Transcript Environmental Management of Pediatric Asthma

Environmental Management of
Pediatric Asthma
West Virginia Department of Education
KingStrong Conference
June 18, 2014
Abby Nerlinger MD
Mid-Atlantic Center for Children’s Health & the Environment
Pediatric Hospital Medicine Fellow
Children’s National Health System
Dr. Nerlinger has NO conflicts of interest to declare
This material was developed by the Mid-Atlantic Center for
Children’s health & the Environment and funded under the
cooperative agreement award number 1U61TS000118-05
from the Agency for Toxic Substances and Disease Registry
(ATSDR).
Acknowledgement: The U.S. Environmental Protection
Agency (EPA) supports the PEHSU by providing funds to
ATSDR under Inter-Agency Agreement number DW-7592301301-0. Neither EPA nor ATSDR endorse the purchase
of any commercial products or services mentioned in
PEHSU publications.
Objectives
Upon completion of this activity, the participant should
be able to:
• Identify 5 environmental triggers of pediatric
asthma
• Identify practical and efficient measures to
decrease environmental asthma triggers in the
home and school
• Provide resources for patients and families with
further questions about children’s environmental
health issues
Asthma Pathology
Chronic, reversible
disease of mediumsized airways
Terminology:
• Airway
inflammation
• Bronchospasm
• bronchiole hyperreactivity
• Reactive airway
disease
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/
Irreversible If Left Untreated
Normal
Asthmatic
Environmental Allergens, Sensitization, and Asthma
Allergen enters
airway
Allergen enters
airway
6
Binds immune
cells in airway
epithelium
Recognized by
allergen-specific
IgE on mast cell
B cells release
allergenspecific IgE
Mast cell
releases
inflammatory
mediators like
histamine and
leukotriene
Inflammation of
bronchioles
including:
- Mucous
production
- Airway edema
- Smooth muscle
contraction
Conceptual Model of Asthma
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National Childhood Asthma Epidemiology
• Most common disease of childhood
• Number one cause of school absenteeism
• 14 million missed school days per year
• Millions of hours of lost work per year for parents
• 10% prevalence of asthma among children in 2008
• Some communities up to 25% of children
• Higher prevalence among families with income below federal
poverty level
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•
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Nicholas et al. 2005. Am J Public Health. 95:245–249
Akinbami L et al. Trends in Asthma Prevalence, Health
Care Use, and Mortality in the US, 2001-2010.
http://www.cdc.gov/nchs/data/databriefs/db94.pdf
National Childhood Asthma Cost
• 7.1 million children <18y living with asthma in the
US in 2009*
• 3.4 million ambulatory visits (2% of total)
• 640,000 ED visits***
• 157,000 hospital admissions***
• Annual direct and indirect cost associated with
asthma: $56 billion****
*National Health Interview Survey
**National Ambulatory Medical Care Survey
***National Hospital Medical Care Survey
****CDC. May 2011. Asthma in the US Vital Signs.
http://www.cdc.gov/vitalsigns/asthma
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Asthma prevalence among children 0 to 17
years of age in the United States, in 1980–2007
Akinbami L J et al. Pediatrics 2009;123:S131-S145
©2009 by American Academy of Pediatrics
Childhood Asthma in West Virginia
Factor
Measure
Disease burden
• Greater than 31,000 children with asthma
• Current prevalence (7.8%) less than national level (10%)
• Lifetime prevalence of 10.6% under age 18
Control
Greater than half of children with asthma had at least one
exacerbation in past 12 months
Risk for hospitalization
Children less than age 15 is age group with greatest risk of
hospitalization due to asthma
Socioeconomic factors
Individuals without high school diploma or household income
less than $25,000 are more likely to suffer from asthma
Cost
Cost of hospitalizations due to asthma increased from $10.3
million in 1996 to $23.2 million in 2005
Quality of Life
Missed days of school, play, and work
A Strategic Plan for Addressing Asthma in West Virginia 2010-2014. West Virginia Asthma Education and
Prevention Program, West Virginia Department of Health and Human Resources.
