Lai_ENVM510_Final Project

Running head: IS THERE A CURE TO ASTHMA? 1
Is There a Cure to Asthma?
The Causes of Asthma and Their Effects to the World Population
Darryl Lai
The University of Findlay

IS THERE A CURE TO ASTHMA? 2
Abstract
Asthma is a chronic disease that affects people from all ages and walks of life. The WHO
reported that 235 million people around the world have asthma (2013). This paper describes the
descriptive epidemiology of asthma incidence in relation to various characteristics of person,
place and time. The causes of asthma were identified to be exposures to environmental tobacco
smoke (ETS), outdoor air pollution, allergens, smoke from wood burning, diseases, chemical
products, physical activities and hyperventilation. The various data interpretation issues and
pertinent knowledge gaps were discussed based on the body of literatures analyzed. A
retrospective cohort study is designed to provide a better analysis concerning the effects of
indoor and outdoor environmental factors in regards to childhood asthma. Treatment and
preventive measures were explained to reduce the prevalence, incidence and severity of asthma.
Keywords: asthma, prevalence, incidence, severity, children, adults

Is There a Cure to Asthma?
The Causes of Asthma and Their Effects to the World Population
Problem Definition
What is Asthma?
Winer, Qin, Harrington, Moorman, Zahran (2012) defined asthma as “a chronic
inflammatory respiratory condition characterized by hyperresponsive airways and reversible
airflow obstruction” (p. 16). In other words, during an asthma occurrence, the airways become
swollen and making breathing impossible. This difficulty in breathing can be fatal if the patient
seeks no medical attention. The symptoms of asthma are coughing, breathing difficulty,
wheezing and chest tightness and ache (Centers for Disease Control and Prevention [CDC],
2013). These symptoms can be misdiagnosed with other major respiratory diseases, such as
Pneumonia, Bronchitis and Sinusitis.
The CDC estimated that around 9 people die from asthma daily and 1 in 12 adults around
the world has the disease. The “WHO estimates that asthma affects 300 million people in the
world in which 24.6 million people are from the United States” (Diaz-Guzman, Khosravi &
Mannino, 2011, p. 400). Besides that, Knoeller, Mazurek and Moorman (2013) stated that 17.5
million of American adults are suffering from Asthma. In short, asthma affects at least five
percent of the current Unites States population.
Moreover, Ahmad et al. (2009) described that asthma is a common severe childhood
disease which occurs in 54 for every 1,000 children in the United States. The Centers for Disease
Control and Prevention (2013) also stated that 1 in 11 children around the world have asthma.

Winer et al. (2012) mentioned that in 2007 alone, the 1.8 million emergency department
admissions, 456,000 inpatients hospitalization, and 3447 deaths were caused by asthma being the
main diagnosis. Besides that, 56 billion dollars were estimated to be the direct and indirect cost
of asthma within the United States population. With this high cost of medical expenditure, it is
no doubt that asthma is one of the most expensive diseases to be treated. These alarming
statistics prove that asthma is a chronic disease that deserves to be paid attention to.
Mortality and Morbidity in United States
The CDC (2013) stated that 18.9 million adults in the U.S. are not hospitalized and 3,404
deaths cases are due to asthma. The death rate of asthma is reported to be 1.1 in 100,000 people.
Not only that, 9.5% of children in the United States has asthma. There are many asthma-related
surveillance programs in the United States. According to the CDC (2013), some examples of the
surveillance programs conducted in the United States are Asthma Callback Survey (ACBS),
AsthmaStats, Behavioral Risk Factor Surveillance System (BRFSS) and National Health
Interview Survey (NHIS).
The AsthmaStats identified obesity as a risk factor for the occurrence of asthma (CDC,
2013). In the year 2010 alone, the obesity rate of adults with asthma is higher than those without
asthma, which are 38.8% and 26.8%, respectively. Arkansas and North Dakota have the highest
and lowest rate of adults with asthma who are obese, respectively. On the other hand, West
Virginia has the highest percentage of people who were obese but had no asthma while Colorado
has the lowest obesity population count without asthma.

Adults having a higher rate of asthma than those without were seen in all states in the
United States except Alabama, Arkansas, Delaware, Kansas, Minnesota, North Dakota, Nebraska,
New York, Puerto Rico, Guam and Virgin Islands (CDC, 2013).
McCoy, Redelings, Sorvillo, Simon (2005) stated that the asthma mortality has increased
from 1985 to 1995 and then decreased after 1996. The age-adjusted rate was 4.4 in 100,000. This
decrease was due to the implementation of the International Classification of Diseases 10th
Revisions (ICD-10) in 1999. The percentage of people dying from asthma as main cause of death
decreased from 46% in 1990 to 41% in 2001. These implementations have been applied around
the world and the rate of asthma has decreased since then.
People with
Asthma who are
Obese
People without
Asthma who are
Obese
State % %
U.S. Total 38.8 26.8
AL 46.3 31.9
AK 35.3 24.0
AZ 35.7 23.8
AR 48.7 29.3
CA 38.4 23.5
CO 30.2 20.5
CT 34.2 22.0
DE 44.7 26.9
DC 33.4 21.1
FL 36.2 26.4
GA 46.3 29.0

