylvania (pĕnsəlvā`nyə), one of the Middle Atlantic states of the United States. It is bordered by New Jersey, across the Delaware River (E), Delaware (SE), Maryland (S), West Virginia (SW), Ohio (W), and Lake Erie and New York has a reliable surveillance and
potential tracking system in place for the entire commonwealth via the
current reporting mechanisms.
Pennsylvania's 501 public school districts, 11 comprehensive vocational-technical schools Vocational-technical schools, often called vo-tech schools, are high schools in the United States and Canada designed to bring traditional academia to their students, as well as provide them with vocational and technical skills. , and 100 charter schools submit an annual Illnesses and Injuries report to the Pennsylvania Department of Health (PADOH) (PADOH, 2002). This report is part of the Request for Reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. and Report of School Health Services School Health Services are services from medical, teaching and other professionals applied in or out of school to improve the health and well-being of children and in some cases whole families. that all school districts are required to submit after the end of the school year in order to apply for reimbursement for mandated health services health services Managed care The benefits covered under a health contract (including mandated health screenings by certified See certification. school nurses). One condition specifically included in the report is asthma, either previously diagnosed or diagnosed within the current school year. Since 1997-1998, PA-DOH has collected the asthma data that individual school districts have reported annually to the department. The information reported includes a count of the total number of students with asthma, average daily enrollment, and calculated rate (percentage) of students with asthma by school district. The data are aggregated by individual school district, county, and school year. CDC established the EPHT Program in response to recommendations from PEHC (McGeehin, Qualters, & Niskar, 2004). Both PEHC and the EPHT Program have identified asthma as a priority health end point. CDC's EPHT Program funded PADOH in 2002 to conduct planning and capacity-building activities. As part of the EPHT activities, PADOH initiated the Asthma School Project in 2004 to track childhood asthma in Pennsylvania school districts through the existing reporting system. The Asthma School Project had two major goals. The first was to review all available asthma data reported by school districts covering the six-year period from 1997-1998 through 2002-2003. The review focused on historical trends of student asthma rates (percent lifetime prevalence) in counties as well as in school districts. The second goal was to initiate a descriptive pilot investigation based on that review, targeting students with asthma in the two school districts with the highest rates of asthma. The descriptive pilot investigation had four specific objectives: 1) validate To prove something to be sound or logical. Also to certify conformance to a standard. Contrast with "verify," which means to prove something to be correct. For example, data entry validity checking determines whether the data make sense (numbers fall within a range, numeric data school nurses' reporting of students with asthma, 2) track exacerbations of the asthma condition throughout the year on the basis of documentation by the school nurses, 3) review the home environment for potential asthma triggers, and 4) review the indoor and outdoor school environment for potential asthma triggers. This article presents findings related to the two major goals of the Asthma School Project, as well as to the four objectives of the descriptive pilot investigation associated with that project. Methods Six-Year Prevalence Trends in Pennsylvania Counties and School Districts PADOH reviewed all available asthma data reported by Pennsylvania school districts covering the six-year period 1997-1998 through 2002-2003. The condition of asthma, either previously diagnosed or diagnosed within the current school year, is voluntarily reported to PADOH every year by school nurses via the Illnesses and Injuries and Request for Reimbursement and Report of School Health Services reports (PADOH, 2002). The data review focused on historical trends of student asthma rates both in counties and in school districts. A county or school district was considered "high risk" if it consistently demonstrated a pattern of elevated student asthma rates over the six-year period, compared with the corresponding average state or county rate for the given school year under review. Pilot Investigation at High-Risk high-risk adjective Referring to an ↑ risk of suffering from a particular condition Infectious disease Referring to an ↑ risk for exposure to blood-borne pathogens, which occurs with blood bank technicians, dental professionals, dialysis unit School Districts The authors shared information about the pilot investigation with the PADOH Institutional Review Board (IRB IRB