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Asthma in West Virginia
Goals of Asthma Care in West Virginia
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Asthma Assessment and Management
• National Heart, Lung, and Blood
Institute, National Asthma Education
and Prevention Program
• Expert Panel Report 3
• Guidelines for the Diagnosis &
Management of Asthma
• http://www.nhlbi.nih.gov/gui
delines/asthma/asthgdln.htm
• Guidelines Implementation Panel
Report
• http://www.nhlbi.nih.gov/gui
delines/asthma/gip_rpt.pdf
Guidelines Implementation Panel Report
6 Priority Messages:
•
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•
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•
•
Use inhaled corticosteroids
Use a written asthma action plan
Assess asthma severity
Assess and monitor asthma control
Schedule periodic asthma visits
Control environmental exposures
Principles of Management
• Focus on concepts of “severity”: intermittent vs persistent
• Domains of impairment and risk
• Impairment (current)
• Frequency/Intensity
• Functional limitations
• Risk (future)
• Asthma exacerbations
• Pulmonary function assessment
• Determine control: well controlled, not well controlled, very poorly
controlled
• Six treatment steps (step-up/step-down)
• Frequent follow up visits with goal of minimum medications as possible
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First Line Controller: Inhaled Corticosteroid
• ICS are the most potent and consistently effective
long term control medication
• Compliance and daily use imperative for control
• No matter how compliant with meds, still need to
address environmental exposures
• Control of triggers will help minimize use of controller
medications
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The Joint Commission Core Measures
Measures for children’s asthma care:
1. Use of relievers for inpatient asthma
2. Use of systemic corticosteroids for inpatient asthma
3. Home management plan of care given to
patient/caregiver
http://www.jointcommission.org/core_measure_sets.aspx
West Virginia Child
Asthma Plan (0-5 years)
• All medications written in one place
• Based on peak flow monitoring
• Find out predicted peak flow based
on height
• Green Zone: 80% of predicted or
more
• Yellow Zone: 50-80% of predicted
• Red Zone: 50% of predicted or less
Control of Environmental Measures
• Patients who have asthma at any level of severity
should be asked about allergen and irritant
exposure and counseled appropriately
• Children with indoor allergen sensitization have
worse outcomes
Children Are Not Little Adults
• Lungs not completely
formed at birth
• Continued development
until adolescence
• The bronchial tree
• The alveoli (air sacs)
• More lung surface area per
unit body weight
• Different respiratory pattern
• Different activity pattern
• Have a longer “shelf life”
Taking a Pediatric
Environmental Exposure
History
• National Environmental
Education Foundation
• Environmental History Form
for Pediatric Asthma Patients
• Applies to all childhood
environments
• Administered by health care
provider
• Available in English and
Spanish
www.neefusa.org/health/asthma/asthmahistoryform
The Role of Allergy Testing
• Focus on low-cost interventions that
target allergens identified in patient’s
environment
• Consider allergy referral to define
clinically significant allergens
• Allergen specific IgE through skin
and serum testing
• Test results interpreted in context
of environmental history
• More costly interventions performed
after allergy testing completed
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WVA Goals of Environmental Control
• West Virginia Asthma Education and Prevention
Program Strategic Plan
• Disease surveillance, coalition building,
strategic plan, address health disparities
• Strategic Plan 2010-2014
• Decrease environmental smoke exposure in
asthmatic children from 19.3% to 10%
• Decrease exposure to home wood burning in
asthmatic children from 26% to 15%
• Home visiting programs for family education
Importance of Protecting Children from Indoor
Air Allergens
• Home and school
environment
• Children spend about
90% of their time
indoors
• School age children
spend 30-50 hours a
week in and around
school buildings
Source:
http://www.cdc.gov/nceh/publications/books/
housing/cha05.htm
Allergens in the Indoor Air
Indoor air pollutants that can
trigger asthma exacerbations:
Other triggers:
Causal Relationship:*
• Cat
• Cockroach
• Environmental tobacco
smoke (preschooler)
• House dust mite
• Animals: pets, rodents
• Chemicals and
pollutants in the air
• cleaning agents
• perfume, cosmetics
• Pesticides
Association:*
• Dog
• Molds
• Rhinovirus
• NO2/NOx
• Clearing the Air. Committee on the Assessment of Asthma and Indoor
Air; Division of Health. Promotion and Disease Prevention; Institute of
Medicine, 2000.