HI 37.5 21.5
ID 37.7 25.7
IL 42.8 27.3
IN 38.9 29.3
IA 39.5 28.3
KS 33.0 29.8
KY 38.9 31.1
LA 43.6 30.9
ME 37.3 26.1
MD 35.1 27.2
MA 31.5 22.7
MI 42.6 30.5
MN 32.9 24.7
MS 47.3 33.3
MO 45.0 29.9
MT 33.7 22.5
NE 37.2 26.7
NV 34.0 21.9
NH 30.9 24.6
NJ 34.5 23.9
NM 34.8 24.6
NY 34.0 23.3
NC 38.9 27.7
ND 29.7 27.5
OH 40.2 28.6
OK 41.3 30.2
OR 36.9 26.5
PA 38.2 28.2

RI 36.6 24.8
SC 43.4 30.9
SD 35.8 27.0
TN 40.8 31.1
TX 42.3 30.8
UT 34.0 22.0
VT 34.5 22.7
VA 47.4 24.6
WA 36.5 25.1
WV 43.6 25.4
WI 43.6 25.4
WY 36.4 24.6
Territories and Commonwealth
GU 57.6 26.2
PR 39.6 26.4
VI 45.6 28.9
Table 1: Percentages of United States Total Population who are obese with and without Asthma
in 50 states including DC, but not Puerto Rico and the two territories in 2010 (CDC, 2013)
Mortality and Morbidity Worldwide
In comparison to the asthma mortality and morbidity rate in the United States, the death
rate in Japan has decreased tremendously from 8.8 to 3.0 per 100,000 people, from the year 1970
to 2002. The number of deaths has decreased from 6200 in the year 1980 to 3755 in 2002. The
death ratio between males and females has gone from 3:2 in 1980 to 1:1 (Nakazawa & Dobashi,
2004). The reduction of asthma death cases in Japan was due to the preventive measures taken
by the Department of Public Health in Japan.

In Canada, around 20 children and 500 adults die from asthma yearly. Statistics Canada
reported that in 2010, 8.5% of Canadian residents have been detected to having asthma. These
alarming mortality rates were due to lack of diagnosis, treatment and education about asthma
management (Asthma Society of Canada, n.d.).
In France, the mean yearly death rate of asthma has reduced from 1,567 in 2000 to 1,166
in 2005 (Fuhrman, Jougla, Uhry & Delmas, 2009). Besides that, approximately 44% of death
certificate that have a connection with asthma from the year 2000 to 2005 stated that asthma was
the main cause of death.
Below is the table from the Global Burden of Asthma (GINA) study conducted by Masoli,
Fabian, Holt and Beaslesy (n.d.).
Regions Countries Included Total
Population
Number of
persons with
Asthma
Mean
Prevalence
of Clinical
Asthma
Scandinavia/Baltic
States
Denmark, Estonia, Finland,
Iceland, Latvia, Lithuania,
Norway, Poland and Sweden
70.2 m 3.4 m 4.9%
United
Kingdom/Republic
of Ireland
England, Guernsey, Isle of
Man, Jersey, Northern
Ireland, Republic of Ireland,
Scotland and Wales
63.6 m 10.1 m 16.1%
Western Europe Austria, Belgium, France,
Germany, Italy, Luxembourg,
Netherlands, Portugal, Spain
and Switzerland
290.8 m 17.2 m 5.9%
Balkans/Turkey/Ca
ucasus/Mediterran
ean Islands
Albania, Armenia,
Azerbaijan, Bosnia-
Herzegovina, Croatia, Cyprus,
Georgia, Greece, FYR
Macedonia, Malta, Serbia,
Slovenia and Turkey
112.4 m 6.9 m 6.1%

Russia & Former
Socialist Republics
of Eastern Europe
Belarus, Bulgaria, Czech
Republic, Hungary,
Moldovia, Romania, Russian
Federation, Slovakia and
Ukraine
264.0 m 9.8 m 3.7%
Middle East Bahrain, Iran, Iraq, Israel,
Jordan, Kingdom of Saudi
Arabia, Kuwait, Lebanon,
Occupied Territory of
Palestine, Oman, Qatar, Syria,
United Arab Emirates and
Yemen
177.5 m 10.3 m 5.8%
Central Asia &
Pakistan
Afghanistan, Kazakhstan,
Kyrgyzstan, Pakistan,
Tajikistan, Turkmenistan and
Uzbekistan
224.7 m 9.7 m 4.3%
Southern Asia Bangladesh, Bhutan, India,
Nepal, Seychelles and Sri
Lanka
1,210.0 m 42.2 m 3.5%
China/Taiwan/Mo
ngolia
China, Hong Kong, Macau,
Mongolia and Taiwan
1,324.1 m 27.8 m 2.1%
Northeast Asia Japan, North Korea and South
Korea
196.8 m 11.4 m 5.8%
Southeast Asia Brunei, Cambodia, Indonesia,
Laos, Malaysia, Myanmar,
Philippines, Singapore,
Thailand and Vietnam
529.3 m 17.5 m 3.3%
Oceania Australia, Fiji, New Zealand,
Papua New Guinea, Samoa,
Tahiti and Other Pacific
Islands
30.7 m 4.5 m 14.6%
North America Canada and United States of
America
316.9 m 35.5 m 11.2%
Central America Belize, Costa Rica, El
Salvador, Guatemala,
Honduras, Mexico, Nicaragua
and Panama
137.3 m 5.2 m 3.8%
Caribbean Barbados, Cuba, Dominican
Republic, Haiti, Jamaica,
Puerto Rico, Trinidad &
32.6 m 3.4 m 10.4%

