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A Preliminary Investigation of Asthma Mortality in Schools

Posted on: Thursday, 6 October 2005, 06:00 CDT

By Greiling, Andrea K; Boss, Leslie P; Wheeler, Lani S

ABSTRACT:

Although asthma deaths in children are rare, most asthma deaths should be preventable. No information has been identified in the professional literature addressing the occurrence of asthma deaths in schools. This investigation identified asthma deaths that occurred in US schools between 1990 and 2003 and the circumstances surrounding those deaths. Data were obtained through newspaper articles in the LexisNexis database and death certificates. Between 1990 and 2003, 38 asthma school deaths were reported. Eighteen (47%) identified deaths occurred among black children and 12 (31%) among white. Twenty-seven (72%) of the deaths occurred among teens. Of the fatal asthma attacks, 16 (42%) occurred while the children were participating in a physically active event. Twelve (31%) children died while waiting for medical assistance. Due to the nature of these data, inferences may be subject to source bias. For the identified asthma deaths, key findings include the following: (1) most deaths occurred in teens and high school students; (2) frequently, the precipitating event was related in time to exercise; and (3) a delayed response or hesitancy of school staff to provide medical assistance may have contributed to some of the deaths. Although few school-related asthma deaths are reported each year, the true number is unknown. Key factors in managing the disease and preventing asthma deaths and exacerbations in schools include identification of students with diagnosed asthma, communication with parents and health care providers, removal of triggers in the immediate school environment, and maximizing access to needed medications. (J Sch Health. 2005;75(8):286-290)

In the United States, in 2003, approximately 5.0 million children aged 5 to 17 years had active asthma, representing one of the most prevalent diseases in school children.1 Of these, 3.1 million children had at least 1 asthma episode,2 equaling at least 353 asthma episodes in this country every hour. During the years 1999 to 2002, an average of 159 children aged less than 15 years died of asthma each year.1

The annual cost of treating asthma in those under 18 years of age in 1994 was estimated to be $3.2 billion.3 Additionally, in 1996, the direct medical expenditure for school-aged children with asthma was $1009.8 million, or $401 per child with asthma, and the total economic impact of asthma for that year alone was $1993.6 million.4 The burden and cost of the disease have resulted in an intense effort to minimize the effects of asthma by improving medical and self-management and by controlling factors known to exacerbate asthma (eg, environmental allergens, irritants, concurrent disease states, and improper utilization of inhaled asthma medications).5,6

Asthma deaths among children are rare.7 Between 1990 and 2001, 2484 children aged 5 to 19 years died from asthma.8 Although asthma mortality rates in childhood are lower than in older age groups,2 a childhood death is always a tragedy and causes need to be understood. Several studies9"13 have identified preventable or avoidable factors associated with near-fatal asthma attacks and asthma mortality in children (including deficiencies in professional and self-management, the presence of psychiatric disorders in the child, significant denial, psychosocial pathology, and delays in seeking care). In about 60% of children who die from asthma, the final episode is sudden in onset (not preceded by milder symptoms) and fatal within 1 hour.14

The impact of asthma in the classroom is significant. Several studies have shown that childhood asthma is associated with an increased risk for school problems, including increased school absence, graduate failure, and learning disabilities,15-17 and that the risk is amplified by increasing severity of the disease.18 While the impact of asthma morbidity in the classroom is documented throughout formal research channels, data on fatal asthma episodes in schools are not. This investigation sought to identify and describe school-associated asthma deaths and the circumstances surrounding those deaths that have occurred in the United States since 1990. Outcomes included demographic variables, time frames, situations at the time of death, and information on the settings where deaths occurred.

METHODS

Case Definition

A school-associated asthma death was defined as the occurrence of a fatal asthma attack or the precipitating event prior to a fetal asthma attack that occurred between January 1990 and December 2003 in a student in one of the following locations: (1) on the school campus of a public or private primary or secondary school, (2) while the student was en route to or from school, or (3) while the student was en route to or attending a schoolsponsored event (eg, field trip or sporting event).