• *Roberts JR. Environmental Management of Pediatric Asthma:
Guidelines for Health Care Providers Training PowerPoint. National
Environmental Education Foundation.
Indoor Air Quality
• No governmental agency regulates
indoor air pollutants with the exception
of laws pertaining to smoking in public
places
• EPA recommendations for voluntary
programs
• Report by the U.S. Government
Accounting Office, the Condition of
America's Schools
• over half schools surveyed reported at
least one environmental problem which
affects indoor air quality
Home Indoor Air Pollution
Sources:
• Particulates
• Environmental
tobacco smoke
• Wood burning
fireplace/stove
• VOCs
• Chemicals/cleaners
• NO2 secondary to
combustion
• gas heat and
appliances
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Remediation:
• Install exhaust fans close to source
• HEPA filters for particulates but source
removal is ideal
• Ventilate room if fuel burning appliance used
• Tight-fitting wood stove doors
• Venting of fireplaces and gas stoves
• Consider replacement of gas stove with
electric
• Never use gas-cooking appliances as heat
sources
• Avoid use of products that act as irritants
Roberts JR. Environmental Management of Pediatric
Asthma: Guidelines for Health Care Providers Training
PowerPoint. National Environmental Education
Foundation.
**Matsui et al. AAP Clinical Report: Environmental Control
Practices and Asthma Management. Publication Pending.
Schools and Indoor Air Quality
• Outdoor pollutants infiltrating building
• School bus idling
• Dampness
• Mold: potted plants, gym lockers, gym showers
• VOCs off-gassing
• Building materials, carpet, cleaning materials
• Toxic debris from construction or demolition inside occupied
schools
• Dust and chalk
www.impact-dc.org
Indoor Air Quality and Asthma Symptoms at School
Clues to indoor air problems
• Symptoms widespread within class or school
• Symptoms diminish or disappear after leaving
school
• Sudden onset after a change in school; i.e.,
painting, pesticide application
• Those with allergies and asthma have reactions
indoors but not outdoors
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Schools and Air Pollution Resources
• School bus Idling
• EPA: Clean School Bus Idle Reduction Campaign
• West Virginia Idling Policy*
• State Board of Education Rule
• prohibits school bus idling except if outdoor temp ≥40F,
necessary to defrost windows, or student safety at risk
• School driveways appropriately placed to avoid
accumulation of carbon monoxide in idling school buses
• Toxic fumes from paints, glues and new carpets
• Toolkit for Safe Chemical Management
*Environmental Law Institute: Vehicle Idling at Schools – Overview of State Laws. May 2013.
http://www.eli.org/buildings/topics-school-environmental-health
EPA Environmental School Resources
• www.epa.gov/schools/programs.
html
• Tools for Schools
• Some state laws direct
school districts to
implement
• HealthySEAT
• School Environments
Assessment Tool
• Software to help school
districts evaluate school
facilities for environmental,
safety, and health issues
Green Cleaning
• Industrial strength cleaning products and room deodorizers
can add to indoor air pollution
• Why is non-toxic cleaning important?
• Most chemicals, including those found in household
cleaning products, have no human health toxicity data
• Cleaning for Healthy Schools Toolkit
• http://www.cleaningforhealthyschools.org/
• Identification of green cleaning products
• Educational materials
http://www.epa.gov/schools/gr-clean.pdf
Cleaning Product Selection
Non-toxic alternatives:
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Baking soda
Liquid soap
Vinegar
Choosing safer cleaning products:
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Ingredients listed on the label
Non-aerosol
No overwhelming chemical odor
Fragrance-free
Dye-free
Source: American Academy of Pediatrics Council on Environmental Health. Child Care Settings. In: Etzel, PA, ed.