Tobago and Other Caribbean
Islands
South America Argentina, Bolivia, Brazil,
Chile, Colombia, Ecuador,
French Guiana, Guyana,
Paraguay, Peru, Suriname,
Uruguay and Venezuela
350.4 m 34.7 m 9.9%
North Africa Algeria, Chad, Egypt, Libya,
Morocco, Niger, Sudan and
Tunisia
196.5 m 7.7 m 3.9%
West Africa Benin, Burkina Faso,
Cameroon, Cape Verde,
Central African Republic,
Equatorial Guinea, Gabon,
Gambia, Ghana, Guinea,
Guinea-Bissau, Ivory Coast,
Liberia, Mali, Mauritania,
Nigeria, Senegal, Sierra
Leone, Togo and Western
Sahara
239.5 m 13.7 m 5.7%
East Africa Burundi, Djibouti, Eritrea,
Ethiopia, Kenya, Madagascar,
Malawi, Mauritius,
Mozambique, Rwanda,
Somalia, Tanzania and
Uganda
230.2 m 10.1 m 4.4%
Southern Africa Angola, Botswana, Congo,
Namibia, south Africa,
Swaziland, Zaire, Zambia and
Zimbabwe
186.3 m 15.1 m 8.1%
Table 2: Burden of asthma in different study regions (Masoli, Fabian, Holt & Beasley, n.d.).

Disease Description
Asthma is diagnosed based on questionnaires by physicians about breathing issues at
various times of day, during certain activities or occurrences at certain times of the year. The
questions include family asthma, allergies and breathing problems histories. Besides that, a lung
function test, called spirometry, is used to diagnose asthma. The spirometer measures the amount
of air a person breathes in and out after taking a deep breath (CDC, 2013).
Characteristics of Person
Gender
The CDC (2013) stated that adult women have a higher risk of developing asthma than
men. But as for children, boys were at a higher risk than girls. McCoy, Redelings, Sorvillo and
Simon (2005) stated that females have a higher age-adjusted death rate than males from all racial
background but not of Asians or Pacific Islanders origin. In fact, more females were reported to
be hospitalized longer for asthma, higher bronchial hyperresponsiveness than males (McCoy et
al., 2005).
In contrast, according to Ahmad et al. (2009), males were at a higher rate of contracting
asthma than females between the ages of 0 to 17 years, especially younger children. Kitabayashi,
Iilura and Tokutome (2002) agreed that Japanese men have a higher deaths rate than women, the
ratio was 1.8:1. There is not much information why the difference in gender has an effect on the
prevalence of asthma. Some research correlates the differences in genetic make-ups between
males and females have an impact on the severity of asthma.

Race
According to the CDC (2013), any race, apart from white, has a higher risk of contracting
asthma, in both adults and children. McHugh, Symanski, Pompeii and Delcos (2009) conducted
a research to determine the asthma rates between Mexican women born in Mexico versus United
States. Mexican women born in the United States have a higher rate of asthma compared to
Mexican women born in Mexico. Mexican Americans born in Mexico have a lower incidence
rate of asthma than other races in the United States (McHugh et al., 2009). In contrast, Ahmad et
al. (2009) stated that blacks have a higher rate of asthma than whites and other ethnicities.
McCoy et al. (2005) agreed to the statement that blacks have a higher mortality rate than other
ethnic backgrounds at all ages. The authors stated that blacks may not have proper healthcare
attention, inability to obtain asthma prescriptions and being in contact to allergens and pollutions.
But older Asians have been reported to have higher asthma mortality due to smoking habits
(McCoy et al., 2005).
Age
Children are always known to be at high risk of developing asthma. Winer et al. (2012)
stated that younger children have a higher incidence rate of developing asthma than adults.
Children and the elderly are at a higher risk of developing any diseases because they are
immunocompromised. Their immune systems are not fully developed, making them prone to
catching diseases easily. In that case, they take a longer time to recuperate from diseases.
In contrast, the CDC (2013) reported that adults aging from 18 to 24 are more prone to
have asthma than the older population. McHugh et al. (2009) stated that women ages from 20 to
29 and 70 to 85 have a higher rate of developing asthma than the range of 30 to 69 of age. In

