Asthma in Hispanics

Asthma control and associated risk factors among adults with current asthma: Findings from 2019 behavioral risk factor surveillance system asthma call-back survey

BACKGROUND

Despite the availability of effective treatments, many adults with asthma have uncontrolled asthma. Uncontrolled asthma can lead to severe exacerbations. This study aimed to determine the prevalence and predictors of uncontrolled asthma among adults (≥18 years) with current asthma in the United States.

METHODS

We analyzed the 2019 Behavior Risk Factor Surveillance System Asthma Call-Back Survey data from 27 states. Asthma control status was classified as "well-controlled" or "uncontrolled" according to the National Asthma Education and Prevention guidelines. The study population consisted of 7937 adults (weighted n = 13,793,220) with current asthma. We used multivariable logistic regression models to identify predictors of uncontrolled asthma.

RESULTS

Overall, 62 % of adults with asthma reported having uncontrolled asthma, and 26 % had emergency or urgent care visits or hospitalizations in the past year. Potentially modifiable risk factors associated with uncontrolled asthma included cost barriers to asthma-related healthcare (OR = 2.94; 95%CI 1.96-4.40), complementary and alternative medicine use (OR = 1.84; 95%CI 1.45-2.32), current smoking (OR = 2.25; 95%CI 1.48-3.44), obesity (OR = 1.39; 95%CI 1.02-1.89), COPD (OR = 1.98; 95%CI 1.43-2.74), depression (OR = 1.47; 95%CI 1.16-1.88), fair/poor general health (OR = 1.54; 95%CI 1.14-2.07), household income <$15,000 (OR = 2.59; 95%CI 1.42-4.71), and less than high school education (OR = 2.59; 95%CI 1.42-4.71). Non-modifiable risk factor was Hispanic ethnicity (OR = 1.73; 95%CI 1.09-2.73).

CONCLUSION

Our findings suggest that uncontrolled asthma is common among adults and can be impacted by several factors. Effective asthma control programs are needed to improve asthma management and reduce unnecessary healthcare utilization.

Improving equity in kidney transplant allocation policies through a novel genetic metric: The Matched Donor Potential

The demand for donors' kidneys continues to increase amid a shortage of available donors. Managing policies to thoughtfully allocate this scarce resource is a complex process. Although human leukocyte antigen (HLA) matching has been shown to prolong graft survival, its relative contribution to allocation schemes is empirically compromised owing to competing priorities. We explored using a new metric, Matched Donor Potential (MDP), to facilitate improved HLA matching while promoting equity. We interrogated all active kidney waitlist patients (N = 164 427), their corresponding unacceptable antigen files, and all effective donors in the Scientific Registry of Transplant Recipients (January 1, 2016-December 31, 2017). Cause-specific hazard functions were evaluated to assess the potential impact of the MDP metric on deceased donor transplant access rates for all candidates. Access was affected by ethnicity, blood group type, and calculated Panel Reactive Antibody (cPRA). Importantly, we show that access to transplantation is influenced by the patient's own HLA makeup regardless of their ethnicity and by the HLA makeup of effective donors. The MDP metric demonstrates a high association with access to transplantation. Adjusting Cox models to include this new metric resulted in improved access to kidney transplantation for waitlist candidates of minority heritage while significantly promoting HLA matching. Thus, the MDP metric accounts for balanced, equitable organ allocation algorithms.

Caribbean Latinx with moderate-severe asthma bear greater asthma morbidity than other Latinx

BACKGROUND

Hispanic/Latinx (HL) ethnicity encompasses racially and culturally diverse subgroups. Studies suggest that Puerto Ricans (PR) may bear greater asthma-related morbidity than Mexicans, but these were conducted in children or had limited clinical characterization.

OBJECTIVES

This study sought to determine whether disparities in asthma morbidity exist among HL adult subgroups.

METHODS

Adults with moderate-severe asthma were recruited from US clinics, including from Puerto Rico, for the Person Empowered Asthma Relief (PREPARE) trial. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans [C&D]), the investigators compared baseline self-reported clinical characteristics between Caribbean HL (CHL) (PR and C&D: n = 457) and other HLs (OHL) (Mexicans, Spaniards, Central/South Americans; n = 141), and between CHL subgroups (C&D [n = 56] and PR [n = 401]). This study compared asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids, emergency department/urgent care (ED/UC) visits, hospitalizations, health care utilization) through negative binomial regression.

RESULTS

CHL compared to OHL were similar in age, body mass index, poverty status, blood eosinophils, and fractional exhaled nitric oxide but were prescribed more asthma controller therapies. Relative to OHL, CHL had significantly increased odds of asthma exacerbations (odds ratio [OR]: 1.84; 95% CI: 1.4-2.4), ED/UC visits (OR: 1.88; 95% CI: 1.4-2.5), hospitalization (OR: 1.98; 95% CI: 1.06-3.7), and health care utilization (OR: 1.91; 95% CI: 1.44-2.53). Of the CHL subgroups, PR had significantly increased odds of asthma exacerbations, ED/UC visits, hospitalizations, and health care utilization compared to OHL, whereas C&D only had increased odds of exacerbations compared to OHL. PR compared to C&D had greater odds of ED/UC and health care utilization.

CONCLUSIONS

CHL adults, compared with OHL, adults reported nearly twice the asthma morbidity; these differences are primarily driven by PR. Novel interventions are needed to reduce morbidity in this highly impacted population.

Trends in asthma among adults in the United States, National Health and Nutrition Examination Survey 2005 to 2018

BACKGROUND

Asthma is a common chronic disease in American adults. The prevalence of asthma has varied over time, but there are few studies on the long-term trend of asthma in American adults.