Pediatrics Environmental Health 3rd Edition Elk Grove Village, IL: American Academy of Pediatrics; 2012:125
Pest Management in Schools
What is a pest?
• Living organisms that occur
where they are not wanted
or cause damage to crops or
humans or other animals
• Insects
• Mice and other animals,
• Unwanted plants
(weeds)
• Fungi (mold), bacteria,
viruses
• Balancing risk and benefit
• Allergen control versus
• Minimizing exposure to
pesticide
• Children are routinely
exposed to pesticides in
their home, diet and
schools
Solution: Integrated Pest Management
Pest control strategy that involves “least toxic methods first.”
Principles:
• Target pesticides to areas not contacted by or accessible
to the students, faculty or staff
• Goal is prevention
• Apply pesticides only as needed
• Select the least hazardous pesticides
EPA IPM in schools: www.epa.gov/pesticides/ipm
Other IPM Strategies
• Address sources: water, temperature, food
• Mousetraps or gels
• Sealing cracks and holes
• Generalized cleaning
• Keeping trash covered
• Reducing moisture
• Education
• Food storage
http://schoolipm.ifas.ufl.edu/doc/whatipm.ppt
Cockroach Allergen
Favorable environment: warmth, moisture, food
Questions for Family:
• How many cockroaches do you see every day?
• Do you see cockroach droppings?
Environmental Management of Pediatric Asthma: Guidelines for Health Care
Providers. National Environmental Education Foundation.
Asthma Morbidity Associated with Cockroach Antigen
0.4
-/- no allergy/low exposure
-/+ no allergy/high exposure
+/- allergy/low exposure
+/+ allergy/high exposure
0.35
0.3
0.25
ER visits/yr
Hsptl/yr
0.2
0.15
0.1
0.05
0
-/-
-/+
+/-
+/+
Rosenstreich, et al. NEJM. 336(19):1356-63, 1997 May 8
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Cockroach Environmental Control
Reduction in cockroach allergen correlates with asthma symptom
improvement*
Environmental remediation strategies**
• Integrated Pest Management
• Baits, traps, and gels before sprays
• Limit access to food
• Keep food and trash in closed containers
• Clean up all spilled food
• No food in bedrooms
• Clean counters daily
• Eliminate water - leaky plumbing, leaky roof
• Boric acid
*Morgan et al. Results of a home-based environmental intervention among urban
children with asthma. N Engl J Med. 2004;351(11):1068-80.
**Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for
Health Care Providers Training PowerPoint. National Environmental Education
Foundation.
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DO NOT
•Spray liquids in
the house
•Use industrial
strength pesticide
sprays that require
dilution
Dust Mite Allergen
• Favorable environment: warmth,
moisture, food
• Live in mattresses, upholstered
furniture and carpet
• Mites and allergens most common in
humid environments
• Difficult to see so take climate into
account or home dust testing
• Children who are sensitized to dust
mites have more severe asthma
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Evidence for Dust Mite Control
• 1992 randomized controlled trial comparing dust mite
interventions for mattresses and carpets*
• Children using bedding casing and carpet treatment
showed decreased dust mite allergen on mattresses and
decreased airway reactivity
• 2003 Danish study using mattress covers**
• Decreased dust mite allergen in those children using
dust mite covers
• Decreased dose of controller ICS by 9 months
• No effect on airway reactivity
• Overall: allergen removal correlates with clinical improvement
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*Enhert B, et al. Allergy Clin Immunology 1992;90:135-8.
**Halken S, et al. J Allergy Clin Immunol 2003;111.169-176.
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for
Health Care Providers Training PowerPoint. National Environmental
Education Foundation.