addition, men ages from 20 to 29 were at the highest risk of asthma and lowest to ages from 70
to 85 (McHugh et al., 2009). These research proved that asthma is prevalent at all ages.
Health Habits
The CDC (2013) reported that smokers and obese adults are more likely to have asthma.
McHugh et al. (2009) stated that obese women have a higher rate of asthma than women with
normal BMI. Over obese men have the highest rate of asthma compared to other BMI
classifications (McHugh et al., 2009). Ahmad et al. (2009) also agreed to the statement that
obese children and adolescents were reported to suffer more from asthma. Additionally, there
was an increase of asthma in women who smoke versus those who do not (McHugh et al., 2009).
Sixty percent of cases were reported where smokers with asthma were admitted to emergency
rooms versus non-smokers (Ahmad et al., 2009). Smoking worsens an asthma inflamed lungs
while obesity impedes the inhaled air to the lung due to atherosclerosis. All of these harmful
health habits increase the severity of asthma.
Education
The CDC (2013) reported a higher risk in asthma occurrence for those who did not
complete high school than those who did. Women who completed more than a high school
education have a lower risk of developing asthma than those who did not (McHugh et al., 2009).
Higher education promotes an individual’s quality of life. A highly educated individual has a
longer life durations, better health care access and health habits.

Poverty
Every country has its own economy status. An increase or decrease in a country’s
economy has an effect on disease management. With regards to poverty, adults with household
income over $ 75,000 have a lower rate of developing asthma than those with lower income
(CDC, 2013). Furthermore, McHugh et al. (2009) stated that women and men who are living
under poverty level have a higher rate of asthma than those who live above the poverty line. The
financial crisis in the United States has affected other countries’ economy. When a country’s
economy declines, it creates a higher shift of poverty among the population. High poverty would
affect sick patients because they cannot afford the high medical cost when they can use the
money to support their families.
Characteristics of Place
International
WHO (2013) stated that asthma is prevalent in all countries no matter at what state the
country’s growth is at. Majority of asthma death cases are prevalent in small and small-mid
income countries.
Within Country
Hsieh and Liao (2013) conducted a research in Taiwan about the distribution of asthma
hospitalizations rate in five regions in Taiwan during 1998 to 2010. The regions analyzed
consisted of Northern, Central, Eastern, Island and Southern of Taiwan. The northern part of
Taiwan which consisted of three counties and four cities, including Taipei City as the country’s

capital, has the highest percentage with 42.2% of asthma prevalence while the Island part has the
lowest with 1.0%. Every country should have a report on which geographic region has the
highest and lowest rate of asthma.
Urban/Rural
A research was conducted in Chile and confirmed the theory of hygiene hypothesis
associated with asthma prevention. The hygiene theory, originated from Europe, which stated
that exposure to bacteria, farm animals and having a pet at an early stage of life act as defense
mechanisms against asthma. The effectiveness of this theory has been widely debated in many
countries. The issues raised were the huge differences in environmental exposures between rural
and urban areas. For instance, exposures between being in contact with farm animals in rural
area versus cockroaches in urban areas are so difficult to compare, thus making this theory not
valid yet (Boneberger et al., 2011). There was a debate about why urban areas have a higher rate
of asthma incidence but there were some instances where rural areas have a higher rate than
urban areas. This is because more industrial areas are moving to rural areas, thereby boosting the
economy and employment rate of the population.
Local
There are five boroughs in New York City: Manhattan, Staten Island, Queens, Brooklyn
and Bronx. Carr, Zeitel and Weiss (1992) stated that in New York City itself, Bronx has the
highest asthma hospitalization rate of 65.8 per 10,000 people while Queens has the lowest with
21.3 in 10,000 people. On the other hand, Bronx has the highest asthma death rate of 1.7 in
100,000 people Staten Island has the lowest with 0.2 in 100,000 people. Both of these
hospitalizations and deaths rates were collected from 1982 to 1987, based on the age group

between 0 to 34 years. This research provided an insight of asthma status at various local areas in
a city.
Characteristics of Time
According to McCoy et al. (2005), most of the higher asthma deaths cases recorded in the
United States occurred during the winter season. These deaths were hypothesized to be highly
correlated with the high cases of viral respiratory infections during the cold season, such as, flu.
Similarly, in Japan, there was a higher death case of asthma from during December to February,
while lower in June, July and September (Kitabayashi et al., 2002). Likewise, in Taiwan, there
was a higher rate of asthma hospitalizations from winter to spring while lowest from summer to
fall seasons (Hsieh & Liao, 2013). All of these research proved that the occurrence of asthma is
based on cyclic fluctuations. Most countries with four seasons see a higher trend in asthma cases
during cold season. But there are some countries reported that the highest recorded asthma can
be scattered around the year.