Case Identification and Confirmation

Two case-finding strategies were employed. The first included a systematic search of the LexisNexis database, a resource bank with information on legal research, government periodicals, public records, and national and local news. For the purposes of this effort, LexisNexis was used to search nationwide newspaper reports on asthma deaths that met the case definition. The second strategy solicited voluntary reports from the Centers for Disease Control and Prevention's state asthma contacts, local American Lung Association (ALA) affiliates, National Association of State School Nurse Consultants, Asthma & Allergy Network-Mothers of Asthmatics (AANMA), state child death review committees, and state departments of education. Copies of death certificates were obtained for 37 of 38 identified decedents from state vital records offices. Death certificates were used to confirm the underlying cause of death as asthma, to collect consistent and reliable data, and to identify and confirm study variables not clearly stated in the newspaper reports, such as ethnicity and gender. Confirmation of cause of death for those whom the death certificate could not be obtained was received verbally from the state vital records office.

The precipitating event prior to death was described as active, nonactive, or unknown. Active events included a school-sponsored sporting event, physical education class, recess, field trip, or pep rally. Nonactive events included travel to or from school on a bus, sitting in class, or standing in the hallway. Parameters for school- level characteristics including urbanicity, school type, and school size were extracted from the National Center for Education Statistics' Common Core Data Set.19

RESULTS

Forty-four school-associated asthma deaths were identified and reviewed. Two were eliminated because death certificates did not support cause of death as asthma. Four deaths (3 males, 1 female) occurred at universities, while this study focused only on primary and secondary US schools.

Consequently, 38 school-associated asthma deaths met the case definition. Thirty-seven cases (97%) were identified and described in the LexisNexis database. One (3%) was identified by a state Child Fatality Review team. Thirteen cases were identified by AANMA and 1 case was identified by a local ALA affiliate; however, none of these deaths were new to the search.

Demographics

Of the 38 identified students, 20 (53%) were male and 18 (47%) were female. Seventy-one percent of the deaths occurred among teenagers, with 7 deaths (18%) among those aged 17 years. Almost one half (47%) of the deaths occurred among black children and one third (31%) among white children. Deaths were more likely than expected to occur in small and urban schools (Table 1).

Time Frame

The number of identified deaths per year fluctuated over the 14 years of the review with an increase of deaths over time (Figure 1). The average annual number of reported deaths was 2.7. Seasonal variations were also noted (Figure 2). The school year was divided into three 15-week seasons. Seventeen deaths (45%) occurred in the fall (mid-August through mid-November), 5 (13%) occurred in the winter (mid-November through early March), and 16 (42%) occurred in the spring (early March through mid-June). This distribution parallels the seasonal occurrence of asthma exacerbations.

Location

The 38 deaths occurred in 20 states throughout the country. Six deaths (16%) occurred in Illinois, all in the Chicago metro and surrounding areas. This is consistent with previous findings indicating that asthma deaths in Chicago are among the highest in the United States, with particularly high mortality among low- income communities and minority populations.20 The number of deaths by state varied. California is the most populous state in the nation, while Nebraska is the 38th,21 yet 4 deaths were identified in each of these states. This may be a result of reporting bias or a potential area of concern in Nebraska. Additional information on asthma deaths and specific state statutes may be obtained on request from the first author.

The type, size, and location of the schools in which these deaths occurred were examined. Seventeen deaths (45%) occurred among students in high school. Eight deaths (20%) occurred among middle or junior high school students and 6 (16%) among elementary school s\tudents. Four deaths (11%) occurred at state-funded rehabilitative centers or vocational schools and were categorized as "other." The school setting was not available for 3 cases: 2 of these students were aged 14 and 15 years, probably high school students, and the age of the third student is unknown.

Reported Health Services

Seven (18.5%) of the identified reports included specific mention of a school nurse being involved on the scene, with an equal amount (18.5%) of the cases having some type of reported medical assistance by a health technician, CPR-trained staff, or paramedic. No mention of medical assistance was made in 24 (63%) cases; however, this does not confirm that none was provided at the time of death.

Table 1

Demographic and School Characteristics of School-Associated Asthma Deaths

Figure 1

Number of Asthma Deaths in Schools by Year, 1990-2003

Circumstances of Death

The circumstances surrounding the deaths were categorically identified as participation in an active or nonactive event. Sixteen (42%) circumstances suggest physical activity occurred prior to the fatal asthma episode (Table 2). Nonactive events were categorized as traveling to or from school by bus or being in a hallway or classroom. In 12 (31%) cases, the precipitating event prior to death was not described adequately enough to categorize.

Nearly one third (31 %) of the newspaper articles reported delays in the students receiving emergency asthma medication at the time of the fatal attack. Reasons for the delays included the following: staff were unaware that a student had asthma and no quick-relief medication was available (17%); staff were not trained in how to properly respond in an asthma emergency situation (33%); the campus was a drug-free school zone, so no medications were available (17%); and children's requests for help were not acted upon (33%).

IMPLICATIONS FOR SCHOOL HEALTH PRACTICE

Given the significant time spent in school, it is understandable that some of the 2484 deaths in children between 1990 and 2001 occurred in schools or resulted from events precipitated in schools. With no surveillance systems established to consistently capture the occurrence of such deaths, this study sought to provide a preliminary look at asthma deaths that have occurred in schools and the circumstances surrounding those deaths based on already published information. Asthma deaths reported in newspapers are increasing in number over time. This may represent a real increase or a greater likelihood of asthma deaths in children being reported.

Figure 2

Number of Asthma Deaths in Schools by Season, 1990-2003

Table 2

Circumstances of Death: School-Associated Asthma Mortality Events, United States, 1990-2003

This study has several limitations. Given the total number of asthma deaths in school-aged children, we assume that more school- related asthma deaths occur than are identified. Nearly all the cases reported here were identified through newspaper reports. This introduces the potential for inaccurate data or significant inconsistencies in the type of data provided among the various articles, making it difficult to compare on a case-by-case basis. Many of the deaths occurred during school-sponsored sporting events. Sporting events may have existing media coverage, increasing the likelihood that an asthma death during that event is reported in the newspaper. The potential for reporting bias also exists. A newspaper reporter may have a particular interest in asthma and may seek out related events, resulting in regional variations in what is considered newsworthy. Despite these limitations, there appears to be an increased risk of school-related asthma deaths among teenagers in comparison to younger counterparts. Adolescents are more likely to be responsible for their own disease management, including self- carrying and self-administering quick-relief inhalers. Several factors might affect a teen's ability to make the successful transition from dependent care to self-care management of their asthma.22 These factors include the following:

1. Teens' knowledge about self-management occasionally contradicts their disease self-management practices.

2. Their sense of invulnerability results in delays in seeking treatment or viewing asthma as a serious condition.

3. Their desire for normalcy may result in jeopardized safety.

4. Their perception of their credibility with adults is very important to them.

Teens might be a particularly important group to ensure coordination of medical care providers, parents, and teens to create management plans together that are customized to the teen's individual asthma experiences within the context of his or her own personal development and goals.

Many of the deaths reviewed for this study were precipitated by exercise, despite asthma often not being considered as a possible etiology for morbidity or death during sports.23,24 During a school- related athletic event, coaches, physical education instructors, and affiliated staff should be aware of which children have asthma, know symptoms of asthma exacerbations, and know how to assist in administering medications. Students, parents, health care providers, and school administrators and staff should ensure that quick-relief bronchodilators are available. The National Asthma Education and Prevention Program (NAEPP) offers suggestions for physical educators, coaches, and trainers to prevent breathing difficulties related to physical activities.25 They include the following:

1. Identify students with asthma in your class or on your team.

2. When prescribed, students should take preexercise medicine 5 to 10 minutes prior to exercise.

3. Prevent physical activity if symptoms are present prior to exercise.

4. Engage students in adequate warm-up.

5. Consider modified exercise as needed.

6. Remove the student's environmental triggers.

Figure 3

Number of Identified School-Associated Asthma Deaths, 1990-2003 and State Statutes Protecting Student Rights to Carry and Use Prescribed Asthma and Anaphylaxis Medications, by State, United States, May 2004

For exercise-induced asthma exacerbations that occur on the field or in the gym, NAEPP also suggests immediately stopping the activity, ensuring the student has an asthma management plan and quick-relief bronchodilator therapy, involving appropriate medical services, school administration, and parents, and never leaving a child with breathing problems alone.

