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Asthma Backgrounder
February 2014
Steven Mayher
Why asthma is an issue
Asthma is a life-long, incurable disease that affects the lungs, inhibiting a person’s capacity to
breathe. This chronic disease causes inflammation and narrowing of the airways, leading to
wheezing, chest tightness, shortness of breath and coughing – all of which often occur at night or
in the early hours of the day (National Heart, Lung and Blood Institute, 2012). Figure 1
illustrates the difference between normal air passageways and those affected by asthma.
Figure 1: Comparison between healthy and asthmatic airway
Part A shows the location of the lungs and airways in the body. Part B shows a cross-section of a normal
airway. Part C shows a cross-section of an airway during asthma symptoms.
Source: National Heart, Lung, and Blood Institute, 2012 (access at http://www.nhlbi.nih.gov/health/health-topics/topics/asthma)
The exact cause of asthma is unknown, but it tends to run in families, indicating a genetic link. It
also appears that environmental factors contribute to its occurrence. The swollen, inflamed
airways of asthmatics are especially sensitive to respiratory infections, such as colds, and
allergens such as dust, chemicals, smoke and pet dander (American Lung Association, n.d.).
However, not all asthmatics are allergic; some react to particulate matter and other non-
allergenic material in the environment (Natural Resources Defense Council, 2014). These
infections and irritants cause the asthmatic’s airways to synthesize extra mucus and swell up
more, initiating asthma flare-ups. (American Lung Association, n.d.). While attacks may be mild
and can be treated at home with inhaled medications, moderate to severe attacks usually require
treatment in a clinic or hospital. Treatment options include not only inhaled medications, but oral
glucocorticosteroids to reverse inflammation and speed recovery, oxygen treatment and other
medications (Global Initiative for Asthma, 2012).

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The prevalence of asthma has increased extensively over the past 20 years, including both
globally and within the United States. It is estimated that approximately 300 million people are
affected worldwide and that children are especially affected (GINA, 2012). In the United States
from 2001 to 2010, asthma increased from 7.3% to 8.4%, with an estimated number of 25.7
million persons with asthma in 2010. Of this number, 18.7 million were adults aged 18 and over,
while 7.0 million were children between 0-17 years of age (Akinbami et al., 2012).
Figure 2: Asthma Prevalence from 2001 to 2010
As noted in Figure 2 above, asthma prevalence has been steadily increasing since 2001 and as of
2010 was at its highest level. Children are particularly vulnerable to asthma, since their immune
systems are not fully developed and are subject to early sensitization by allergens. Later in life,
those who have had childhood asthma are prone to developing other lung diseases. This causes
even greater concern about rising asthma prevalence (Lebowitz, 2000).
Airborne particles, including dust, soot, diesel exhaust particles, wood smoke and sulfate
aerosols all contribute to the particulate matter that can also trigger asthma (Natural Resources
Defense Council, 2014). In addition, ground level ozone, sulfur dioxide and nitrogen oxide are
major contributors to asthma. According to the Natural Resources Defense Council, the number
of asthma-related hospitalizations increases when particulate matter in the air rises.
Approximately 44 million people live in areas that do not meet national air quality standards for
particulate matter while nearly 38 percent of Americans live in areas that have ozone levels that
are considered unhealthy (NRDC, 2014). Sulfur dioxide, a respiratory irritant produced by coal-
fired power plants, affects 8.1 million Americans (NRDC, 2014). Air pollution resulting from
increased fossil fuel usage is a leading cause of the increase in allergic airway diseases (Saxon &