OBJECTIVE

To describe the prevalence and trend of asthma in American adults from 2005 to 2018 and analyze the risk factors for asthma.

METHODS

Data collection was performed from National Health and Nutrition Examination Survey 2005 to 2018. The unweighted number and weighted percentages of normal participants and patients with asthma and the trends of asthma were calculated. Weighted univariate logistic regression was used to analyze the risk factors for asthma.

RESULTS

A total of 39,601 adults were included in this study. From 2005 to 2018, the overall prevalence of asthma in American adults was 8.41%, whereas that in young, middle-aged, and elderly adults was 8.30%, 8.70%, and 7.92%, respectively. The estimated prevalence of asthma in the overall adults and young adults increased with time (P for trend = .03, difference = 0.023 and P for trend = .007, difference = 0.060, respectively), and the estimated prevalence of middle-aged and elderly adults remained stable with time (P for trend = .33, difference = 0.015 and P for trend = .80, difference = -0.024, respectively).

CONCLUSION

Asthma in American adults was on the rise. Female sex, non-Hispanic Blacks, individuals with low annual household income, active smokers, obese patients, patients with hypertension, patients with diabetes, and individuals with positive asthma family history were associated with a higher risk for developing asthma.

Metabolomic Associations of Asthma in the Hispanic Community Health Study/Study of Latinos

Asthma disproportionally affects Hispanic and/or Latino backgrounds; however, the relation between circulating metabolites and asthma remains unclear. We conducted a cross-sectional study associating 640 individual serum metabolites, as well as twelve metabolite modules, with asthma in 3347 Hispanic/Latino background participants (514 asthmatics, 15.36%) from the Hispanic/Latino Community Health Study/Study of Latinos. Using survey logistic regression, per standard deviation (SD) increase in 1-arachidonoyl-GPA (20:4) was significantly associated with 32% high odds of asthma after accounting for clinical risk factors (p = 6.27 × 10−5), and per SD of the green module, constructed using weighted gene co-expression network, was suggestively associated with 25% high odds of asthma (p = 0.006). In the stratified analyses by sex and Hispanic and/or Latino backgrounds, the effect of 1-arachidonoyl-GPA (20:4) and the green module was predominantly observed in women (OR = 1.24 and 1.37, p < 0.001) and people of Cuban and Puerto-Rican backgrounds (OR = 1.25 and 1.27, p < 0.01). Mutations in Fatty Acid Desaturase 2 (FADS2) affected the levels of 1-arachidonoyl-GPA (20:4), and Mendelian Randomization analyses revealed that high genetically regulated 1-arachidonoyl-GPA (20:4) levels were associated with increased odds of asthma (p < 0.001). The findings reinforce a molecular basis for asthma etiology, and the potential causal effect of 1-arachidonoyl-GPA (20:4) on asthma provides an opportunity for future intervention.

An Overview of Health Disparities in Asthma

Asthma is a heterogeneous disease characterized by inflammation in the respiratory airways which manifests clinically with wheezing, cough, and episodic periods of chest tightness; if left untreated it can lead to permanent obstruction or death. In the US, asthma affects all ages and genders, and individuals from racial and ethnic minority groups are disproportionately burdened by this disease. The financial cost of asthma exceeds $81 billion every year and despite all the resources invested, asthma is responsible for over 3,500 deaths annually in the nation. In this overview, we highlight important factors associated with health disparities in asthma. While they are complex and overlap, we group these factors in five domains: biological, behavioral, socio-cultural, built environment, and health systems. We review the biological domain in detail, which traditionally has been best studied. We also acknowledge that implicit and explicit racism is an important contributor to asthma disparities and responsible for many of the socio-environmental factors that worsen outcomes in this disease.

Resolving Clinical Phenotypes into Endotypes in Allergy: Molecular and Omics Approaches

Allergic diseases are highly complex with respect to pathogenesis, inflammation, and response to treatment. Current efforts for allergic disease diagnosis have focused on clinical evidence as a binary outcome. Although outcome status based on clinical phenotypes (observable characteristics) is convenient and inexpensive to measure in large studies, it does not adequately provide insight into the complex molecular determinants of allergic disease. Individuals with similar clinical diagnoses do not necessarily have similar disease etiologies, natural histories, or responses to treatment. This heterogeneity contributes to the ineffective response to treatment leading to an annual estimated cost of $350 billion in the USA alone. There has been a recent focus to deconvolute the clinical heterogeneity of allergic diseases into specific endotypes using molecular and omics approaches. Endotypes are a means to classify patients based on the underlying pathophysiological mechanisms involving distinct functions or treatment response. The advent of high-throughput molecular omics, immunophenotyping, and bioinformatics methods including machine learning algorithms is facilitating the development of endotype-based diagnosis. As we move to the next decade, we should truly start treating clinical endotypes not clinical phenotype. This review highlights current efforts taking place to improve allergic disease endotyping via molecular omics profiling, immunophenotyping, and machine learning approaches in the context of precision diagnostics in allergic diseases. Graphical Abstract.

Race and Asthma Outcomes in Older Adults: Results from the National Asthma Survey

BACKGROUND

The number of older adults with asthma continues to rise, yet the effects of race and ethnicity on asthma outcomes in this population are unknown.

OBJECTIVE

To characterize the effect of race and ethnicity on asthma outcomes in a large national sample of older adults and to identify factors that are associated with disparities found.