Dust Mite Control
• Allergen impermeable pillow and mattress
covers
• Wash bedding weekly
• Wash and dry, or freeze stuffed toys
weekly
• Wash in HOT water (130F) to kill mites
• Damp mop floor surfaces, dust with wet
rag
• Remove carpeting or vacuum carpets with
HEPA vacuum cleaner
• Humidity below 50% - avoid humidifiers
• Results usually seen in one month
• Since dust is larger particle it settles
• Unclear benefit of air filtration
45
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health
Care Providers Training PowerPoint. National Environmental Education
Foundation.
Mold = Fungus = Mildew
• Microorganisms that grow in warm
and damp environments
• Many types of mold often
occurring in the same
environment
• Spore aerosolization
• No guideline for acceptable levels
• Molds irritate mucous membranes
• Produces allergic responses in
children who are sensitive to mold
Institute of Medicine. Damp Indoor Spaces and Health. NAS; 2004.
http://www.epa.gov/iedmold1/mold_remediation.html
http://i2.cdn.turner.com/cnn/dam/assets/111222124333-school-mold-cnnstory-top.jpg
Questions for Families*
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Do you see mold growth in the home?
How large is the area?
Do other locations (school, daycare) have mold growth?
Do you have moisture or leaks in your home?
Do you frequently have condensation on windows?
Have you made attempts to decrease humidity?
*Environmental Management of Pediatric Asthma: Guidelines for Health Care
Providers. National Environmental Education Foundation.
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Mold Control
Prevention of growth:
• Dehumidifier ideally below 50%
• Central air conditioner
• Vent bathrooms and clothes
driers to outside
• Use exhaust fan in bathroom or
other damp areas
• Keep drip pans for fridge, air
conditioner dry
• Fix leaks of faucets and pipes
• Prevent condensation on
windows
No raking, mowing if allergy
Home remediation of mold:
• Discard items too moldy to clean
• Hard surfaces: Clean small areas
with detergent and water
• Dilute chlorine bleach improves
appearance but does not remove
allergen
• Fix sources of water
• If area larger than 3x3 ft:
professional remediation
• Porous materials usually require
replacement
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health
Care Providers Training PowerPoint. National Environmental Education
Foundation.
48
Evidence for Mold Remediation
2006 randomized controlled trial examining mold remediation
and asthma symptoms*
• Mold remediation group:
• Significant decrease in mold levels
• Significant decrease in asthma symptoms days
• Significant decrease in rate of asthma exacerbations
*Kercmar CM, et al. Env Health Persp 2006;114:1574-80.
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health
Care Providers PowerPoint Training. National Environmental Education Foundation.
49
Animal Allergens: Pets and Nonpets
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Cats
Dogs
Rodents
Birds
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Prevalence of Animal Allergens
Cats:
• Smaller particles so remain suspended and easily transferred
• Cat dander and schools
Mice:
Mouse allergen in inner cities
• Found in most inner city homes**
• Allergen concentration higher in cities than suburbs
• Boston: 42% of population tested had mouse allergen
detectable in house*
• Risk factors: black race, visible mice, cockroach allergen
*Phipatanakul W et al. Allergy 2005;60:697-701.
**Matsui et al. AAP Clinical Report: Environmental Control Practices
and Asthma Management. Publication Pending.
51
Pet Allergen Control
• Find a new home for indoor pets
• Keep pet outside
• Pillow/mattress encasings
• HEPA air filter and vacuum
• Keep pet out of bedroom
• 24-30 weeks of interventions prior to
allergen levels normalizing to levels of
non-cat household*
• Bathing cat may only decrease allergen
for 1-2 days**
52
• *Wood RA et al. J Allergy Clin Immunol 1989;83:730-4
• **Ownby D et al. J Allergy Clin Immunol 2006:118:521-2
• Roberts JR. Environmental Management of Pediatric
Asthma: Guidelines for Health Care Providers Training
PowerPoint. National Environmental Education Foundation.