Causes of Asthma
The CDC (2013) reported that an asthma attack can be triggered by environmental
tobacco smoke, dust mites, outdoor pollution, cockroach allergen, furry pets, molds, smoke from
wood or grass burning, respiratory diseases, physical activities and hyperventilation.
Environmental Tobacco Smoke (ETS)
Comhair et al. (2011) stated that asthmatics exposed to ETS were reported to have lower
scores in quality of life, higher expenses on health care and deteriorating lung health. This was
due to congested airways flow through ETS inhalation and resulting in asthma prevalence in
adults. In fact, both passive and active tobacco smoking activities are contributors to the severity
of asthma in adults. This is because the contents in cigarettes impede the function of antioxidants
in the human body (Comhair et al., 2011).
In regards to pregnant women, Xepapadaki et al. (2009) stated that passive exposure to
ETS would result in babies suffering from low birth weight. Consequently, due to passive
exposure of ETS, the lung growth of fetuses would be affected during the third trimester of
pregnancy. Even more, pregnant mothers who smoke tobacco often reported frequent
occurrences of breathlessness.
On the other hand, Tanaka and Miyake (2011) reported that postnatal is the only factor
that increases the risk of asthma among children at 14 to 18 of age. The authors result matched to
similar research done in Denmark but contrasted in California. In California, prenatal instead of
postnatal smoking posed a higher risk of asthma among children (Tanaka & Miyake, 2011).

Concerning ETS and pregnancy, it is best that women refrain from any form ETS exposure to
protect the wellbeing of the baby from developing asthma after birth.
Outdoor Air Pollution
There are many harmful allergens in the air we breathe in daily. Urbanization is a key
factor in the increasing of air pollutions worldwide. Most of the respiratory infections reported
are caused by exposure to the harmful allergens in the air. The Environmental Protection Agency
(n.d.) reported that ozone and particle from air pollution are the major contributors to asthma.
Hsieh and Liao (2013) reported that ozone (O3), nitrogen dioxide (NO2), carbon dioxide
(CO) and sulfur dioxide (SO2) were the main contributors to asthma and bronchitis
hospitalizations among children and adults. Moreover, To et al. (2013) stated that in Canada, an
increased in the daily maximum Air Quality Health Index (AQHI) would result in the increased
of asthma-related medical costs. More importantly, severe exposure to NO2, O3, and PM10 could
result in the increasing rate of asthma mortality among Canadians.
On the other side of the world, in Tasmania, Australia, Bui et al. (2013) reported that
vehicle exhaust, consisted of nitric oxide, nitrogen dioxide, carbon monoxide and benzene were
the major causes of reported breathing problems. These will in turn affect lung function and
eventually worsen asthma.
It is very important to be aware of what we inhale daily. Some countries have issued
people to wear protective face masks if the air quality drops below the safe level of air quality.

Allergens
Mold
Park, Kreiss and Cox-Ganser (2012) stated that workers with building-related (BR)
rhinosinusitis have a higher rate of developing BR- asthma problems. This research was
conducted in a previously water-ruined 20-floors building in northeastern United States. The
building was occupied in 1994 and research was conducted in 2001. The results stated that
workers who were diagnosed with work-related asthma have a 4 times tendency of developing
BR-asthma working in a building with humid environment. The authors also found out when the
building was first occupied in 2001, there was a 7.5 times increase in newly diagnosed asthma
cases and discovered that the molds in floor dust were responsible for the problem. In addition,
workers with BR-rhinosinusitis and working in a previously water-damaged building infested
with fungi have a higher rate of developing asthma at a later age.
Similarly, in Taiwan, Hwang, Liu and Huang (2011) stated an estimated 100% and 70%
asthma risk increased in the first two years children life, developing the disease due to living at
home with mold smell or observable molds, respectively. Inal et al. (2007) agreed that
development of indoor mold is a risk factor of asthma and allergies occurrence among children
in Turkey. The spores from indoor mold were identified to be Penicillium and Aspergillus. The
authors suggested that using air-conditioners and heaters during summer and winter, respectively,
were beneficial in reducing indoor mold growths at home. Yearly home inspection especially in
the basements for any growth observable molds would reduce the likelihood of occupants
developing asthma and other respiratory-related diseases.

Dust Mites
House dust mites are more commonly found in beds and floor. The dust mites would not
only affect sensitivity to the dust but also worsens asthma. According to Feng, Yang, Zhuang,
Yanagi and Cheng (2012), there were over 10 genera and 40 species of dust mites found living in
the world. The two main species of dust mites are Dermatophagonides pteronyssinus (D.p) and
Dermatophagoides farinae (D.f.). The Der.p was found in Eurasia while the Der.f was popular in
the United States. Gent et al. (2012) stated that children exposed to Der. P were more likely to
rely on asthma medications for recovery.
As a matter of fact, Li et al. (2013) agreed that house dust mites were the major
contributor to the high prevalence of asthma among children in Guangzhou, China. The authors
shared their concern that the changes in weather, for instance, less cold in the winter and
increased humidity in the summer have resulted in the increase likelihood of house dust mite
sensitization. In fact, there was a higher rate of asthma reported because of being in contact with
house dust mites found in bed and infested air conditioned filters at homes.
Therefore, it is advisable to constantly clean items that could potentially harbor dust
mites in order to reduce the prevalence of asthma.
Cockroaches
Gao (2012) stated that exposure to cockroach allergen posed the greatest risk factors with
increasing incidences and seriousness of allergies and asthma among urban children. The author
also mentioned that there is a 3.4 times increase in children hospitalized for asthma based on the
positive result of cockroach antigen skin test and excessive amount of cockroach allergen
discovered in bedroom. More importantly, children with asthma were more likely to experience