METHODS

Data from the 2015 Behavioral Risk Factor Surveillance Survey and Asthma Call-Back Survey were analyzed. Respondents were included if they had a current asthma diagnosis, were aged ≥55, and self-identified as non-Hispanic white, African American, or Hispanic. Demographic variables, health care access, comorbidities, and asthma history were correlated with asthma outcomes (health care utilization and asthma control). Asthma outcome variables were further analyzed using multivariable logistic regression.

RESULTS

A total of 4700 individuals were included. Compared with non-Hispanic white respondents, African American and Hispanic respondents had lower incomes, greater impaired access to health care due to cost, and increased reliance on rescue medications. After controlling for factors including income, education, comorbidities, and health insurance, African American and Hispanic respondents were twice as likely to visit the emergency room (ER) for asthma (P < .001 for both) and 40% less likely to report uncontrolled daytime symptoms (P = .002 and .008).

CONCLUSIONS

Racial differences in asthma outcomes persist despite controlling for multiple social determinants of health and access to health insurance through Medicare. Minority patients were more likely to visit the ER but less likely to report frequent daytime symptoms. These findings indicate that comprehensive strategies to address assessment, monitoring, and treatment are needed to decrease health disparities.

Disparities in complementary alternative medicine use and asthma exacerbation in the United States

Background: Complementary and alternative medicines (CAM) are associated with poor asthma medication adherence, a major risk factor for asthma exacerbation. However, previous studies showed inconsistent relationships between CAM use and asthma control due to small sample sizes, demographic differences across populations studied, and poor differentiation of CAM types.Methods: We examined associations between CAM use and asthma exacerbation using a cross-sectional analysis of the 2012 National Health Interview Survey. We included adults ≥18 years with current asthma (n = 2,736) to analyze racial/ethnic differences in CAM use as well as the association between CAM use and both asthma exacerbation and emergency department (ED) visit for asthma exacerbation across racial/ethnic groups. We ran descriptive statistics and multivariable logistic regressions.Result: Blacks (OR = 0.63 [0.49-0.81]) and Hispanics (OR = 0.66 [0.48-0.92]) had decreased odds of using CAM compared to Whites. Overall, there was no association between CAM use and asthma exacerbation (OR = 0.99 [0.79-1.25]) but the subgroup of 'other complementary approaches' was associated with increased odds of asthma exacerbation among all survey respondents (1.90 [1.21-2.97]), Whites (OR = 1.90 [1.21-2.97]), and Hispanics (OR = 1.43 [0.98-2.09). CAM use was associated with decreased odds of an ED visit for asthma exacerbation (OR = 0.65 [0.45-0.93]). These associations were different among racial/ethnic groups with decreased odds of ED visit among Whites (OR = 0.50 [0.32-0.78]) but no association among Blacks and Hispanics.Conclusion: We found that both CAM use and the association between CAM use and asthma exacerbation varied by racial/ethnic group. The different relationship may arise from how CAM is used to complement or to substitute for conventional asthma management.

Long-term Breastfeeding in the Prevention of Allergic Rhinitis: Allergic Rhinitis Cohort Study for Kids (ARCO-Kids Study)

OBJECTIVES

There is a great deal of interest in the possibility that environmental factors may influence the risk of developing allergic rhinitis (AR) in early life. We investigated the simultaneous effects of mode of delivery and duration of breastfeeding on the development of AR in children.

METHODS

Data from 1,374 children participating in the Allergic Rhinitis Cohort Study for kids (ARCO-kids study) was analyzed. All subjects were divided into AR or non-allergic rhinitis (NAR) groups. Data on environmental factors, mode of delivery and duration of breastfeeding were collected using a questionnaire.

RESULTS

Compared with short-term breastfeeding (<6 months), long-term breastfeeding (≥12 months) was significantly associated with a lower prevalence of AR (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.34 to 0.88). Children in the AR group also had a higher cesarean delivery rate than those in the NAR group (39.1% vs. 32.8%, P=0.05). Regarding the combined effects of mode of delivery and duration of breastfeeding, long-term breastfeeding with a vaginal delivery strongly suppressed the development of AR, compared to short-term breastfeeding with a cesarean delivery (aOR, 0.47; 95% CI, 0.30 to 0.73).

CONCLUSION

Long-term breastfeeding (≥12 months) and a vaginal delivery are associated with a lower risk of developing childhood AR.

US racial/ethnic disparities in childhood asthma emergent health care use: National Health Interview Survey, 2013-2015

Objective: Racial/ethnic disparities in Emergency Department (ED) visits due to childhood asthma are well documented. We assessed disparities among multiple racial/ethnic groups and examined the effects of asthma management in emergent health care use among children in the United States.Methods: Data come from the sample child component of the 2013-2015 National Health Interview Survey (NHIS) (ages 2-17). Among children with current asthma, (N = 3336) we assessed racial/ethnic disparities in ED visits due to asthma in the past 12 months. We used multivariate logistic regression to calculate model adjusted odds ratios (ORs) including adjustment of asthma management questions available in NHIS 2013: use of an asthma action plan, preventative medication use, and an asthma management course.Results: Using 2013-2015 NHIS data, Puerto Rican children had the highest prevalence of current asthma (21.2%). Among children with asthma, significantly higher odds of ED visits were seen among all minority subgroups (except non-Hispanic other) compared to non-Hispanic white children with Hispanic other having the highest adjusted odds ratio (OR = 2.4), followed by Puerto Rican (OR = 2.0), Mexican American (OR = 1.8) and non-Hispanic black children (OR = 1.7). In sub analyses using 2013 data, adjustment of management measures resulted in a modest to no effect in the odds of having an ED visit due to asthma.Conclusions: The high prevalence of asthma and the disparity in asthma related ED visits among minority children exemplify the need for further research in understanding the mechanisms underlying the continuing existence of these health imbalances.