Some deaths from asthma may be occurring because of a delayed response or hesitancy of school staff to provide medical assistance. They may also occur because school medication policies require students to keep medication in a secured office. The National Association of School Nurses recommends 1 nurse for every 750 students in the general school population.26 In 1996, only 6 states in the United States (Alaska, Connecticut, Delaware, Maine, New Hampshire, and Vermont) met the recommended ratio.27 Teachers and other school personnel may be called on to assist with students experiencing asthma episodes that occur in the classroom. An alternative is to allow students to carry and administer their own medications. Three federal statutes exist that require schools to accommodate students whose asthma qualifies as a disability: the Individuals with Disabilities Education Act, section 504 of the Rehabilitation Act of 1973, and Title II of the Americans With Disabilities Act. Such accommodations may include allowing some students to carry and self-administer their medications according to their asthma management plan.28 Despite these statutes, some school district policies prohibit children from administering their own medication (FigureS). To override these policies, most states have passed laws mandating the right to carry asthma medications. Schools should focus on developing policies and emergency plans that encourage the appropriate management of asthma in classrooms and that enable children and appropriate school personnel to access asthma medications. Such access can minimize time lost from class and school and prevent emergency medical services (911) calls.29 Approaches might include self-carrying inhalers, storage of extra personal inhalers by the school, stocking inhalers, stocking albuterol, and storage of a nebulizer by the school.29 Emergency plans will vary among schools depending on the type of system and need, the advice from local School Health Advisory Councils and other local resources, and the continuous assessment of suitability of existing options. This information could be used to determine the most appropriate access methods for schools.29

The purpose of this study was to provide a preliminary look at asthma mortality in schools and provide recommendations for schools to be better prepared to handle school-associated asthma exacerbations. Although generalizations of these findings cannot be made because of the small sample size and data sources, asthma mortality in schools merits continued analysis. Asthma deaths in schools represent only a small fraction of all childhood asthma deaths and the burden placed on children with asthma, their families, and school districts. Reducing the burden of asthma on schools has been identified as a public health priority.30 To effectively do so, identification of students with diagnosed asthma, communication with parents and health care providers, removal of triggers in the immediate school environment, and maximizing access to medication when needed are all key factors in managing the disease and preventing acute exacerbations and deaths at school. School districts could also work with local and state health agencies to document causes and circumstances surrounding asthma deaths and severe exacerbations in students that may have a causal link to the school setting. Just as deaths in workers are reportable, state health agencies might consider mandating reporting of all school-related deaths \of any cause.

References

1. American Lung Association. Trends in Asthma Morbidity and Mortality, May 2005. Available at: http://www.lungusa.org/atf/cf/ {7A8A42C2-FCCA-4604-8ADE-7F5D5E762256)/ASTHMAl.pdf. Accessed July 19, 2005.

2. National Center for Health Statistics. Summary Health Statistics for US Children: National Health Interview Survey, 2003. Available at: http://www.cdc.gov/nchs/data/series/sr_10/ srl0_223.pdf. Accessed July 19,2005.

3. Weiss KB, Sullivan SD, Lytle CS. Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin lmmunol. 2000; 106:493-499.

4. Wang LY, Zhong Y, Wheeler L. Direct and Indirect Costs of Asthma in School-Aged Children. Preventing Chronic Disease [serial online]. January 2005. Available at: http://www.cdc.gov/pcd/issues/ 2005/jan/ 04_0053.htm. Accessed July 19, 2005.

5. Dickinson J, Hutton S, Atkin A, et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respir Med. 1997;91(10):634-640.

6. McFadden ER. Improper patient techniques with metered dose inhalers: clinical consequences and solutions to misuses. J Allergy Clin Immunol. 1995;96:278-283.

7. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilizations, and mortality. Pediatrics. 2002; 110(2):315-322.