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Diaz-Sanchez, 2005). Both particles and gases in air pollution can set off and worsen
inflammation and change the body’s ability to defensively respond to allergens (Saxon & Diaz-
Sanchez, 2005). According to the U.S. Centers for Disease Control, asthma is one of the most
serious chronic diseases of childhood, with more than 10 million school days lost each year,
while employers lose 14 million work days every year due to asthma (NRDC, 2014). The annual
economic cost of asthma is estimated at more than $56 billion, which includes direct medical
costs from hospital stays and indirect costs from lost school and work days (U.S. Environmental
Protection Agency, 2013). These statistics demonstrate the significance of asthma as both a
public health and environmental issue.
Research studies on asthma
In 2002 the Environmental Protection Agency released its Asthma Research Strategy. It
characterized asthma as a disease with reversible airway obstruction and chronic inflammation
that can lead to permanent structural airway changes. The EPA noted certain factors that increase
a person’s vulnerability to developing asthma, which include genetics, their overall health, their
lifestyle, their socioeconomic status, where they live and their overall exposure history to
allergens and non-allergic triggers. The Asthma Research Strategy identified three research areas
of need:
1) Induction and exacerbation of asthma, including combustion-related products,
bioaerosols, air toxics and pesticides;
2) Susceptibility factors, including genetic susceptibility, health status, socioeconomic
status, residence and exposure history and lifestyle/activity patterns;
3) Risk assessment, including studies involving human environmental exposure,
epidemiology, occupational exposure and animal toxicology (EPA, 2002).
The following articles are examples of the research that has been done in these priority areas:
 Induction of asthma and the environment: What we know and need to know. This
article, written by 16 individuals in response to a workshop held by the U.S. EPA and the
National Institute of Environmental Health Sciences in October 2004, reviews current
scientific evidence related to the cause of asthma. Two main questions were posed to
address what regulatory and public health agencies could do to reduce the incidence of
asthma and what research would improve the understanding of the factors that contribute
to the cause of asthma and the ability to manage the problem. From the group discussions
that ensued, there was strong scientific support for public health agencies to limit babies’
exposure to cigarette smoke before birth, from their mothers’ smoking. With respect to
other interventions, more research is needed because there were many more questions
than answers (Selgrade et al., 2006).
 Environmental issues in managing asthma. This study examined both indoor and
outdoor environmental exposure to pollutants that can induce asthma or make it more
severe. Environmental controls to limit exposure to allergens help asthmatics to manage
the disease. With respect to indoor pollutants, the National Asthma Education and
Prevention Program 2007 guidelines recommend not smoking indoors and improving
ventilation to reduce particulate matter, nitrogen dioxide, secondhand smoke, ozone and
allergens from furred pets, dust mites, cockroaches, rodents and molds. They also suggest
limiting exposure to outdoor pollutants such as particulate matter, ozone, nitrogen

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dioxide, sulfur dioxide and pollen allergens. This can include avoiding outdoor exercise
or heavy labor when levels of certain air pollutants are high, staying indoors, keeping
windows and doors closed, using air conditioning and room-air filters. Washing daily to
remove allergens from one’s body is another control measure (Diette et al., 2008).
 The effect of environmental oxidative stress on airway inflammation. The purpose of
this study was to see the effects of air pollution on people’s immune response, and to
consider the best treatments and medical advice, depending on how an individual
responds to allergens in the air. The study examined how airway inflammation can be
caused and suggested new clinical trials to investigate using antioxidants to treat this. It
also found that air pollution does significantly impact the development of asthma and that
certain patients are affected more than others. It suggested further genetic studies that
could help target certain populations that are at greater risk for asthma (Auerbach &
Hernandez, 2012).
 Genetics of asthma susceptibility and severity. Environmental exposure to allergens and
interaction of genes influences the development of asthma and also its severity. Several
genes/regions have been identified to be associated with asthma susceptibility. This study
concluded that an important goal of the genetic approach in a complex disease of this sort
is to identify a group of variants that consistently predict the susceptibility and severity of
disease and to use these variants to develop personalized therapy for those with asthma
(Slager et al., 2012).
Government action on asthma
Due to the significance and widespread occurrence or prevalence of asthma, a number of
government agencies are interested and involved in the issue of asthma as a public health and
environmental concern. The Centers for Disease Control are the nation’s health protection
agency that is responsible for detection and response to health threats, and this agency plays a
big role in the issue of asthma through computer and lab analysis of data, tracking disease, and
building strong public health leaders at the national, state and local levels (CDC, 2014). Other
federal agencies involved in asthma include the EPA, the National Institutes of Health (including
the National Heart, Lung and Blood Institute and National Institute of Allergy and Infectious
Diseases, plus other agencies that are part of the NIH). The CDC also collaborates with the
Centers for Medicare and Medicaid Services, the Health Resources and Services Administration
and the Department of Housing and Urban Development.
Federal agencies began to respond to the control of asthma as its prevalence increased during the
1980s and 1990s. As a result, the following measures were taken:
 1991 — The National Asthma Education and Prevention Program of the National
Institutes of Health’s National Heart, Lung, and Blood Institute issued guidelines for
diagnosis and management of asthma. The guidelines included practical advice for people
with asthma, such as management strategies for prevention and reversal of airway
inflammation and asthma attacks, standard methods for doctors to gauge severity of
disease and monitoring of treatment, and measures to avoid or eliminate environmental
factors. These guidelines were updated in 1997 and 2007 in response to new research
findings.