Under-diagnosis of atopic dermatitis in Puerto Rican children

Background

Little is known about atopic dermatitis (AD) among children in Puerto Rico.

Objective

To examine risk factors and identify approaches to better diagnose AD in Puerto Rican children.

Methods

Case-control study of AD among 540 children aged 6-14 years in San Juan, Puerto Rico. AD was defined as: 1) physician-diagnosed AD, 2) RAST-AD: AD symptoms plus ≥1 positive IgE to allergens, and 3) STR-AD: AD-symptoms and skin test reactivity to ≥1 allergen. Logistic regression was used for the multivariable analysis. We also evaluated the diagnostic performance of various approaches by comparing their sensitivity, specificity, positive predicted value [PPV], negative predictive value [NPV], and area under curve [AUC]).

Results

Of the 70 children with STR-AD, only 5 (7.1%) had PD-AD. In children without asthma, a positive IgE to Dermatophagoides (D.) pteronyssinus and signs of mold/mildew at home were significantly associated with 3.3 and 5 times increased odds of STR-AD, respectively. Among children with asthma, private/employer-based health insurance and a positive IgE to D. pteronyssinus were each significantly associated with approximately twofold increased odds of STR-AD. A combination of current eczema symptoms and a positive IgE to D. pteronyssinus yielded a sensitivity ≥ 70%, specificity and NPV ≥ 95%, PPV ≥ 88%, and an AUC ≥ 0.85 for STR-AD. Replacing a positive IgE to D. pteronyssinus with a positive IgE to ≥1 allergen slightly increased sensitivity without affecting other parameters.

Conclusions

AD is markedly under-diagnosed by physicians in Puerto Rico. This could be improved by assessing eczema symptoms and measuring IgEs to common allergens.

Health Literacy and Income Mediate Racial/Ethnic Asthma Disparities

BACKGROUND

Health literacy and socioeconomic status (SES) are associated with both race/ethnicity and asthma outcomes. The extent to which health literacy and SES mediate racial/ethnic asthma disparities is less clear.

OBJECTIVE

To determine if health literacy and SES mediate racial/ethnic asthma disparities using advanced mediation analyses.

METHODS

A secondary analysis was performed using a Chicago-based longitudinal cohort study conducted from 2004 to 2007 involving 342 adults age 18 to 41 years with persistent asthma. Phone interviews were conducted every 3 months assessing asthma quality of life (AQOL; scored 1-7, with 7 being the highest) and asthma-related health care use measures. Structural equation models assessed mediation of race/ethnicity effects on AQOL and health care use through health literacy and SES. Covariates in the best-fit model included sex, year and season of interview, and cigarette smoking.

KEY RESULTS

The study sample was 77.8% female, 57.3% African American/non-Hispanic, and 28.7% Hispanic. Race/ethnicity was significantly associated with AQOL and asthma-related emergency department (ED) visits, but only indirectly, through the effects of health literacy and income. Compared with White/non-Hispanics, African American/non-Hispanics and Hispanics had significantly higher odds of low health literacy and lower income. Low health literacy was associated with significantly lower AQOL scores (β = -0.24, 95% confidence interval (CI) [-0.38, -0.10]) and higher odds of an ED visit (adjusted odds ratio = 1.24, 95% CI [1.07, 1.43]). Increasing income was associated with significantly higher AQOL scores (β = 0.18, 95% CI [0.08, 0.28]) and lower odds of an ED visit (adjusted odds ratio = 0.88, 95% CI [0.80, 0.97]).

CONCLUSIONS

The relationships between race/ethnicity and several asthma outcomes were mediated by health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers. [HLRP: Health Literacy Research and Practice. 2019;3(1):e9-e18.].

PLAIN LANGUAGE SUMMARY

Using advanced statistical methods, this study suggests racial/ethnic differences in several asthma outcomes are largely due to effects of health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers.

Asthma Risk Associated with Indoor Mold Contamination in Hispanic Communities in Eastern Coachella Valley, California

Indoor mold contamination has been associated in many studies with an increased risk of asthma and respiratory illness. This study investigated indoor mold contamination and the prevalence of asthma/respiratory illness in two low-income, Hispanic communities, Mecca and Coachella City, in the Eastern Coachella Valley (ECV) of California. The study consisted of a questionnaire to assess asthma/respiratory illness and the quantification of mold contamination in house dust samples using the Environmental Relative Moldiness Index (ERMI) scale. About 11% of the adults and 17% of the children in both Mecca and Coachella City met our definitions of asthma/respiratory illness. The average ERMI values in Mecca and Coachella City housing (10.3 and 6.0, respectively) are in the top 25% of ERMI values for the United States (US) homes. Overall, the homes surveyed in these ECV communities had an average prevalence of occupant asthma of 12.8% and an average ERMI value of 9.0. The prevalence of asthma/respiratory illness in the Hispanic communities of Mecca and Coachella City and the mold contamination in their homes appear to be greater than the averages for the rest of the US. The higher levels of mold contamination in their homes appear to be associated with a greater risk of asthma/respiratory illness for these low-income, Hispanic communities.