bad allergies and missed classes at schools. Not only were the children are at higher risk of
developing asthma due to cockroach allergen, the elderly were hypothesized to be at risk too.
Rogers et al. (2002) stated that cockroach allergen tops the highest allergen sensitization in
comparison to other animal’s dander, plants or molds in the northeastern United States.
In contrast, Safari, Amin, Kashef, Aleyasin and Ayatollahi (2009) described that in rural
areas of Iran; more than 25% of children with asthma were tested positive for cockroach allergen.
Their result were supported by similar research done by other researchers, where 43% of
children and adults living in rural Kentucky, United States, were skin tested positive for
cockroach antigen in comparison to 41% in urban people.
Whether it is living in an urban or rural area, eliminating cockroach droppings at homes
are essential in preventing the likelihood of developing asthma.
Rodent
Berg et al. (2007) conducted a research among migrant Latino families in Los Angeles,
California, stated that rodent allergen were associated with the increased rate of asthma. These
allergens were reported to be originated from unclean and poor condition of homes which
attracted rodents to infest the household. Moreover, separate homes were found to have higher
rodent allergen infestation in comparison to living in high rise apartments. This is because
detached homes provide an easier and accessible breeding ground for rodents.
Jeal and Jones (2010) stated that in the United States, middle class children and adults
from urban, suburbs and rural areas, who were exposed to rodent allergen, have been shown to
develop asthma. Similar researches were conducted in Poland and Brazil and yielded same
results that exposure to rat allergen have contributed to higher incidence rate of asthma.

Furthermore, Jeal and Jones (2010) described that kindergarten and urban kids with asthma and
women are the new targets of being highly exposed to rodent allergen. Women are at high risk of
developing asthma from rodent allergen despite of race or socioeconomic background. Exposure
to rodent allergen on top of parental asthma will not only cause asthmatics to develop
sensitization but could lead to longer recovery time.
Animal Dander
Lönnkvist et al. (1999) stated that the amount of cat and dog dander were higher in
school dust than at home based on a study done in Sweden. The study has proven that there was
a higher rate of asthma due to the high concentrations of animal dander found at school. In
contrast, Platts-Mills, Erwin, Perzanowski and Woodfolk (2004) stated that having a cat as a pet
would reduce the prevalence of asthma to four times, even though cat dander is hypothesized as
a contributor to the disease. It is believed that asthmatics have developed tolerance because of
the IgE antibody positive to cat.
Having a pet at home is an option that requires a lot of consideration. If pet dander is
believed to cause asthma among children at home, it is then best to eliminate the pet to reduce
the severity of the disease.
Smoke from Wood Burning
Bui et al. (2013) stated that both smoke from outdoor wood burning and vehicle pollution
contributed to severe asthma among adults in Tasmania, Australia. This is because smoke from
burned wood caused irritation to the human respiratory system. This study was proven to be true

when firefighters had respiratory hyperresponsiveness problems from inhaling wood smoke. In
addition, similar study was conducted among people in Guatemala, in which breathing
difficulties were experienced due to the excessive exposure to biomass smoke. More importantly,
indoor wood burning worsens asthma and Chronic Obstructive Pulmonary Disease (COPD). It is
very difficult to prevent indoor wood burning at home because it is a common practice during the
cold season for heating purposes (Bui et al., 2013).
Disease and Infections
Diaz-Guzman et al (2011) stated that asthmatics have a higher risk of developing COPD,
which could result in higher death rate. This is because both diseases have similar symptoms,
where the airflow difficulty is to be blamed. Not only that, patients who started off having
asthma will eventually develop COPD at a later age. On top of that, smoking tobacco will only
worsen a patient currently diagnosed with both asthma and COPD.
Additionally, Nakazawa and Dobashi (2004) stated that respiratory illnesses, such as, flu,
acute bronchitis, tiredness and stress were the main causes to deadly asthma attacks. All of these
respiratory diseases have similar symptoms to asthma, which make it difficult for physicians to
administer suitable treatment.
Cleaning Products
The California Department of Public Health (2012) described that 10% of all work-
related asthma cases were caused by being in contact with some form of cleaning products.

