Asthma triggers among children in school environment

Blesson M Abraham
MPH 2010 Batch, CHTC, CMC Vellore
Introduction
Asthma (Greek- breathe hard) can be defined as a condition of altered dynamic state of respiratory passages due to the action of diverse stimuli resulting in airways obstruction of varying degree and duration, and reversible partially or completely, spontaneously or under treatment. Asthma affects people of all ages, but it most often starts during childhood. In India studies showed prevalence of asthma among school children as 29.5 % (Paramesh 2002)and 11.9% (Chhabra 1999) in urban area and 9% (Chakravarthy 2002) in rural area. Asthma is a leading cause of school absenteeism due to a chronic condition, and also accounts for poor academic and co-curricular activities performance. Schools are settings were children spend many hours and may get exposed to both indoor and outdoor asthma triggers. American Academy of Allergy, Asthma, and Immunology (AAAAI) found that 41 percent of the children with asthma who are surveyed recently had as many as three asthma episodes each month at school. So it is important to identify these triggers in the school environment to carry out effective prevention and early management.

Types of asthma triggers in school environment

There are both indoor and outdoor triggers. 1. Indoor triggers Comments Aero- biological Dust mite Dust mites need very Wet mold warm temperatures and Cockroach and other high humidity. pests Mold spores can waft Fungi pollens through the indoor and Dander brought in on outdoor air continually. clothing from animals Viruses include Respiratory at home syncytial virus (RSV), Para Viruses influenza, Corono and Adeno virus. Irritants Environmental tobacco The main sources emit smoke (ETS) irritants like Volatile Vapors from cleaning Organic Compound products, paint include paints, paint Asbestos and strippers, cleaning chemicals supplies, pesticides, Smoke and pollutants building materials and from unvented stoves furnishings and craft Pesticide sprays materials including glues Spray deodorants and and adhesives, and scented cosmetics permanent markers. 2. Outdoor triggers Particle pollution Ozone Vehicle exhaust Miscellaneous triggers Chalk dust Strong emotional states Physical exercise Foods and food additives. Transportation to school is also a critical period of exposure to triggers. Schools favor Propagation of respiratory infection. Bad weather such as thunderstorms, high humidity, or freezing temperatures can also trigger asthma.

Particulate matter in school environment

The six criteria air pollutants are particulate matter, ozone, sulfur dioxide, nitrogen dioxide, carbon monoxide and lead; among which particulate matter is a major risk in the context of school environment. 1. Particulate matter Particulate matter (PM) denotes a mixture of solid particles and liquid droplets found in the air. Examples include dust, dirt, soot, soil, and smoke.

Prevention: Concept of asthma friendly school

The school buildings and grounds are free of tobacco smoke and indoor air quality is well maintained. Policy allows the students to carry and use their own medicines. A written emergency plan for the teachers and staff to take care of a student who has an asthma attack and availability of quick relief medicine. A written asthma action plan from the students doctor to manage and prevent asthma. Availability of a regular/ part- time school nurse in school hours to monitor this issue and to educate the school staff about asthma. Care for susceptible children during sports, physical education and field trips.

Initiatives and guidelines

Graphics shows the size and types particulate matter (PM) in comparison with a human hair. Courtesy: www.epa.gov

How environmental triggers work?

The environmental triggers can act through bronchoconstriction, airway edema and airway remodeling. The basic mechanism can be depicted as below Environment
Allergens Genetic factors Cytokine response profile Pollution Infections Microbes Stress Inflammation Airway hyperresponsiveness Clinical symptoms Airway obstruction

Age

The entry of particles depends on the size as particles sized 10 m or less are considered respirable PM, particles smaller than 5 m reach the bronchial tubes, while particles 2.5 m diameter or smaller are breathed into the deepest portions of the lungs. 2. Precursors of particulate matter in school environment Sulfur dioxide (SO2), nitrogen dioxide (NO2) and volatile organic compounds (VOC) can act as precursors of particulate matter. They can trigger asthma even at low concentration level.

Observations from studies

Studies available in PubMed are appraised. Used assays like dust mite allergens Dermatophagoides pteronyssinus (Der p 1) at threshold level of 2000 ng/g dust. Sensitization threshold levels is found to be exceeded in all studies especially in libraries. 4 cross sectional studies showed result as change in daily asthma response for each 10 g/m3 increase in PM10 ranged from 6.9% to 11.4%

India Rennuka Ray school health committee (1961) advised health care for school children should be covered through primary health centers (PHC). National health policy (1983), and national policy on education (1986) also supported school health programs and health education. The Central Pollution Control Board (CPCB) and National environment policy (2006)

International World Asthma Day on May 3rd is organized by Global Initiative for Asthma (GINA). World health organization (WHO) sets Air quality guidelines Centers for Disease Control and Prevention (CDC) put forward Coordinated School Health Program. National Asthma Education and Prevention Program (NAEPP) in US.

Conclusion
Asthma among children grows to an epidemic proportion. So that maintenance of good indoor air practices is needed to reduce the presence of environmental asthma triggers in school. Establishing an asthma management plan can be taken as a first step to be an asthma friendly school. India needs to focus on a standardized national policy for the same.

Courtesy: http://www.nhlbi.nih.gov/

Individual susceptibility among children

Genetic factors, innate and adaptive immune responses influence both the development and regulation of inflammation. In early life, the prevalence of asthma is higher in boys. At puberty, asthma appears predominantly among girls. Children are more susceptible for exposure to triggers and asthma attack due to their nature of physical activity, short stature and lower breathing zone, immature defence system and smaller airway.

Following graph depicts location of school as a determinant of asthma among children

35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Schools in low traffic Schools in heavy traffic Schools in heavy traffic regions regions with low socio economic status P. Value I, II & III < 0.001. Courtesy: H. Paramesh (2001), www.pinche.hvdgm.nl
11.15% (2565) 19.34% (3722) Indian study shows Prevalence of asthma in school children Age 6-15 years. Number of participants in bracket 31.14% (273)

Key areas of Indoor Air Quality (IAQ)

According to US Environmental protection agency (EPA) Ventilation, building maintenance, waste management and renovation and repairs are the key areas to be checked for IAQ in school. World health organization (WHO) Air quality guidelines (2005) set annual mean level of PM2.5 at 10 g/m3 and PM10 at 20 g/m3.
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Bibliography
Jan A Kuzemko (1980) Asthma among children (2nd Edition)London: Pitman Medical US Environmental protection agency (EPA): http://www.epa.gov/asthma/ Stuart L. Abramson, Allergens in School Settings: Results of Environmental Assessments in 3 City School Systems, J Sch Health. 2006 August ; 76(6): 24649. http://www.ncbi.nlm.nih.gov/pubmed/16918848 Kyle Steenland, Topics in Environmental Epidemiology, 150- 54: Oxford university press WHO, Air quality guidelines - global update 2005: www.who.int

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RESEARCH POSTER PRESENTATION DESIGN 2011

www.PosterPresentations.com

This poster is prepared as an assignment for the environment and occupational health module; presented on 30/04/2011