See: Industrial Revenue Bond ), and the IRB had no objections to or concerns about the investigation. During July 2004, PADOH contacted the superintendents of the two school districts with the highest asthma rates to describe the investigation and solicit their participation. Fact sheets and other materials provided additional information about asthma, the CDC Environmental Public Health Tracking grant, and activities that would take place in the school district as part of the investigation. PADOH presented to the two school boards at the beginning of the 2004-2005 school year. Both school boards approved the investigation at those meetings, but the legal solicitors of both school districts had concerns about how the Family Educational Rights and Privacy Act The Family Educational Rights and Privacy Act of 1974 (FERPA or the Buckley Amendment) is a United States federal law codified at 20 U.S.C. 1232g, with implementing regulations in title 34, part 99 of the Code of Federal Regulations. would relate to the investigation. As a result of these concerns, PADOH agreed to delay the pilot investigation at both school districts until the school districts obtained consent from the parents/guardians of students with asthma to allow those students to participate in the investigation. PADOH also provided new information to the schools about additional steps required to initiate the pilot investigation. The information included a "Dear Parent/Guardian" letter signed by PADOH, a consent form to be signed by the parent/guardian, and a fact sheet providing additional information to the parent/guardian about the investigation. Before the investigation began, both school districts assisted PADOH by mailing consent/authorization forms and other related material to the parents/guardians of all students with asthma. Both school districts conducted two mailings of these consent/authorization forms, and the parents/guardians who granted consent/authorization for their child or children to participate in the investigation returned these completed forms via mail directly to PADOH. PADOH planned four distinct components of the investigation: 1) baseline The horizontal line to which the bottoms of lowercase characters (without descenders) are aligned. See typeface. baseline - released version information, 2) asthma incidents, 3) home environment, and 4) school environment. At the beginning of the investigation, PADOH collected and compiled, via questionnaire forms, baseline medical information from the participating students' school records, such as demographic information, grade level, and personal and family medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. . PADOH reviewed the baseline information to validate the school nurses' reporting and identification of students with asthma, and utilized the school records to look for documentation of an asthma diagnosis or documentation that asthma medication was taken or required. Documentation that asthma medication was taken or required was defined as a prescription for asthma medication, a nurse's or physician's note regarding asthma medication, or some comparable documentation indicating that asthma medications had been taken or were required. School nurses documented each asthma incident that affected participating asthma students after the investigation began and throughout the school year. An asthma incident was defined as an incident or episode in which a student reported to the school nurse for breathing difficulty or for asthma-related symptoms. PADOH collected and compiled, via questionnaire forms, the asthma incident information. From a mailing to parents/guardians, PADOH collected information on the home environment once during the year. PADOH collected and compiled, from questionnaire forms mailed in by the parents/guardians, information on residence, household, child care, asthma management, and medical history. PADOH also documented issues related to the indoor and outdoor environment of each school building on the basis of one-day site visits. PADOH planned to conduct two site visits for each school building, once in the fall/winter and once in the spring. PADOH collected and compiled, via questionnaire forms completed by PADOH district environmental health specialists, information on any obvious environmental problems or issues, as well as odors Odors anosmia Medicine. the absence of the sense of smell; olfactory anesthesia. Also called anosphrasia. — anosmic, adj. halitosis bad breath; an unpleasant odor emanating from the mouth. , mold mold, name for certain multicellular organisms of the various classes of the kingdom Fungi, characteristically having bodies composed of a cottony mycelium. The colors of molds are caused by the spores, which are borne on the mycelium. , rodent rodent, member of the mammalian order Rodentia, characterized by front teeth adapted for gnawing and cheek teeth adapted for chewing. The Rodentia is by far the largest mammalian order; nearly half of all mammal species are rodents. or insect infestation infestation /in·fes·ta·tion/ (-fes-ta´shun) parasitic