The combined effect of ambient ozone exposure and toxic air releases on hospitalization for asthma among children in Harris County, Texas

This study represents an analysis of the effect of exposure to ambient ozone and toxic air releases on hospitalization for asthma among children in Harris County, Texas. Our study identified temporal and spatial variations in asthma hospitalization across the study region and explored the combined effect of exposure to ambient ozone and air toxics on asthma hospitalization. Asthma hospitalization hot spots and clusters were mostly not located on zip codes with reported high quantities of total air releases of chemical pollutants. There was no significant interaction between ambient ozone exposure and toxic air releases relative to asthma hospitalization. The major predictor of asthma hospitalization was season, with hospitalization rate per 10,000 people for asthma being highest in winter period when ozone levels are usually lowest.

A Genome-Wide Association Study in Hispanics/Latinos Identifies Novel Signals for Lung Function. The Hispanic Community Health Study/Study of Latinos

RATIONALE

Lung function and chronic obstructive pulmonary disease (COPD) are heritable traits. Genome-wide association studies (GWAS) have identified numerous pulmonary function and COPD loci, primarily in cohorts of European ancestry.

OBJECTIVES

Perform a GWAS of COPD phenotypes in Hispanic/Latino populations to identify loci not previously detected in European populations.

METHODS

GWAS of lung function and COPD in Hispanic/Latino participants from a population-based cohort. We performed replication studies of novel loci in independent studies.

MEASUREMENTS AND MAIN RESULTS

Among 11,822 Hispanic/Latino participants, we identified eight novel signals; three replicated in independent populations of European Ancestry. A novel locus for FEV1 in ZSWIM7 (rs4791658; P = 4.99 × 10-9) replicated. A rare variant (minor allele frequency = 0.002) in HAL (rs145174011) was associated with FEV1/FVC (P = 9.59 × 10-9) in a region previously identified for COPD-related phenotypes; it remained significant in conditional analyses but did not replicate. Admixture mapping identified a novel region, with a variant in AGMO (rs41331850), associated with Amerindian ancestry and FEV1, which replicated. A novel locus for FEV1 identified among ever smokers (rs291231; P = 1.92 × 10-8) approached statistical significance for replication in admixed populations of African ancestry, and a novel SNP for COPD in PDZD2 (rs7709630; P = 1.56 × 10-8) regionally replicated. In addition, loci previously identified for lung function in European samples were associated in Hispanic/Latino participants in the Hispanic Community Health Study/Study of Latinos at the genome-wide significance level.

CONCLUSIONS

We identified novel signals for lung function and COPD in a Hispanic/Latino cohort. Including admixed populations when performing genetic studies may identify variants contributing to genetic etiologies of COPD.

Association of systemic inflammation, adiposity, and metabolic dysregulation with asthma burden among Hispanic adults

RATIONALE

Obesity-related asthma is associated with higher disease burden than normal-weight asthma among Hispanics. Adiposity, metabolic dysregulation, and inflammation are all implicated in pathogenesis of obesity-related asthma, but their independent contributions are poorly understood.

OBJECTIVE

To examine the independent contributions of body fat distribution, metabolic abnormalities and inflammation on asthma symptoms and pulmonary function among Hispanics.

METHODS

Participants of the Hispanic Community Health Study/Study of Latinos with doctor-diagnosed asthma who completed an asthma symptom questionnaire and performed a valid spirometry were included in the analysis (n = 1126). Multivariate analysis was used to examine the independent association of general adiposity (assessed using body mass index), truncal adiposity (assessed by waist circumference), metabolic dysregulation (presence of insulin resistance and low HDL) and inflammation (high-sensitivity C-Reactive Protein≥3 mg/L) with reported asthma symptoms or pulmonary function measures (FEV₁, and FVC) while adjusting for demographic and clinical covariates.

RESULTS

Of the 1126 participants, 334 (29.5%) were overweight, and 648 (57.8%) were obese. FEV₁ and FVC were lower in obese compared to normal-weight asthmatics. In analyses controlling for metabolic and adiposity factors, high hs-CRP (>7 mg/L) was associated with more symptoms (prevalence-ratio 1.27 (95%CI 1.05, 1.54), and lower FVC (β -138 ml (95%CI -27 ml, -249 ml)) and FEV₁ (β -155 ml (95% CI -38 ml, -272 ml). Low HDL was also associated with lower FVC (β -111 ml (-22 ml, -201 ml) and FEV₁ (β -100 ml (-12 ml, -188 ml)). Results were similar in men and women.

CONCLUSIONS

Our findings suggest that hs-CRP and low HDL, rather than general and truncal adiposity, are associated with asthma burden among overweight and obese Hispanic adults.

Rural residence, farming environment, and allergic diseases in Argentinean adolescents

RATIONALE

Little is known about residence in a rural or farming environment and allergic diseases in Latin America.

METHODS

Cross-sectional study of rural residence and current wheeze, current asthma and current symptoms of allergic rhino-conjunctivitis in 1,804 adolescents (ages 13-14 years) attending 31 schools in urban and rural areas of San Francisco (Córdoba, Argentina). Rural residence was classified as never, previous, and current. Duration of rural residence was categorized as 0, >0 but ≤5 years, and >5 years. Current wheeze, current asthma, and current allergic rhino-conjunctivitis were defined on the basis of responses to an extensively validated questionnaire from the International Study of Asthma and Allergies in Childhood. Logistic regression was used for the multivariable analysis of rural residence and the outcomes of interest.

RESULTS

After adjustment for current smoking and other covariates, current rural residence (odds ratio [OR] = 0.15, 95% confidence interval [CI] = 0.03-0.81) and rural residence for >5 years (OR = 0.32, 95%CI = 0.12-0.84) were significantly associated with reduced odds of current wheeze. In a multivariable analysis, current residence in a rural area (OR = 0.52, 95%CI = 0.32-0.86) and rural residence for >5 years (OR = 0.44, 95%CI = 0.26-0.73) were significantly associated with reduced odds of allergic rhino-conjunctivitis. This association was no longer significant after additional adjustment for current residence in a dairy farm, which was significantly associated with reduced odds of allergic rhino-conjunctivitis. Similarly, current regular contact with farm animals was significantly associated with reduced odds of allergic rhino-conjunctivitis.

