Christine L.M. Joseph

Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren

OBJECTIVE The extent to which urban children endure the symptoms and consequences of asthma without a physician diagnosis has not been well studied. Our objective was to obtain an estimate of the prevalence of possible undiagnosed asthma in a population of urban schoolchildren. DESIGN AND METHODS A population-based cross-sectional study was conducted in urban schoolchildren, grades 3 to 5. Undiagnosed asthma was defined as caretaker report of symptoms and/or bronchial hyperresponsiveness, defined as a 15% or greater drop in baseline forced expiratory volume in 1 second, after exercise challenge. RESULTS A total of 230 children (61% of those eligible) participated in the study. Forty children (17.4%; 95% Confidence interval (CI) = 12.5% to 22.3%) had reports of a physician diagnosis of asthma. Of these, 33 (14.3%; (95% CI = 9.8% to 18.9%) reported wheezing in the past 12 months. Among the remaining 189 eligible children, 11 (5.8%; 95% CI = 2.5% to 9.2%) met study criteria for undiagnosed asthma based on bronchial hyperresponsiveness (BHR). Another 16 (8.5%; 95% CI = 4.5% to 12.4%) met study criteria for undiagnosed asthma through modified American Thoracic Society symptom criteria. Overall, 27 children (27/189; 14.3%) fulfilled criteria for undiagnosed asthma. Children identified as having undiagnosed asthma were compared with children who had no BHR and no symptoms and who did not report a physician diagnosis of asthma (children without asthma). Children with BHR were more likely to have a report of allergies and eczema than children without asthma, odds ratios (OR) = 8.5 (95% CI = 2.4 to 30.7) and 6.4 (95% CI = 1.1 to 38.1), respectively. Children meeting symptom criteria were more likely to have a report of allergies, OR = 6.2 (95% CI = 2.0 to 19.1), and bronchitis, OR = 6.7 (95% CI = 2.0 to 22.4), and were also more likely to report sleep disruption, OR = 7.1 (95% CI = 2.3 to 21.8) and missed physical education classes, OR = 15.0 (95% CI = 4.8 to 46.7), compared with children without asthma. CONCLUSIONS We estimated a prevalence of 14.3% for possible undiagnosed asthma among urban schoolchildren, grades 3 to 5, through caretaker report of symptoms or BHR postexercise challenge. Children with undiagnosed asthma reported more atopic disease than children without asthma. In addition, children meeting symptom criteria for asthma reported more bronchitis, sleep disruption, and missed physical education classes than did those without asthma. These results suggest that rates of undiagnosed asthma may be high in this predominantly black school-age population.

Design and Methods of the National Cooperative Inner-City Asthma Study

The National Cooperative Inner‐City Asthma Study (NCICAS) was established to identify and then intervene on those factors which are related to asthma morbidity among children in the inner‐city. This paper describes the design and methods of the broad‐based initial Phase I epidemiologic investigation. Eight research centers enrolled 1,528 children, 4 to 9 years of age, from English‐ or Spanish‐speaking families, all of whom resided in major metropolitan inner‐city areas. The protocol included an eligibility assessment and an extensive baseline visit, during which symptom data, such as wheezing, lost sleep, changes in activities of daily living, inpatient admissions, and emergency department and clinic visits were collected. A comprehensive medical history for each child was taken and adherence to the medical regimen was assessed. Access, as well as barriers, to the medical system were addressed by a series of questions including the location, availability, and consistency of treatment for asthma attacks, follow‐up care, and primary care. The psychological health of the caretaker and of the child was also measured. Asthma knowledge of the child and caretaker was determined. Sensitization to allergens was assessed by skin‐prick allergen testing and exposure to cigarette smoke and the home environment were assessed by questionnaire. For more than a third of the families, in‐home visits were conducted with dust sample allergen collection and documentation of the home environment, such as the presence of pets and evidence of smoking, mildew, and roaches. Urine specimens were collected to measure passive smoke exposure by cotinine assays, blood samples were drawn for banking, and children age 6 to 9 years were given spirometric lung function assessment. At 3, 6 and 9 months following the baseline assessment, telephone interviews were conducted to ask about the childs symptoms, unscheduled emergency department or clinic visits, and hospitalizations. At this time, peak flow measurements with 2‐week diary symptom records were collected. Pediatr. Pulmonol. 1997;24:237–252.