attack or subsistence on the skin and/or its appendages, as by insects, mites, or ticks; sometimes used to denote parasitic invasion of the organs and tissues, as by helminths. , general maintenance, renovations, and HVAC (Heating Ventilation Air Conditioning) In the home or small office with a handful of computers, HVAC is more for human comfort than the machines. In large datacenters, a humidity-free room with a steady, cool temperature is essential for the trouble-free system issues. Results High-Risk Counties and School Districts The six counties that consistently had the highest asthma rates out of the 67 counties in Pennsylvania The following is a list of the sixty-seven counties of the Commonwealth of Pennsylvania in the United States of America. The city of Philadelphia is coterminous with Philadelphia County, and governmental functions have been consolidated since 1854. are shown in Table 1. McKean County, Montour County, and Berks County experienced the highest rates according to data collected from all reporting schools within the counties. The 12 school districts that consistently had the highest student asthma rates out of the 501 school districts in Pennsylvania List of school districts in Pennsylvania, United States. The article for each Pennsylvania county with more than one school district includes a map showing all public school districts in the county. are shown in Table 2. Bradford Area School District in McKean County (average six-year rate of 18.2 percent) and Oley Valley The Oley Valley is a valley 10 miles northeast of Reading, Pennsylvania, United States of America. It covers all of Oley, Pike, Ruscombmanor, Alsace and part of Exeter Township. At the center of the valley is the village of Oley. School District in Berks County (average six-year rate of 17.1 percent) had the highest and second highest rates, respectively. For this reason, PADOH targeted these two school districts for the pilot investigation. Although Montour County had the second highest asthma prevalence among counties, the Danville School District is the only school district in that county. The Danville School District had the 12th highest asthma prevalence among school districts. According to the statewide prevalence rate, the number of school-age children reported to have or to ever have had asthma increased steadily, from a low of 6.6 percent during 1997-1998 to a high of 9.2 percent during 2002-2003. Results of the Pilot Investigation The pilot investigation officially began during November 2004 in the Bradford Area School District (BASD BASD Bethlehem Area School District (Pennsylvania) BASD Business Action for Sustainable Development BASD Basic Active Service Date BASD Bellefonte Area School District (Bellefonte, Pennsylvania) ) and during December 2004 in the Oley Valley School District (OVSD OVSD Openview Service Desk (Hewlett Packard helpdesk system) OVSD Oley Valley School District (Oley, Pennsylvania) OVSD Open View Service Desk ). At the beginning of the investigation in 2004, nursing and administrative staff from both school districts provided PADOH with the counts of all students with asthma (473 in BASD, 308 in OVSD). As a result of two mailings, a total of 167 students in BASD (35 percent) and 162 students in OVSD (53 percent) agreed to participate, as shown in Figure 1. A total of 155 of 165 participating students (94 percent) in BASD had documentation of physician-diagnosed asthma, and 135 of 165 students (82 percent) had documentation that they were taking or required asthma medication. Among the 155 students who had documentation of physician-diagnosed asthma, 134 students (86 percent) also had documentation that they were taking or required asthma medication, as shown in Figure 1. A total of 91 of 159 participating students (57 percent) in OVSD had documentation of physician-diagnosed asthma, and 103 of 159 students (65 percent) had documentation of that they were taking or required asthma medication. Among the 91 students who had documentation of physician-diagnosed asthma, 69 students (76 percent) also had documentation that they were taking or required asthma medication, as shown in Figure 1. Both school districts had informal action plans in place or treatment steps to be taken during the first year of the investigation. Nevertheless, no formal asthma action plan documents existed for the students. PADOH determined that 22 asthma incidents were reported in BASD, involving seven students, from November 2 to the end of the school year, with 19 of the incidents occurring in elementary school. PADOH also determined that 38 asthma incidents were reported in OVSD, involving 17 students from December 21 to the end of the school year, with 34 of the incidents occurring in elementary school. These results are given in Table 3. PADOH sent out a mailing to all parents/guardians who had provided written consent for their children. According to information provided by the BASD parents/guardians of 74 students, 23 students (32 percent) lived in a rural/farm location, 21 (29 percent) lived in a