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

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

3. 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)

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Have an Asthma Action Plan

13. 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

14. 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.

15. 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!

16. 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.

17. Pre- and Post-Intervention Data
Pre-Intervention
Post-Intervention
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

18. 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.

19. 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!!

20. 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

21. Registration http://lungresearch.arizona.edu/stockinhaler
Complete the registration form and it to
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

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

23. 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

24. 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.

25. 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

26. 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%.

27. 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

28. Questions?