Lillienberg et al. (2013) conducted a research on the effect of occupational usage of
cleaning agents from various countries in Northern Europe. The authors stated that exposure to
reactive chemicals in cleaning agents, such as, epoxy, diisocyanates and acrylates, have proven
to increase the prevalence of asthma among workers. The workers who were at high risk due to
being in contact with these chemicals are male painters, plumbers and female hairdressers.
In order to prevent cleaning agents-caused asthma, health and safety educational
programs should be implemented at all work place so workers are informed about the risks of
their jobs. Public health officials should propose banning of cleaning agents that pose high risk to
workers health.
Physical Activities
Dimitrakaki et al. (2013) conducted a research based on the response of frequency in
physical activities between non-asthmatic and asthmatic children in Greece. The results proved
that non-asthmatic students were more involved in intense, mild and systematic exercise. In spite
of that, both non-asthmatic and asthmatic were educated and tested on the importance of exercise
and both groups showed no difference in results. This study proved that asthmatics knew the
importance of physical exercise but failed to be much involved in it, fearing that excessive body
exertion would aggravate the disease.
In addition, Chiang, Huang and Fu (2005) stated that nearly half of the asthmatics
participants involved in their research reported to have experienced no less than one occurrence
of exercise-stimulated asthma attack. Some of these attacks have resulted in hospitalizations.

Asthmatics should know the self-maximum level of physical activities intensity that
could potentially trigger the onset of the disease. Light activity, such as, walking at a slower pace
in a long period of time might not hurt the lung but would at least strengthens the heart.
Strong Emotions
According to Ritz, Rosenfield, Meuret, Bobb and Steptoe (2008), hyperventilation is “a
breathing pattern beyond the metabolic demands of the organism” (p. 97). In other words, faster
or deeper breathing than the usual pattern are symptoms of hyperventilation. Nervousness
triggers hyperventilation, which will then escalate to anxiety attacks. Anxiety attacks will further
worsens asthma and eventually the overall health condition of a person (Ritz et al., 2008).
Meuret and Ritz (2010) stated that hyperventilation was closely related to the occurrence of
asthma. The sudden heavy breathing than usual is caused by anxiety, a symptom of asthma.
Furthermore, various emotional problems, such as, tremendous stress, panic, psychiatric
problems have been discovered to cause lower levels of partial pressure of carbon dioxide
(PCO2) in the human airways system, making breathing difficult. Thus, stress must be handled
wisely and it is advisable to take deep breaths and short breaks in moments of a panic attack.

Data Interpretation Issues
Bias
Selection Bias
Bornehag, Sundell, Sigsgaard and Janson (2006) stated that selection bias occurred in
their study because participants with asthma related symptoms and potential risk factors were
more likely to be part of the study. For instance, smokers were not likely to be part of the study,
knowing that the habit is a contributor to the severity of asthma. Therefore, more clinical
examination need to be administered to reduce selection bias apart from relying based on
answers provided by participants.
Information Bias
Hsieh and Liao (2013) expressed the limitation of their research because all the results
collected were based on hospital admittance records only. The authors believed that there was a
trend where asthmatic patients were more likely to be treated in outpatients care instead of the
emergency care at the hospital. This may due to the lower medical cost in clinics in comparison
to hospitals. Furthermore, Diaz-Guzman et al. (2011) mentioned that there may have been
misclassifications of health information because the results collected rely solely on participants
answers to the surveys, in which was not validated by physicians. Thus, information bias can be
prevented by having clinical examination on participants instead of relying solely on self-
reported questionnaires.

Recall bias
Boneberger et al. (2011) stated that recall bias is present in their research because all the
results were based on self-reported by parents of asthma patients. Every self-reported study
designs are bound to have recall bias because the patients difficulty in retaining information. One
way to reduce recall bias is analyzing patient’s medical history through physician’s records.
Prevarication bias
Knoeller et al. (2013) explained that workers were not inclined to report asthma caused
by work-related element, fearing the possibility of losing their jobs and thus not reporting to the
research. Another example of prevarication bias is parents with asthmatic children tend not to
report smoking habits because they know that it is a major contributor to the disease (Boneberger
et al., 2011). It is best to be honest while being part of a research because the information
collected would benefits the researchers in answering their questions and also facilitate better
treatment to the disease in the future.
Confounding
Hsieh and Liao (2013) stated that the research they conducted did not take any
environmental confounders such as infections or exposure to allergens into consideration when
analyzing the reason behind increasing incidence rate of asthma hospitalization. Their research
was based solely on the effect of air pollution with asthma hospitalization.
Therefore, it is important for epidemiologists to identify potential confounding factors
besides the main correlation in relation to their research.

Experimental Design
A retrospective cohort studies will be used to determine the effects of indoor and outdoor
environment factors on the prevalence of asthma among children from 1 to 18 years old in six
different states in the United States. Three highest populated states (California, Texas and New
York) and three lowest populated states (British Colombia, Vermont and Wyoming) were used to
analyze the effect of environmental factors among children with asthma. The asthma rates
between high populated states versus low populated states were compared to see if population
rates have an effect to the disease.
Here is the proposed study design based on similar research conducted by Bornehag et al.
(2006). This is a triple blind experiment in which the researchers, public health investigators and
educators are not related in any sort of way.
1. Baseline questionnaire is issued to all parents in the six selected states. Information
requested :
a. Demographics (Age, Gender, Race).
b. Home development status (Urban, Suburban, Rural).
c. Day care attendance.
d. Family characteristics (Number of children and age, two-parent or one-parent
family).
e. History of pet keeping at home (Current, At Birth, Eliminated or avoided due to
asthma).
f. Frequency of home cleaning in a week.
g. Smoking at home (Father, Mother and other family members at home).