suburban/suburbs location, and 28 (39 percent) lived in an urban/city location. It was reported that in the last 12 months, 18 students (25 percent) had people who smoked cigarettes, cigars, or pipes inside the home or residence; eight (11 percent) had damp damp, in mining, any mixture of gases in an underground mine, especially oxygen-deficient or noxious gases. The term damp probably is derived from the German dampf, meaning fog or vapor. Several distinct types of damp are recognized. or water spots on the walls or ceiling of the home or residence; eight (11 percent) had mold or fungus fungus Any of about 200,000 species of organisms belonging to the kingdom Fungi, or Mycota, including yeasts, rusts, smuts, molds, mushrooms, and mildews. Though formerly classified as plants, they lack chlorophyll and the organized plant structures of stems, roots, and on the walls or ceiling of the home or residence; and 39 (52 percent) had had, because of asthma, some change in the home or residence, such as removal of pets; cessation cessation Vox populi The stopping of a thing. See Smoking cessation. or reduction of smoking; or changing of bedding, pillows, or floor coverings. These results are given in Table 3. According to information provided by the OVSD parents/guardians of 90 students, 63 students (70 percent) lived in a rural/farm location, and the remaining 26 (30 percent) lived in a suburban/suburbs location. It was reported that in the past 12 months, six students (7 percent) had people who smoked cigarettes, cigars, or pipes inside the home or residence; eight (9 percent) had damp or water spots on the walls or ceiling of the home or residence; seven (8 percent) had mold or fungus on the walls or ceiling of the home or residence; and 43 (48 percent) had, because of asthma, some change in the home or residence, such as removal of pets; cessation or reduction of smoking; or changing of bedding, pillows, or floor coverings. These results are given in Table 3. PADOH staff conducted site visits at each of the four school buildings in BASD and each of the three school buildings in OVSD in November 2004 and in March/April 2005. As part of those visits, PADOH completed environmental assessment forms for each building, documenting environmental conditions at the schools. PADOH shared the results of its findings with BASD and OVSD and also put each school district in contact with the U.S. Environmental Protection Agency's (U.S. EPA's) Region 3 staff regarding the Tools for Schools program (U.S. EPA EPA eicosapentaenoic acid. EPA abbr. eicosapentaenoic acid EPA, n.pr See acid, eicosapentaenoic. EPA, n. , 2000). During these site visits, PADOH identified no major environmental health problems that would suggest possible links between the school environments and higher asthma prevalence rates in these two school districts. Discussion School nurses in Pennsylvania identify students who have had a diagnosis of asthma, either previously diagnosed or diagnosed within the current school year, on the basis of family and medical information made available to them. Since 1997-1998, school nurses have reported a count of the total number of students with asthma, the average daily enrollment, and the calculated rate (percentage) of students with asthma for each school district. PADOH initiated the Asthma School Project in 2004 to track childhood asthma in Pennsylvania school districts through the existing reporting system. The first goal of the project was to review all asthma data reported by school districts covering the six-year period of 1997-1998 through 2002-2003. For the state as a whole, the number of school children with a diagnosis of asthma increased steadily, from a low of 6.6 percent during 1997-1998 to a high of 9.2 percent during 2002-2003. Out of a total of 501 school districts in Pennsylvania, BASD in McKean County (18.2 percent) and Oley Valley School District in Berks County (17.1 percent) had the highest and second highest average six-year rates of asthma, respectively. [FIGURE 1 OMITTED] The second goal of the Asthma School Project was to initiate a descriptive pilot investigation. A major objective of this investigation was to validate the reporting of students with asthma by school nurses. On the basis of a review of school medical charts of the participating students, PADOH concluded that reporting of asthma by school nurses appears to be a reliable data source since a majority of participating students from both school districts had documentation of asthma diagnosis or asthma medication. It is important to note that the limited participation rates for this investigation were taken into account with respect to any conclusions drawn by the authors. The school districts participating in the pilot investigation had the highest rates of asthma in Pennsylvania. PADOH could nevertheless find no obvious environmental factors in the school districts associated either with the high asthma prevalence rates or with the occurrences of unusual asthma episodes documented during the school year. The patterns of unusual occurrences did differ between the school districts. Of the 22 incidents involving seven students at BASD, 16 (73 percent) occurred during November 2004. By contrast, the 38 incidents involving 17 students at OVSD were fairly evenly distributed across the period of November 2004 through May 2005. A future goal for projects of this type is to obtain real-time air quality data at participating school districts and to test for unusual associations between periods when clusters of unusual occurrences are documented and higher levels of air contaminants are measured. PADOH used this approach in the past in a school investigation of student illness and elevated levels of hydrogen sulfide hydrogen sulfide, chemical compound, H2S, a colorless, extremely poisonous gas that has a very disagreeable odor, much like that of rotten eggs. It is slightly soluble in water and is soluble in carbon disulfide. measured at the school (Logue, Ramaswamy, & Hersh, 2001). As part of the pilot investigation, PADOH also investigated the home environment. Exposure to indoor environmental tobacco smoke environmental tobacco smoke (ETS/passive smoke), n the gaseous by-product of burning tobacco products, including but not limited to commercially manufactured cigarettes and cigars; contains toxic elements harmful to the health of adults and children in the home is an important risk factor for asthma incidence and prevalence in children (Pearce, Beasley, Burgess BURGESS. A magistrate of a borough; generally, the chief officer of the corporation, who performs, within the borough, the same kind of duties which a mayor does in a city. In England, the word is sometimes applied to all the inhabitants of a borough, who are called burgesses sometimes it , & Crane, 1998). A recent review of interviews completed for the Pennsylvania Behavioral Risk Factor Surveillance System The Behavioral Risk Factor Surveillance System (BRFSS) is a United States national health survey that looks at behavioral risk factors. It is run by Centers for Disease Control and Prevention and conducted by the individual states. indicated that about 25 percent of all Pennsylvania adults are current cigarette smokers (PADOH, 2005). PADOH found that 25 percent of the responding households representing BASD students with asthma said they had smokers as members of the household, but only 7 percent of the corresponding OVSD households said they had smokers as members of the household. Other potential risk factors in the households also demonstrated no unusual patterns that could be linked with asthma. Thus, this home investigation identified no unusual environmental factors in the home environment that might have contributed to the higher asthma prevalence rates noted at the two school districts. The Pennsylvania Department of Environmental Protection The Pennsylvania Department of Environmental Protection (often abbreviated PA DEP, or just DEP) is state agency in the U.S. state of Pennsylvania. See also
2. Crimes are frequently committed under circumstances which are not justifiable nor excusable, yet they show that the offender has been greatly tempted; as, for example, when a starving man steals bread to satisfy , and cleanup efforts have been instituted or completed for these sites, the respective locations of the schools and student residences, as well as potential past, current, and future exposures were not examined by the authors for this pilot investigation. Socioeconomic so·ci·o·ec·o·nom·ic adj. Of or involving both social and economic factors. socioeconomic Adjective of or involving economic and social factors Adj. 1. factors in these counties may be of importance as well. In 1999, Berks County had a slightly higher median household income The median household income is commonly used to provide data about geographic areas and divides households into two equal segments with the first half of households earning less than the median household income and the other half earning more. ($44,714) and a lower percentage of residents below poverty level (9.4 percent) than did McKean County ($33,040 and 13.1 percent, respectively) (U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States Bureau of the Census , 2005). PADOH provided written and verbal updates to both school districts throughout the school year. It also provided the head school nurses with paper and electronic copies of a PADOH-approved Asthma Action Plan to help encourage nurses, parents, students, and physicians coordinate each child's asthma management. PADOH traveled to BASD and OVSD to discuss the project and held an asthma training session in each community for school nurses and care providers. The asthma training sessions presented and promoted American Lung Association The American Lung Association (ALA) is a non-profit organization that "fights lung disease in all its forms, with special emphasis on asthma, tobacco control and environmental health". (ALA) programs for schools (ALA, 2005). In addition, the sessions referred to certain National Asthma Education and Prevention Program (NAEPP NAEPP National Asthma Education and