Issues in identifying asthma and estimating prevalence in an urban school population

UNLABELLED This article first presents salient issues related to identifying children in urban schools who might benefit from asthma services. It discusses a brief questionnaire for identifying cases and problems in estimating asthma prevalence. Subsequently, results of case detection in 14 urban schools are presented and discussed in light of these issues. The questionnaire was employed with parents of 4,653 African-American children in Detroit. Results suggest that determining number, type, and frequency of symptoms may be necessary to ascertain prevalence of asthma. Using only number and type produced a rate of asthma of 25%. Adding frequency provided a more conservative estimate of 19%. About 9% of children exhibiting symptoms of asthma had no physician diagnosis. Only 25% with symptoms reflecting mild persistent, 35% with moderate persistent, and 26% with severe persistent disease had prescriptions for anti-inflammatory medicine. Further, 23% of children with asthma-like symptoms had no prescription for asthma medicine of any type. CONCLUSIONS (1) low-cost procedures can be used in schools to identify children with suspected undiagnosed and undertreated asthma; (2) prevalence estimates for asthma in the group of urban school children studied are among the highest in the United States; and (3) asthma is undertreated in this sample.

Successful Techniques for Retention of Study Participants in an Inner-City Population

The purpose of this work was to describe methods of retaining participants in studies of inner-city populations, including the timing and intensity of contacts; and to describe the characteristics of participants who did not complete all follow-up interviews and/or return all peak flow diaries in the National Cooperative Inner-City Asthma Study. A cohort study design was used involving hospital emergency rooms and community clinics in seven major urban areas. Participants included 1337 4- to 9-year-old asthmatic children and their caretakers. Nearly 89% of participants completed 3-, 6-, and 9-month follow-up interviews. The 15% of participants who completed a baseline interview on the weekends were significantly more likely to complete follow-up interviews on a weekend. The percent of follow-up interviews conducted in person increased over time from 5% to 8%. The percent of participants with complete follow-up increased as the number of contact names increased (86% with zero contacts, 91% with two contracts; p = 0.03, test for trend). Participants who required at least four phone calls to complete the 3- and 6-month assessment were significantly more likely to be black, have higher participant stress, and have a smoker in the household (p < 0.05). Multiple logistic regression suggests that higher social support and lower parental stress were both predictors of completed interviews. Within our study sample of inner-city minority participants with asthmatic children, only a small proportion of participants missed any follow-up interviews. Increased caretaker stress, decreased social support, and inability to provide several alternate contacts were all predictive of retention problems. Having a flexible staff, computer tracking, and face-to-face recruitment appear essential to achieving nearly complete follow-up within a population historically difficult to follow.

Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications

BACKGROUND African-American children use the emergency department (ED) for asthma care more than their Caucasian counterparts. OBJECTIVE We sought to compare ED utilization for asthma care by race, adjusting for prescriptions filled for antiinflammatory medications, type of index visit (specialist vs nonspecialist), and demographic variables. METHODS An index asthma visit was identified for a cohort of managed care enrollees aged 4 to 11 years. Information on asthma encounters and drug claims data was evaluated during a prospective observation period of 12 months. RESULTS African-American race was associated with one or more ED visits during the observation period (relative risk [RR] = 1.8, 95% CI = 1.3 to 2.5, p < 0.01). After adjusting for index visit type, prescriptions filled, and selected demographic variables, African-American race remained associated with post-index ED utilization (adjusted RR = 1.6, 95% CI = 1.0 to 2.4, p = 0.05). Additional findings included an inverse relationship between African-American race and antiinflammatory medications among children with nonspecialist index visits (RR = 0.5, 95% CI = 0.3 to 0.9, p = 0.02) and a positive relationship between African-American race and hospitalization after an ED visit for asthma care (RR = 10.2, 95% CI = 1.4 to 74.8, p < 0.01). CONCLUSION African-American children were more likely to use ED asthma care even after adjusting for the type of index visit, prescriptions filled for antiinflammatory medications, and selected demographic variables. Racial differences in ED utilization for asthma care could be caused by a higher prevalence of uncontrolled or undertreated disease among African-American children not receiving specialty care.

Differences in Allergic Sensitization by Self-reported Race and Genetic Ancestry

BACKGROUND Many allergic conditions occur more frequently in African American patients when compared with white patients; however, it is not known whether this represents genetic predisposition or disparate environmental exposures. OBJECTIVE We sought to assess the relationship of self-reported race and genetic ancestry to allergic sensitization. METHODS We included 601 women enrolled in a population-based cohort study whose self-reported race was African American or white. Genetic ancestry was estimated by using markers that differentiate West African and European ancestry. We assessed the relationship between allergic sensitization (defined as > or =1 allergen-specific IgE results) and both self-reported race and genetic ancestry. Regression models adjusted for sociodemographic variables, environmental exposures, and location of residence. RESULTS The average proportion of West African ancestry in African American participants was 0.69, whereas the mean proportion of European ancestry in white participants was 0.79. Self-reported African American race was associated with allergic sensitization when compared with those who reported being white (adjusted odds ratio, 2.19; 95% CI, 1.22-3.93), even after adjusting for other variables. Genetic ancestry was not significantly associated with allergic sensitization after accounting for location of residence (adjusted odds ratio, 2.09 for urban vs suburban residence; 95% CI, 1.32-3.31). CONCLUSION Self-reported race and location of residence appeared to be more important predictors of allergic sensitization when compared with genetic ancestry, suggesting that the disparity in allergic sensitization by race might be primarily a result of environmental factors rather than genetic differences.

