Asthma in Schools Joe K. Gerald, MD, PhD Associate Professor Public Health Policy and Management Associate Scientist Asthma & Airway Disease Research Center

Asthma in Schools 10% of all school-age children have asthma Leading cause of hospitalization Leading cause of health-related school absences

What Is Asthma? A chronic condition that: causes cough, wheeze, and shortness of breath may trigger sudden episodes of respiratory distress is potentially life-threatening if not quickly treated cannot be cured, but can be controlled What is Asthma? (4:03)

Is There a Cure? No, but treatment can reduce: Impairment by minimizing symptoms, reducing use of albuterol, and allowing normal activities Risk by preventing asthma attacks and the need for ED and/or hospital care.

How Is Asthma Treated? Individualized asthma action plan based on severity (Step-Care) Quick-relief medicine (albuterol) as needed for sudden attacks Controller medicine (ICS) daily to reduce inflammation

Impact of Poor Asthma Control Academic function sleep loss, fatigue, poor memory recall, loss of concentration, behavioral problems School engagement inability to fully participate in school activities missed class time absenteeism

What Can Schools Do? Identify and monitor Provide asthma education Reduce environmental exposures Have an asthma action plan manage asthma attacks supervise controller use Becoming an Asthma Friendly Classroom (1:49) NHLBI Report: Managing Asthma a Guide for Schools

Identify Children with Asthma School-wide screening is not recommended few children are undiagnosed undiagnosed have relatively mild disease Schools should ask parents to report a diagnosis and monitor those students for potential problems Percent of parents reporting >1 asthma-related ED visit or hospitalization in the past 12 months *LB Gerald et al (2007). Proceedings of the American Thoracic Society

Provide Asthma Education The American Lung Association (ALA) offers several standardized educational programs Children with asthma (Open Airways for Schools) Teachers and staff (Asthma Basics) School nurses and health assistants (Asthma Basics + Asthma Medicines in Schools) Open Airways Asthma Awareness Asthma 101 Donna Bryson Kelly Szymanski - Phoenix Open Airways for Schools (1:02) ALA Asthma-Friendly Schools Initiative

Provide Asthma Education Education is necessary but not sufficient! Systematic review of 25 trials indicated asthma education programs improve: knowledge, self-efficacy, and self-management behaviors impact on QoL, health care use, and absences not confirmed Open Airways Asthma Awareness *Coffman et al. (2009). Pediatrics

Reduce Environmental Exposures Indoor Air Quality (IAQ) an important aspect of asthma care US Environmental Protection Agency “Tools for Schools” program control animal and cockroach dander clean mold and control moisture reduce dust mite exposure diesel exhaust from buses and cars Poor IAQ is associated with illness, absenteeism, and decreased academic performance and can trigger asthma episodes Children and adults can experience nausea, dizziness, headaches, sleepiness, fatigue, upper respiratory infections, and irritated eyes, nose, and throat. Priorities include the heating, ventilation, and air conditioning systems; moisture and mold; pest management; cleaning and maintenance; materials selection; and source control Extreme classroom makeover

Have an Asthma Action Plan

Access to Quick Relief Medication Support students who carry and administer their own medications Every child should have ready access to quick relief medication during all school and school-sponsored activities transportation to and from school and school events

Access to Quick Relief Medication In many settings, <25% of children have a personal inhaler at school inhalers may be empty, expired, or lost obtaining documentation and inhaler from parents is difficult obtaining asthma action plans from providers is difficult obtaining a 2nd inhaler for school can be costly *JK Gerald et al. (2012). Pediatric Allergy, Asthma, and Immunology *LB Gerald et al. (2016). Annals of the American Thoracic Society.

Create Policies for Stock Inhalers Currently, 9 states have stock albuterol laws single inhaler shared among many students Potential benefits Fewer 911 calls and EMS transports Fewer children sent home, more return to class Arizona legislation signed into law in 2017!

Stock Albuterol in SUSD Relieved school nurse stress Provided students with immediate relief of symptoms and anxiety Demonstrated to parents the benefit of having quick-relief inhaler at school, encouraged some to seek diagnosis Easier to carry 1 stock inhaler and a few disposable holding chambers during fire drills Example of a Stock Inhaler with Disposable Holding Chamber (LiteAire®) *LB Gerald et al. (2016). Annals of the American Thoracic Society.

Pre- and Post-Intervention Data   Pre-Intervention 2012-2013 Post-Intervention 2013-2014 Enrollment (September 1) 17,313 16,784 Students with asthma 8.6% 8.9% Students with personal asthma inhaler 29% 26% Number of stock albuterol administrations 222 Number of 911 calls (per 100 students with asthma) 36 (2.43 per 100) 29 (1.95 per 100) Number of EMS transports 18 (1.21 per 100) 11 (0.74 per 100) Gerald LB (2016) Annals of the American Thoracic Society

HB2208 On March 27th, 2017 Gov. Ducey signed HB2208 “Stock Inhalers for Schools” into law allows schools to purchase, store and administer albuterol indemnifies personnel for their good faith use Albuterol can be safely given by trained personnel to any student who experiences respiratory distress while at school or school sanctioned event.

County-Wide Implementation ALL Pima County schools can participate in the 2017 – 2017 school year albuterol inhaler and supply of disposable valved holding chambers will be made available at no cost!!

Participation Benefits Metered dose inhaler (albuterol) and supply of valved holding chambers (LiteAire®) standing medical orders for administration protocols to recognize and manage respiratory distress An on-line training curriculum for school personnel Administration forms that comply with state regulations and policies regarding documentation of use

Registration http://lungresearch.arizona.edu/stockinhaler Complete the registration form and email it to stockinhaler@email.arizona.edu Registration form asks for some basic data including last year’s 911 calls and EMS transports from your school this data is very important for program evaluation and sustainable funding

School kits and the on-line training program will be available July 1, 2017

Once-Daily ICS in Schools: The SAMS Study Two-year, cluster-randomized trial in 20 Tucson elementary schools Implementation study conducted in collaboration American Lung Association of Southern Arizona Tucson Unified School District

Access to Health Care, Asthma Treatment, Asthma Control Immediate % Health Insurance Public Private None 69 18 8 Medical Home Specialist Primary Care Clinic 6 70 5 15 Taking ICS 36 Not Well-Controlled 74 SAMS Prescribed ICS 78 The average SAMS participant was An 8 year old Hispanic male who Was eligible for the NSLP.

Schools Supervision Was Successful Process adherence: percent of days in which student was present and was given ICS. Calendar adherence: percent of calendar days in which student was given ICS at school. Mean ICS Adherence Rates for Children Prescribed ICS during Years 1 or 2. Year 1 (mean,%) Year 2 Process Adherence 98 85 -school absences 89 78 Calendar Adherence 53 47

Adherence Did Not Predict Control Calendar adherence during the preceding 28 days all students receiving ICS data from Years 1 and 2 No relationship between adherence and asthma control ACQ score and prior 28-day calendar adherence among participants with ≥1 ACQ from Years 1 or 2. Curve shows least-squares means from ACQ model averaged over-time with pointwise CI95%.

Study Conclusions Increased ICS exposure did not improve control Enrolled an at-risk and high need population 75% not well-controlled 33% controller medication Implementation was successful doubled ICS use schools consistently delivered ICS Increased ICS exposure did not improve control threshold of effectiveness may be >75% Future recommendations more potent treatment combine with absence intervention

Questions?