Prevention Program ) guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. (NIH "Not invented here." See digispeak. NIH - The United States National Institutes of Health. , 2003). BASD and OVSD were put in contact with U.S. EPA regarding the Tools for Schools program, which is designed to help schools identify potential indoor air quality Indoor Air Quality (IAQ) deals with the content of interior air that could affect health and comfort of building occupants. The IAQ may be compromised by microbial contaminants (mold, bacteria), chemicals (such as carbon monoxide, radon), allergens, or any mass or energy stressor issues. PADOH sent a letter to all school nurses, encouraging them to utilize written asthma action plans and to inform them of the recently passed "asthma inhaler Asthma inhalers are devices for treating asthma. They contain an asthma medication--a drug that treats the symptoms of asthma. The most widely used variety are pressurised aerosols metered-dose inhalers (MDI) using a carrier substance to suspend the drug, pressurise the system and bill" in Pennsylvania (Pennsylvania House Bill Number 1113), which makes provisions to allow Pennsylvania school children with asthma to carry and self-administer asthma medications. PADOH also made contact with local media to disseminate dis·sem·i·nate v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates v.tr. 1. To scatter widely, as in sowing seed. 2. information on the project in the BASD and OVSD geographic areas. Because of privacy considerations related to the Family Educational Rights and Privacy Act, PADOH was not able to identify all students with asthma in the two school districts or to determine if the participating students in the project were similar to other students with asthma who were not participating. PADOH lacked real-time environmental air quality data for the pilot investigation. Limitations of the home survey include both the levels of participation by parents who had agreed to let their children participate in the school survey and recall bias among parents who provided information on the home environment. Some of the major goals planned for possible future years of the Asthma School Project are to continue with the annual statewide review and tracking of asthma at all 501 school districts, to include other school districts from one or more of Pennsylvania's two major metropolitan areas (Pittsburgh in Allegheny County and Philadelphia in Philadelphia County), and to obtain real-time indoor and outdoor environmental-air-quality data relevant to the participating school districts. Conclusion From a review of all available asthma data reported by Pennsylvania school districts for 1997-1998 through 2002-2003 in the Asthma School Project, the authors determined that asthma increased steadily from a low of 6.6 percent during 1997-1998 to a high of 9.2 percent during 2002-2003. The reporting of asthma by school nurses appears to be a reliable data source, since a majority of participating students from both school districts in the pilot investigation had documentation of asthma diagnosis or asthma medication. The authors encourage others to track asthma rates in schools and investigate potential environmental exposures in homes and schools that can exacerbate the condition. It is anticipated that such efforts could provide information to help define and address many of the issues and questions about asthma in schools, as well as increase general awareness and knowledge of many of the resources already in place and available to help with management of the disease. Acknowledgements: The authors thank all the staff from the Pennsylvania Department of Health's Bureau of Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause , Bureau of Community Health Systems, Northwest District Office, Southeast District Office, and Bureau of Chronic Disease and Injury Prevention, as well as individuals from the Pennsylvania school districts involved in the investigation who assisted with various project activities. Work on this project was supported in part by an Environmental Public Health Tracking Cooperative Agreement (Cooperative Agreement U50/CCU322454) from the Centers for Disease Control and Prevention (CDC), National Center for Environmental Health. 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TABLE 1 Asthma Prevalence Rates Among Students--High-Risk Pennsylvania
Counties*
Average
1997- 1998- 1999- 2000- 2001- 2002- (6-Year
County 1998 1999 2000 2001 2002 2003 Rate)
McKean 10.92% 12.59% 13.95% 14.52% 13.29% 12.41% 12.95%
Montour 10.30% 11.61% 13.67% 14.94% 13.53% 13.01% 12.84%
Berks 10.56% 10.94% 11.24% 11.31% 12.42% 13.04% 11.59%
Lycoming 9.21% 9.82% 10.66% 13.55% 12.83% 12.49% 11.43%
Monroe 10.04% 10.57% 10.71% 11.61% 10.50% 11.03% 10.74%
Armstrong 7.87% 10.15% 10.61% 12.74% 10.04% 10.86% 10.38%
All counties 6.62% 7.16% 7.82% 8.18% 8.61% 9.23% 7.94%
* A high-risk county is defined as any county in which the asthma
prevalence rate was greater than or equal to the corresponding
commonwealth asthma rate for every year during the six-year period.