Identification of gaps in the diagnosis and treatment of childhood asthma using a community-based participatory research approach

The goal of this investigation was to use a community-based participatory research approach to develop, pilot test, and administer an asthma screening questionnaire to identify children with asthma and asthma symptoms in a community setting. This study was conducted as the recruitment effort for Community Action Against Asthma, a randomized trial of a household intervention to reduce exposure to environmental triggers of asthma and was not designed as a classic prevalence study. An asthma screening questionnaire was mailed and/or hand delivered to parents of 9,627 children, aged 5 to 11 years, in two geographic areas of Detroit, Michigan, with predominantly African American and Hispanic populations. Additional questionnaires were distributed via community networking. Measurements included parent report of their childs frequency of respiratory symptoms, presence of physician diagnosis of asthma, and frequency of doctor-prescribed asthma medication usage. Among the 3,067 completed questionnaires, 1,570 (51.2% of returned surveys, 16.3% of eligible population) were consistent with asthma of any severity and 398 (12.9% of returned surveys, 4.1% of eligible population) met criteria, for moderate-to-severe asthma. Among those meeting criteria for moderate-to-severe asthma, over 30% had not been diagnosed by a physician, over one half were not taking daily asthma medication, and one quarter had not taken any physician-prescribed asthma medication in the past year. Screening surveys conducted within the context of a community-based participatory research partnership can identify large numbers of children with undiagnosed and/or undertreated moderate-to-severe asthma. These children are likely to benefit from interventions to reduce morbidity and improve quality of life.

The Mental Health of Transgender Youth: Advances in Understanding

This review provides an update on the growing body of research related to the mental health of transgender youth that has emerged since the 2011 publication of the Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender people. The databases PubMed and Ovid Medline were searched for studies that were published from January 2011 to March 2016 in English. The following search terms were used: transgender, gender nonconforming, gender minority, gender queer, and gender dysphoria. Age limits included the terms youth, child, children, teenager*, and adolescen*. The combined search produced 654 articles of potential relevance. The resulting abstracts went through a tiered elimination system, and the remaining 15 articles, which presented quantitative data related to the prevalence of transgender youth and their mental health, were included in the present review. In addition to providing new estimates of the number of young people who identify as transgender (.17%-1.3%), studies since 2011 have shown that transgender youth have higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers. Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents. Recent research has demonstrated increased rates of psychiatric morbidity among transgender youth compared to their peers. Future work is needed to understand those youth who identify as gender nonbinary, improve methods to capture and understand diverse gender identities and related health disparities, and delineate the social determinants of such disparities.

Blood Lead Level and Risk of Asthma

Asthma and lead poisoning are prevalent among urban children in the United States. Lead exposure may be associated with excessive production of immunoglobulin E, possibly increasing asthma risk and contributing to racial disparities. The objective of this study was to examine racial differences in the association of blood lead level (BLL) to risk of developing asthma. We established and followed a cohort prospectively to determine asthma onset, using patient encounters and drug claims obtained from hospital databases. Participants were managed care enrollees with BLL measured and documented at 1–3 years of age. We used multiple variable analysis techniques to determine the relationship of BLL to period prevalent and incident asthma. Of the 4,634 children screened for lead from 1995 through 1998, 69.5% were African American, 50.5% were male, and mean age was 1.2 years. Among African Americans, BLL ≥5 and BLL ≥10 μg/dL were not associated with asthma. The association of BLL ≥5 μg/dL with asthma among Caucasians was slightly elevated, but not significant [adjusted hazard ratio (adjHR) = 1.4; 95% confidence interval (CI), 0.7–2.9; p = 0.40]. Despite the small number of Caucasians with high BLL, the adjHR increased to 2.7 (95% CI, 0.9–8.1; p = 0.09) when more stringent criteria for asthma were used. When compared with Caucasians with BLL < 5 μg/dL, African Americans were at a significantly increased risk of asthma regardless of BLL (adjHR = 1.4–3.0). We conclude that an effect of BLL on risk of asthma for African Americans was not observed. These results demonstrate the need for further exploration of the complex interrelationships between race, asthma phenotype, genetic susceptibilities, and socioenvironmental exposures, including lead.

Racial Disparities in Allergic Outcomes in African Americans Emerge as Early as Age 2 Years

Racial disparities in allergic disease outcomes have been reported with African Americans suffering disproportionately compared to White individuals.