h. Asthma-related questions:
i. Time when child was first diagnosed with asthma.
ii. History of allergies and allergic symptoms (Wheezing, Coughs, Runny
Nose, Allergic Rhinitis and Eczema).
iii. History of respiratory infections in the past 12 months.
iv. Length of cold experienced during each asthma incidence.
v. Other diseases diagnosed (Pneumonia, Sinusitis and Bronchitis).
vi. Antibiotic treatment administered by physicians.
vii. Asthma and allergies in parents and siblings.
2. All returned questionnaires will be followed-up with a letter of permission, requesting to
inspect participants’ homes at no cost and damage. The inspection include:
a. Allergens (Dust mites, animal dander, mold, cockroach and rodent)
b. Outdoor air quality index (Pollution).
c. Indoor air quality (humidity, air conditioner).
3. During the home inspection, public health investigators are present to conduct consented
skin prick tests on children with asthma for possible allergens.
4. The results will be collected and sent to an assigned data collection company.
5. Another different group of public health officials are randomly assigned to homes with
asthmatics children and provided asthma prevention education.
6. Three years after the administration of asthma education to some randomly assigned
homes, the exact baseline questionnaire is mailed out to all homes with the inclusion of
whether they received asthma education in the past few years, and if they did, was the
education effective in preventing the severity of asthma?

7. All returned questionnaires are followed-up with a letter of permission, requesting to
inspect participant’s homes at no cost and damage. The inspection include:
a. Allergens (Dust mites, animal dander, mold, cockroach and rodent)
b. Outdoor air quality index (Pollution).
c. Indoor air quality (humidity, air conditioner).
8. The home inspection will be conducted by a different group of public health investigators
and consented skin prick tests will be conducted on children with asthma for possible
allergens.
9. The results are collected and sent to the assigned data collection center. The data
collection center will analyze and determine the effectiveness of asthma education in the
prevention of the disease among children. Additionally, correlations between the highest
populated and lowest populated states and their impact to the severity of asthma will be
evaluated. Not only that, potential causes of asthma will be identified using the results
from skin prick test and home inspection reports.

Treatment and Preventive Measures
The CDC (2013) reported that 1 in 4 black adults and 1 in 5 Hispanic adults could not
afford asthma medications. The CDC (2013) also suggested that people with asthma to obtain flu
and pneumococcal vaccines. These vaccinations will prevent further complications from
respiratory infections like influenza and pneumococcal. An asthma inhaler is usually prescribed
by doctors and to be used by patients in any event of an asthma attack.
The WHO (2002) suggested these preventive steps to reduce the severity of asthma:
 Stay away from any exposure to tobacco smoke, especially during pregnancy. Parents are
advised not to expose children to tobacco and other harmful environmental smoke while
they are young.
 Humid housing condition and indoor air contaminants should be avoided. Feng et al.
(2012) suggested that opening house windows once in every hour would reduce the
indoor humidity and level of dust mites
 Breastfeeding is advisable for the first six months of a baby. This activity provides
nutrients and antibodies to newborn babies to boost their immune system and reduce the
likelihood of developing asthma and other diseases.
 Stay away from potential allergens at work places. Workers are advised to consult a
doctor when irritation is experienced while at work.
 Any allergy-related asthma, rhinitis, conjunctivitis, atopic eczema should be treated
immediately. This includes reducing dust mites, cockroaches and animals dander at home.

 Asthma education about the causes, symptoms and preventive measures should be given
in school and to the public. Nakazawa and Dobashi (2004) stated that lack of asthma
prevention education among children and their parents are one cause of asthma deaths.
Moreover, Garcia et al. (2008) stated that the consumption of fruits and vegetables can
protect against asthma due to the beneficial antioxidants found in them. Besides that, consuming
milk more than three times a week can act as protective agents against asthma (Garcia et al.,
2008; Waser et al. 2006). Waser et al. (2006) also described that milk can prevent the risk of
contracting asthma. However, consumption of raw milk is definitely not advisable due to the
possibility of having food-borne diseases (Waser et al., 2006).
Conclusion
Asthma is a chronic disease that affects people around the world. Until today, there is no
cure found to treat this chronic disease. The only way to reduce the severity of asthma is taking
preventive measures at home and the surrounding. Keeping a clean home and reducing self-
exposure to harmful environment factors would help in reducing the incidence of asthma attacks.
Moreover, maintaining a healthy lifestyle is essential as it prevents us from developing other
diseases related closely to asthma. Getting medical attention in the event of an asthma attack will
further enlighten physician’s mode of diagnosis and treatment. All of these preventive steps will
keep asthma at bay and potentially cure it as time progresses. As the sayings goes, prevention is
better than cure.

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Appendix
None Attached.

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