CONCLUSIONS

Among Argentinean adolescents, current rural residence and rural residence for >5 years were associated with reduced odds of current wheeze and allergic rhino-conjunctivitis. These potential protective effects may be explained by a dairy farm environment, including regular contact with farm animals. Pediatr Pulmonol. 2017;52:21-28. © 2016 Wiley Periodicals, Inc.

Revisiting the Hispanic health paradox: the relative contributions of nativity, country of origin, and race/ethnicity to childhood asthma

This study examined the relationship between race and Hispanic ethnicity, maternal and child nativity, country of origin and asthma among 2,558 non-Hispanic white and Hispanic children across 65 Los Angeles neighborhoods. A series of two-level multilevel models were estimated to examine the independent effects of race, ethnicity, and country of origin on childhood asthma. Lifetime asthma prevalence was reported among 9% of children, with no significant differences between Hispanics and non-Hispanic whites overall. However, in fully adjusted models, Hispanic children of non-Mexican origin reported higher odds of asthma compared to non-Hispanic white children. A protective nativity effect was also observed among children of foreign born mothers compared to US born mothers. Our study provides evidence in support of the heterogeneity of childhood asthma by Hispanic ethnicity and maternal nativity. These findings suggest moving beyond solely considering racial/ethnic classifications which could mask subgroups at increased risk of childhood asthma.

Higher measured moisture in California homes with qualitative evidence of dampness

Relationships between measured moisture and qualitative dampness indicators (mold odor, visible mold, visible water damage, or peeling paint) were evaluated using data collected from California homes in a prospective birth cohort study when the infants were 6 or 12 months of age (737 home visits). For repeated visits, agreement between observation of the presence/absence of each qualitative indicator at both visits was high (71-87%, P < 0.0001). Among individual indicators, musty odor and visible mold were most strongly correlated with elevated moisture readings. Measured moisture differed significantly between repeated visits in opposite seasons (P < 0.0001), and dampness increased with the number of indicators in a home. Linear mixed-effect models showed that 10-unit increases in maximum measured moisture were associated with the presence of 0.5 additional dampness indicators (P < 0.001). Bedroom (BR) walls were damper than living room (LR) walls in the same homes (P < 0.0001), although both average and maximum readings were positively correlated across room type (r = 0.75 and 0.67, respectively, both P < 0.0001). Exterior walls were significantly damper than interior walls (P < 0.0001 in both LRs and BRs), but no differences were observed between maximum wall readings and measurements at either window corners or sites of suspected dampness.

A case-control study of innate immunity pathway gene polymorphisms in Puerto Ricans reveals association of toll-like receptor 2 +596 variant with asthma

BACKGROUND

For many years, African Dust Storms (ADE) has been thought to be associated with high prevalence of asthma in Puerto Rico (PR). Endotoxins (ENX) have been associated with ADE particulate matter (PM) and are known to promote pro-inflammatory responses in lung cells of susceptible individuals through the Toll-like receptor (TLR2/4) signaling pathways. Genetic variants are plausible contributors to such susceptibility. Therefore, we have evaluated a series of nine single nucleotide polymorphisms (SNPs) in TLR genes, which have been correlated positive and negatively to asthma prevalence and/or risk, in the Puerto Rican asthmatic population.

METHODS

The following SNPs were evaluated in 62 asthmatics and 61 controls through Taqman® Real Time PCR Assay: TLR4 (+896A/G, +1196C/T, -6687A/G); TLR2 (+596C/T, -16934 T/A, +399A/G, +1349C/T) and CD14 (-159C/T, +1188C/G). Genotypes were assessed for asthma association employing an odds ratio (OR) analysis.

RESULTS

Minor allele frequencies (n = 123) were determined for those variants as 0.07, 0.06, 0.35, 0.35, 0.37, 0.29, 0.04, 0.35 and 0.11, respectively. Two (+596C/T, +399A/G) TLR2 SNPs showed to be more represented in the asthmatic group by 89 % and 65 %, respectively. TLR4 SNP +896A/G analysis revealed only 1 G/G genotype (2 %) on the asthmatic group. The CD14 SNPs were similarly represented in the Puerto Rican population. Only the TLR2 +596 SNP was found to be significantly associated to asthma (OR = 3.24 for CT, 2.71 for TT) and particularly to females.

CONCLUSIONS

The identification of TLR SNPs will reveal potential candidates for gene-environment interactions in Puerto Ricans. As far as we know this is the first study to evaluate this type of TLR gene polymorphisms in Puerto Rican asthmatics, contributing to the current knowledge in the Hispanic population.

Sensitization to mouse and cockroach allergens and asthma morbidity in urban minority youth: Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II)

BACKGROUND

Pest allergen sensitization is associated with asthma morbidity in urban youth but minimally explored in Latino populations. Specifically, the effect of mouse sensitization on the risk of asthma exacerbation has been unexplored in Latino subgroups.

OBJECTIVE

To evaluate whether pest allergen sensitization is a predictor of asthma exacerbations and poor asthma control in urban minority children with asthma.

METHODS

Latino and African American children (8-21 years old) with asthma were recruited from 4 sites across the United States. Logistic regression models evaluated the association of mouse or cockroach sensitization with asthma-related acute care visits or hospitalizations.