Environmental Tobacco Smoke
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•
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Consists of more than 3800 chemical compounds
Gasses and particulates
Decreasing exposure to ETS over last decade
Children exposed to ETS in utero or infancy are more likely to
develop asthma
• Children with asthma who are exposed to ETS are more likely
to have an asthma attack
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Environmental Tobacco Smoke Interventions
• Ideally smoke-free all environments
• If not: focus on indoor (house, car)
• Support quitting
• Nicotine gum/patch, medications
• HEPA filters will help with particulates but not
gases
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Combined Asthma Trigger Management
• Multitrigger management recommended*
• Variability in evidence-based outcomes for individual allergen
triggers
• Sensitivity and exposure to multiple triggers likely
• Studies: goal to show that
• Intervention decreases allergen level
• Decrease in allergen level associated with decreased
symptoms
*CDC Task Force Findings and Rationale Statement Interventions for Children and Adolescents with Asthma
www.thecommunityguide.org/asthma/rrchildren.html
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers PowerPoint
Training. National Environmental Education Foundation.
55
Evidence In Action: Inner City Asthma Study
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Management of multiple triggers
7 sites including Washington, DC
937 pediatric asthmatics in inner city
Intervention:
• Environmental questionnaire
• Skin testing
• Home allergen sampling
• Environmental control measures
• Mattress and pillow covers
• HEPA air and vacuum filters
• Professional pest control
Results: 1 year follow up
• Increased number symptom
free days
• Decreased allergen levels
• Decreased dust and cockroach
levels associated with
decreased asthma
complications
Morgan WJ et al. New Engl J Med 2004;351:1068-80.
Kattan M et al. J Allergy Clin Immunol 2005;116:1058-63.
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health
Care Providers PowerPoint Training. National Environmental Education Foundation.
56
Population Health and Outdoor Air Pollution
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CO
SOx (SO2)
NOx (NO, NO2)
“criteria” pollutants
Particulates (PM)
Ozone
Lead
Volatile organic compounds (Hydrocarbons)
Air toxics (solvents, pesticides, metals, etc.)
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Sources of Outdoor Air Pollution
• Mobile sources:
cars and trucks
(particulates)
• Coal plans
• Incinerators/open
burning (VOCs)
http://www.airnow.gov/index.cfm?action=aqibasics.ozone
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Particulates
• Mixture of solid and liquid particles
• Natural sources: dust from soil, evaporation of sea
water
• Combustion:
• fly ash from coal
• diesel exhaust
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Traffic-related Air Pollution and Childhood Asthma
• Southern California Children’s Health Study
• Cohort study (n=2,497)
• Examined the effects of traffic-related pollutants near
children’s schools and homes
• Asthma and wheeze were strongly associated with
residential proximity to a major road¹
• Incidence of asthma was positively associated with traffic
pollution among children at school and home²,³
¹McConnell R, et al. (2006) Traffic, Susceptibility, and Childhood Asthma. Environ Health Perspect 114(5)
²Jerrett M, et al. (2008) Traffic-Related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement.
Environ Health Perspect 116(10)
³McConnell R, et al. (2010) Childhood Incident Asthma and Traffic-Related Air Pollution at Home and School. Environ Health Perspect 118(7)
Roberts JR. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers PowerPoint Training. National Environmental
Education Foundation.
60
Asthma and Ozone
• Ozone and ER Visits: Atlanta
• Each increase of 20 ppb ozone associated with 4% increase
in ER visits
• 1996 Summer Olympics – Atlanta
• Increased public transportation
• Decreased traffic
• Peak daily ground level ozone decreased 28%
• 42% reduction in asthma acute care events for children
with Medicaid
Friedman MS, Powell KE, Hutwanger L, et al. JAMA 285:897-905, 2001.