TABLE 2 Asthma Prevalence Rates Among School Students--Top 12
Pennsylvania School Districts
County School District 1997-1998 1998-1999 1999-2000
McKean Bradford Area 15.78% 17.82% 20.53%
Berks Oley Valley 19.28% 16.52% 14.03%
Lycoming Williamsport 11.29% 12.34% 15.33%
Armstrong Apollo-Ridge 11.96% 19.11% 16.46%
Berks Hamburg Area 10.26% 13.11% 14.69%
Berks Governor Mifflin 11.61% 10.67% 11.89%
Berks Wilson 14.40% 14.23% 13.38%
Montgomery Pottstown 11.86% 12.90% 15.78%
Northampton Easton Area 12.46% 12.57% 13.59%
Montgomery Upper Perkiomen 13.47% 14.53% 15.24%
Berks Muhlenburg 9.84% 8.53% 10.67%
Montour Danville 10.30% 11.61% 13.67%
All counties All 6.62% 7.16% 7.82%
Average
(6-Year
County 2000-2001 2001-2002 2002-2003 Rate)
McKean 21.61% 17.62% 15.54% 18.15%
Berks 15.85% 16.94% 20.24% 17.14%
Lycoming 19.42% 17.51% 18.68% 15.76%
Armstrong 36.31%* 13.23% 17.98% 15.75%
Berks 15.80% 15.07% 17.29% 14.37%
Berks 16.61% 16.04% 17.19% 14.00%
Berks 13.51% 14.06% 14.23% 13.97%
Montgomery 15.11% 16.41% 11.55% 13.94%
Northampton 12.97% 15.66% 15.73% 13.83%
Montgomery 14.02% 12.55% 9.42% 13.21%
Berks 13.64% 15.73% 19.17% 12.93%
Montour 14.94% 13.53% 13.01% 12.84%
All counties 8.18% 8.61% 9.23% 7.94%
* This value was considered to be an "outlier" data point and was
excluded from the average calculation for this school district. Thus,
the rate for Apollo-Ridge is actually a five-year average rate.
TABLE 3 Selected Data Captured via Q2 (Incident Report) and Q3 (Home
Environment) Forms
BASD OVSD
Form Data Point n % n %
Q2 Incident Report Form
Number of incidents 22 -- 38 --
Number of students 7 -- 17 --
Actions and action plan
Student returned to class 19 86% 35 92%
Student departed school grounds to go home 3 14% 3 8%
or to doctor
Fast-acting or rescue medication administered 19 86% 21 55%
Not treated because no medication or no 3 14% 4 11%
medication order
Parent/guardian called to physically come 3 14% 5 13%
to school
"Informal" or nonwritten protocol used 22 100% 38 100%
Q3 Home Environment Questionnaire
Respondents (completed forms received) 74 -- 90 --
Geography
Reside in rural/farm area 23 32% 63 70%
Reside in suburbs/suburban area 21 29% 26 30%
Reside in city/urban area 28 39% 0 0%
Medical insurance
Have some form of medical insurance 72 99% 85 94%
Incidents in the last 12 months
More than 12 wheezing or asthma attacks 10 14% 5 6%
Sleep disturbed 1 or more nights/week 12 16% 7 8%
by wheezing
Speech limited to 1-2 words between breaths 14 19% 13 14%
by wheezing
Been to doctor for wheezy episode or asthma 41 56% 45 50%
Been to hospital ED for wheezy episode 7 10% 5 6%
or asthma
Admitted to hospital for wheezy episode 0 0% 0 0%
or asthma
Missed more than 10 full or part school days 11 15% 2 2%
for asthma
Residence/home
People who smoke cigarettes, cigars, or pipes 18 25% 6 7%
inside home
Damp or water spots on walls or ceiling of 8 11% 8 9%
home/residence
Mold or fungus on walls or ceiling of 8 11% 7 8%
home/residence
Have had some change or taken action in 39 52% 43 48%
home/residence
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