RESULTS

A total of 1,992 children with asthma in the Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II) cohorts were studied. Asthmatic children from New York had the highest rate of pest allergen sensitization (42% mouse, 56% cockroach), with the lowest rate in San Francisco (4% mouse, 8% cockroach). Mouse sensitization, more than cockroach, was associated with increased odds of acute care visits (adjusted odds ratio [aOR], 1.47; 95% CI, 1.07-2.03) or hospitalizations (aOR, 3.07; 95% CI, 1.81-5.18), even after controlling for self-reported race and site of recruitment. In stratified analyses, Mexican youth sensitized to mouse allergen did not have higher odds of asthma exacerbation. Other Latino and Puerto Rican youth sensitized to mouse had higher odds of hospitalization for asthma (aORs, 4.57 [95% CI, 1.86-11.22] and 10.01 [95% CI, 1.77-56.6], respectively) but not emergency department visits.

CONCLUSION

Pest allergen sensitization is associated with a higher odds of asthma exacerbations in urban minority youth. Puerto Rican and Other Latino youth sensitized to mouse were more likely to have asthma-related hospitalizations than Mexican youth.

Effectiveness of a multi-level asthma intervention in increasing controller medication use: a randomized control trial

INTRODUCTION

Poor self-management by families is an important factor in explaining high rates of asthma morbidity in Puerto Rico, and for this reason we previously tested a family intervention called CALMA that was found effective in improving most asthma outcomes, but not effective in increasing the use of controller medications. CALMA-plus was developed to address this issue by adding to CALMA, components of provider training and screening for asthma in clinics.

METHODS

Study participants were selected from claims Medicaid data in San Juan, Puerto Rico. After screening, 404 children in eight clinics were selected after forming pairs of clinics and randomizing the clinics) to CALMA-only or CALMA-plus.

RESULTS

For all three primary outcomes at 12 months, the mean differences between treatment arms were small but in the predicted direction. However, after adjusting for clinic variation, the study failed to demonstrate that the CALMA-plus intervention was more efficacious than the CALMA-only intervention for increasing controller medication use, or decreasing asthma symptoms. Both groups had lower rates of asthma symptoms and service utilization, consistent with previous results of the CALMA-only intervention.

CONCLUSIONS

Compliance of providers with the intervention and training, small number of clinics available and the multiple barriers experienced by providers for medicating may have been related to the lack of difference observed between the groups. Future interventions should respond to the limitations of the present study design and provide more resources to providers that will increase provider participation in training and implementation of the intervention.

Occupational exposures and migration factors associated with respiratory health in California Latino farm workers: the MICASA study

OBJECTIVE

To evaluate associations of agricultural work and migration on self-reported respiratory symptoms in a Latino farm worker sample.

METHODS

Work history and respiratory symptoms were assessed in 702 workers through interviews in a community-based cohort.

RESULTS

Prevalence was 6% for asthma, 5% for chronic cough, 3% for chronic bronchitis, and 7% for persistent wheeze. The total number of years in agriculture was associated with asthma; however, time-weighted average dust exposure, use of protective equipment, and pesticide use in the past 12 months were not associated with respiratory outcomes. Living 15 years or more in the United States (adjusted odds ratio = 3.60; 95% confidence interval = 1.16 to 11.16) and medium/high acculturation (adjusted odds ratio = 6.06; 95% confidence interval = 1.40 to 26.29) were associated with increased odds of asthma in women.

CONCLUSIONS

Analysis of this community-based Latino farm worker cohort identified associations with asthma, particularly with migration factors in women.

Genetic Ancestry and Asthma and Rhinitis Occurrence in Hispanic Children: Findings from the Southern California Children's Health Study

Background

Asthma and rhinitis are common childhood health conditions. Being an understudied and rapidly growing population in the US, Hispanic children have a varying risk for these conditions that may result from sociocultural (including acculturative factors), exposure and genetic diversities. Hispanic populations have varying contributions from European, Amerindian and African ancestries. While previous literature separately reported associations between genetic ancestry and acculturation factors with asthma, whether Amerindian ancestry and acculturative factors have independent associations with development of early-life asthma and rhinitis in Hispanic children remains unknown. We hypothesized that genetic ancestry is an important determinant of early-life asthma and rhinitis occurrence in Hispanic children independent of sociodemographic, acculturation and environmental factors.

Methods

Subjects were Hispanic children (5–7 years) who participated in the southern California Children’s Health Study. Data from birth certificates and questionnaire provided information on acculturation, sociodemographic and environmental factors. Genetic ancestries (Amerindian, European, African and Asian) were estimated based on 233 ancestry informative markers. Asthma was defined by parental report of doctor-diagnosed asthma. Rhinitis was defined by parental report of a history of chronic sneezing or runny or blocked nose without a cold or flu. Sample sizes were 1,719 and 1,788 for investigating the role of genetic ancestry on asthma and rhinitis, respectively.

Results

Children had major contributions from Amerindian and European ancestries. After accounting for potential confounders, per 25% increase in Amerindian ancestry was associated with 17.6% (95% confidence interval [CI]: 0.74–0.99) and 13.6% (95% CI: 0.79–0.98) lower odds of asthma and rhinitis, respectively. Acculturation was not associated with either outcome.

Conclusions

Earlier work documented that Hispanic children with significant contribution from African ancestry are at increased asthma risk; however, in Hispanic children who have little contribution from African ancestry, Amerindian ancestry was independently associated with lower odds for development of early-childhood asthma and rhinitis.