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Mean Levels of Major Pollutants Before, During, and After the 1996
Summer Olympic Games as a Percentage of the National Ambient Air
Quality Standard (NAAQS)
AIRNow – www.airnow.gov
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Air Quality Index
Descriptors
Cautionary Statement
No message
Good
0 – 50
Moderate 51 – 100 Unusually sensitive individuals
Unhealthy for
Sensitive Groups
101 – 150
Unhealthy 151 –
200
Very Unhealthy
201 - 300
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Identifiable groups at risk - different
groups for different pollutants
General public at risk; sensitive groups at
greater risk
General public at greater risk; sensitive
groups at greatest risk
Other Outdoor Allergens
• Spring = trees (birch, oak, maple, cedar)
• Summer = grass
• Fall = weeds (ragweed)
• Pollen can stick to skin, clothing, hair so bath after outside play
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Prevention of Outdoor Air Pollution
• Control of mobile sources
•  emissions through cleaner gasoline and
diesel engines
• alternative fuel vehicles e.g. natural gas,
electric, hybrid
•  motor vehicle use e.g. mass transit,
carpools, biking
• changes in driving habits e.g. slower starts,
trip-stacking, off-hours refueling
Prevention of Outdoor Air Pollution
• Control of fixed sources
•  power plant emissions through cleaner
construction and operation, and use of
cleaner fuels
•  industrial emissions through advanced
production techniques
•  production through reduce/reuse/recycle
initiatives
Other Resources
• CDC educational resources
• Initiating Change: Creating An Asthma Friendly School Video
• http://www.cdc.gov/HealthyYouth/asthma/creatingafs/index.htm
• Head Start Asthma Resource Toolkit
• US Department of Health and Human Services and EPA Sponsored
• Resources for providers and families on managing environmental asthma triggers
• http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/center/physical-health/educationactivities/AsthmaResourceT.htm
• West Virginia Asthma Education and Prevention Program
• West Virginia Asthma Coalition
• Coordinate WVa organizations for improved compliance with NAEPP recommendations
• Asthma-friendly School Award
• TakeACTION educational materials/training
• http://www.wvasthma.org/
• National Environmental Education Foundation Pediatric Asthma Initiative
• webinars, educational materials for families and providers
• Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers
• complement to clinical management of NHLBI Guidelines
• steering committee, peer reviewed, evidence –based environmental management strategies
• www.neefusa.org/health/asthma/index.htm
• IMPACT DC
• Asthma Clinic affiliated with Children’s National Medical Center
• http://www.childrensnational.org/impactdc/
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When Confronted with an Environmental Health Issue
Regarding a Child, Where Does One Turn?
To a Pediatric Environmental Health Specialty Unit
(PEHSU).
What is a PEHSU?
• A resource for pediatricians, public health officials,
school personnel, parents and others to get
questions answered about children’s health and the
environment
• National network of pediatricians and
occupational/environmental health specialists,
pulmonologists, toxicologists
• Provides variety of educational functions
What Kinds of Problems do PEHSUs Deal With?
• Exposure to hazardous waste
sites
• Environmentally related
asthma
• Agricultural pollutants
• Solvents
• Carbon monoxide
• Arsenic
• Mercury
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•
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Lead poisoning
Pesticide exposures
Sick building problems
Water pollution
Air pollution
Job related exposures in
adolescents
• Volatile Organic Compounds
The Pediatric Environmental Health Specialty Unit
(PEHSU) Program is funded by:
&
The Association of Occupational and
Environmental Clinics is responsible for
programmatic and financial management.
PEHSU Regions
THE MID-ATLANTIC CENTER FOR CHILDREN’S
HEALTH & THE ENVIRONMENT (MACCHE)
• Region 3 Pediatric
Environmental Health
Specialty Unit (PEHSU)
• Pennsylvania, Delaware,
Maryland, Virginia, West
Virginia, & the District of
Columbia
• Affiliated with Children’s
National Medical Center
• Washington, DC
MACCHE
Director
• Jerome Paulson, MD, FAAP
Pediatrician/Toxicologist
• Maryann Mazer-Amirshahi, PharmD, MD, MPH
Coordinator
• Veronica Tinney, MPH
Staff
• Abby Nerlinger, MD
Contact Information
Mid-Atlantic Center for Children’s Health and the
Environment
www.childrensnational.org/macche
[email protected]
202-471-4829
1-866-622-2431
@MACCHE_DC
QUESTIONS?