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 1998 — The Centers for Disease Control, along with other scientists from government
and other institutions, recognized the need for monitoring to better identify and track
asthma cases.
 1999 — The CDC launched the National Asthma Control Program. It was designed to
achieve the following goals: collecting statistics on asthma at the national and state
levels, interventions to help those with asthma, in co-operation with state and city health
officials and nongovernmental organizations, and building partnerships with other
federal, state, and local agencies and nonprofit organizations to reduce the burden of
asthma (CDC, 2010).
The CDC also partners with state health departments, cities and other local groups, like schools
and nonprofit organizations, to ensure greater success with asthma control. CDC grants support
programs in 33 states (including Ohio), Washington D.C. and Puerto Rico. This improves the
national public health infrastructure for dealing with asthma by boosting surveillance programs,
implementing interventions, and fostering partnerships. In 2001, the CDC started an inner-city
program as part of the Controlling Asthma in American Cities Project, to develop comprehensive
community asthma control plans in Chicago, Minneapolis/St. Paul, New York City, Oakland,
Philadelphia, Richmond and St. Louis (CDC, 2010). This program’s target was to reduce asthma
in children through various efforts, such as programs for daycare centers, schools and parents.
Although the funding for the Cities Project ended in June 2008, data collection, evaluation and
outcome studies are still going on. Figure 3 shows the states and cities that were funded by the
CDC as part of its National Asthma Control Program.
Figure 3: CDC National Asthma Control Program Funding Nationwide
Source: CDC National Asthma Control Program, “America Breathing Easier” (access at
http://www.cdc.gov/asthma/pdfs/breathing_easier_brochure.pdf)
At local levels of government in Ohio, there are additional programs that address the public
health concern of asthma. The Ohio Department of Health developed the Ohio School Asthma
Initiative in partnership with the Ohio Asthma Coalition and partners from Ohio’s major
professional school associations. This project is based on the CDC publication “Strategies for
Addressing Asthma within a Coordinated School Health Program in 2006” (ODH, 2014). The

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Cuyahoga County Board of Health offers Healthy Homes Programs and education on air quality
and asthma, including a collaborated effort with the Healthy Homes Advisory Council of Greater
Cleveland to promote collaborations with community partners to address health concerns in
indoor environments (Cuyahoga County Board of Health, 2014).
On the global front, other countries also recognize the significance of asthma as a public health
issue. It is estimated that 300 million people worldwide suffer from asthma, with 250,000 annual
deaths occurring due to this disease. In addition, the number of people afflicted with asthma will
rise by more than 100 million by 2025 (American Academy of Allergy, Asthma & Immunology,
2014). The Public Health Agency of Canada collaborated with the National Lung Health
Framework to develop an action plan aimed at improving lung health for its citizens (Public
Health Agency of Canada, 2014). The World Health Organization also recognizes the public
health significance of asthma and works to coordinate international efforts against the disease.
The Global Alliance against Chronic Respiratory Diseases contributes to WHO’s efforts to
reduce the burden of asthma (WHO, 2014). Yet another world-wide organization, the Global
Initiative for Asthma works alongside health care professionals and public health officials to
reduce asthma prevalence, morbidity and mortality (Global Initiative for Asthma, 2014).
Groups and organizations outside government active on asthma
 American Lung Association - developed Action on Asthma, a manual that advocates that
there be state and local policies related to asthma (Lara et al., 2001). The American Lung
Association is the oldest voluntary health organization in the United States (WebMD,
2014).
 American Academy of Allergy, Asthma & Immunology - one of the nation’s largest
professional medical specialty organizations, which releases many asthma studies each
month (WebMD, 2014).
 Asthma and Allergy Foundation of America - works in the development and
implementation of public policies to improve the quality of life for those suffering from
asthma and allergies (WebMD, 2014).
 National Heart, Lung, and Blood Institute - performs research, clinical trials and studies
on diseases associated with heart, blood vessel, lung and blood diseases and sleep
disorders (WebMD, 2014).
 National Institute of Allergy and Infectious Diseases - researches allergic asthma and
infections and funded the National Inner City Asthma Study, which determined that
controlling indoor allergens helps control asthma in children (WebMD, 2014).
 National Jewish Medical and Research Center - a global leader in lung, allergic and
immune diseases and provides information and research on Chronic Obstructive
Pulmonary Disease, allergy, asthma, sleep and tuberculosis (WebMD, 2014).
 Allergy & Asthma Network Mothers of Asthmatics - a patient advocacy organization
founded by a mother with asthmatic children; members are families working to overcome
allergies and asthma (WebMD, 2014).
 Robert Wood Johnson Foundation - an active participant in various private research
efforts that implemented its own Pediatric Asthma Initiative in 1999, with the purpose of
addressing gaps in national childhood asthma care through improved treatment of asthma
and further research for disease management (Lara et al., 2001).

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