8. National Center for Health Statistics. CDC Wonder. Available at: http://wonder.cdc.gov/. Accessed July 20, 2004.

9. Robertson CF, Rubinfeld AR, Bowes G. Deaths from asthma in Victoria: a 12-month survey. MedJAust. 1990;152:511-517.

10. Fletcher HJ, Ibrahim SA, Speight N. Survey of asthma deaths in the Northern region, 1970-85. Arch Dis Child. 1990;65:163-167.

11. Rea HH, Scragg R, Jackson R, et al. A case-control study of deaths from asthma. Thorax. 1987;41:833-839.

12. Sears MR, Rea HH, Beaglehole R, et al. Asthma mortality in New Zealand: a two-year national study. NZMedJ. 1985;98:271-275.

13. British Thoracic Association. Deaths from asthma in two regions of England. BMJ. 1982;285:1251-1255.

14. Robertson CF, Rubinfeld AR, Bowes G. Pediatrie asthma deaths in Victoria: the mild are at risk. Pediatr Pulmonol. 1992;13:95- 100.

15. Taggart VS, Fulwood R. Youth health report card: asthma. Prev Med. 1993;22:579-584.

16. Flowler M, Davenport M, Gar R. School functioning of U.S. children with asthma. Pediatrics. 1992;90:939-944.

17. Freudenber N, Feldman CH, Clark NM, et al. The impact of bronchial asthma on school attendance and performance. J Sch Health. 1980;60:522-525.

18. Rutter M, Tizard J, Whitmore K. Education, Health, and Behavior. London, England: Longman Publications; 1970.

19. National Center for Education Statistics, US Department of Education. Common Core of Data. Available at: http://nces.ed.gov/ ccd/. Accessed July 19,2005.

20. Marder D, Targonski P, Orris P, et al. Effect of racial and socioeconomic factors on asthma mortality in Chicago. Chest. 1992; 101:4265-4295.

21. US Census Bureau. Geographic Comparison Table. Available at: http://factfinder.census.gov/servlet/GCTTable?_bm=yamp-geoJd=01000 US&0 -_box_head_nbr=GCT0 -PHl0 -R&0 -ds_name=DEC_2000_SFl_U&- format=US-9S. Accessed July 19, 2005.

22. Velsor-Fiedrich B, Vlasses F, Moberley J, et al. Talking with teens about asthma management. J Sch Nurs. 2004;20(3): 140-148.

23. Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes: clinical, demographic and pathological profiles. JAMA. 1996;276:199-204.

24. Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high school and college sports, 1982-1997. Phys Sportsmed. 1999;27:35-48.

25. National Asthma Education Prevention Program. Breathing Difficulties Related to Physical Activity for Students With Asthma: Exercise-Induced Asthma Information for Physical Educators, Coaches and Trainers. Available at: http://www.nhlbi.nih.gov/health/prof/ lung/asthma/ exercise_induced.htm. Accessed July 20, 2005.

26. National Association of School Nurses. NASN Position Statement: caseload Assignments. Scarborough, Me; 2004. Available at: http:// www.nasn.org/positions/2004pscaseload.pdf. Accessed July 20, 2005.

27. Vail K. A finger on the pulse. Exec Educator. 1996;18(5):24- 27.

28. Jones SE, Wheeler L. Asthma inhalers in schools: rights of students with asthma to a free appropriate education. Am J Public Health. 2004;94(7): 1102-1108.

29. Wheeler LS, Taras H, Jones SE. Ensuring immediate access to medications for students with asthma or allergies in school. Personal communication.

30. Helms PJ. Issues and unmet needs in pediatrie asthma. Pediatr Pulmonol. 2000;30:159-165.

Andrea K. Greiling, MPH, (agreiling@cdc.gov), Multnomah County Health Department, Division of Environmental Health Services, 727 NE 24th St, Portland, OR 97232; Leslie P. Boss, MPH, PhD, (lpbl@cdc.gov), Air Pollution and Respiratory Health Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, Mail Stop E-17, 1600 Clifton Road, NE, Atlanta, GA 30333; and Lani S. Wheeler, MD, (lswheeler@aap.net), Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 163 Cranes Crook Lane, Annapolis, MD 21401- 7267.

Copyright American School Health Association Oct 2005

Source: Journal of School Health, The

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