Mexican-American caregivers' perceptions about asthma management: a photovoice study

OBJECTIVE

The purpose of this study is to report how photovoice was used to (1) ascertain Mexican-American caregiver perspectives about asthma management, and (2) engage caregivers in dissemination.

METHODS

Eleven Mexican-American caregivers of children with asthma were recruited and given cameras to photograph what helped or hindered their ability to care for their child. Participants prioritized which images to share, discussed the images with the group, and wrote accompanying titles and captions in four photovoice sessions. Sessions were in Spanish and occurred in a community setting. Participants presented their work to peers and community members. Identified issues were subsequently categorized by investigators according to the four components of asthma care.

RESULTS

Participants prioritized 32 phototexts, the majority of which (n = 20, 63%) reflected activities associated with environmental control. Caregivers highlighted asthma triggers, and suggested ways to maintain indoor air quality (IAQ) through home cleaning. The need for policies that enforce smoking bans in shared housing and public places was identified as an important strategy to improve outdoor air quality. "Education for a Partnership in Asthma Care" was represented in six (19%) phototexts. Five phototexts (16%) represented "Assessment and Monitoring". Only one phototext (3.13%) primarily represented "Medications".

CONCLUSIONS

Results support the need for active partnerships between caregivers and providers. Photographs can serve as the basis for reciprocal education between patient and provider, especially in the area of environmental triggers. Provider visits should include assessment, strategies and resources to maximize IAQ. Photovoice facilitates caregivers' ability to advocate for improved asthma management and health equity.

Asthma in Latin America

Consistent with the diversity of Latin America, there is profound variability in asthma burden among and within countries in this region. Regional variation in asthma prevalence is likely multifactorial and due to genetics, perinatal exposures, diet, obesity, tobacco use, indoor and outdoor pollutants, psychosocial stress and microbial or parasitic infections. Similarly, non-uniform progress in asthma management leads to regional variability in disease morbidity. Future studies of distinct asthma phenotypes should follow-up well-characterised Latin American subgroups and examine risk factors that are unique or common in Latin America (eg, stress and violence, parasitic infections and use of biomass fuels for cooking). Because most Latin American countries share the same barriers to asthma management, concerted and multifaceted public health and research efforts are needed, including approaches to curtail tobacco use, campaigns to improve asthma treatment, broadening access to care and clinical trials of non-pharmacological interventions (eg, replacing biomass fuels with gas or electric stoves).

"Where they (live, work and) spray": pesticide exposure, childhood asthma and environmental justice among Mexican-American farmworkers

Asthma prevalence is reportedly low for children of Mexican descent compared with other ethnic groups and Latino subgroups. The results of our exploratory ethnographic research among children of farmworkers in California dramatically suggest otherwise. Unstructured and semi-structured open-ended interviews and photovoice methods were combined to explore the lived experiences of members of a marginalized farmworker community. This research gives voice to a population of families living in the highly toxic, yet agriculturally wealthy environment of the San Joaquin Valley. Little work has been reported employing photovoice, a community-based participatory research method, to study childhood exposure to pesticides. A rich narrative about perceptions of pesticide exposure emerged from the ethnographic interviews. Thematic analysis yielded beliefs about the relationship between air quality and childhood asthma. The findings suggest that childhood asthma should be reviewed within the context of local levels of environmental exposure and the principles of environmental justice.

Asthma prevalence among Hispanic adults in Puerto Rico and Hispanic adults of Puerto Rican descent in the United States - results from two national surveys

Abstract Objective: To assess whether asthma prevalence differs between Hispanic adults living in Puerto Rico and Hispanic adults of Puerto Rican descent living in the United States.

METHODS

We used 2008-2010 Behavioral Risk Factor Surveillance System data, administered in Puerto Rico for Hispanic adults living in Puerto Rico (Hispanics in Puerto Rico), and 2008-2010 National Health Interview Survey data for Hispanic adults of Puerto Rican descent living in the United States (Puerto Rican Americans). We used 95% confidence intervals (CIs) to compare asthma prevalence between corresponding subgroups; non-overlapping CIs indicate statistical significance. Chi-square test and multivariate logistic regression were used to assess the association between current asthma status and socio-demographic factors and health risk behaviors within each Puerto Rican population.

RESULTS

Current asthma prevalence among Hispanics in Puerto Rico (7.0% [6.4%-7.7%]) was significantly lower than the prevalence among Puerto Rican Americans (15.6% [13.0%-18.1%]). The prevalence among almost all socio-demographic and health risk subgroups of Hispanics in Puerto Rico was significantly lower than the prevalence among the corresponding subgroups of Puerto Rican Americans. Adjusting for potential confounders did not alter the results. Asthma prevalence was significantly associated with obesity among Puerto Rican Americans (adjusted prevalence ratios [aPR]=1.5 [1.1-2.0]), and among Hispanics in Puerto Rico was associated with obesity (aPR=1.6 [1.3-1.9]), smoking (aPR=1.4 [1.1-1.9]) and being female (aPR=1.9 [1.5-2.4]).

CONCLUSION

Asthma was more prevalent among Puerto Rican Americans than Hispanics in Puerto Rico. Although the observed associations did not explain all variations in asthma prevalence between these two populations, they may lay the foundation for future research.

Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities

This review explores the limitations of self-reported race, ethnicity, and genetic ancestry in biomedical research. Various terminologies are used to classify human differences in genomic research including race, ethnicity, and ancestry. Although race and ethnicity are related, race refers to a person's physical appearance, such as skin color and eye color. Ethnicity, on the other hand, refers to communality in cultural heritage, language, social practice, traditions, and geopolitical factors. Genetic ancestry inferred using ancestry informative markers (AIMs) is based on genetic/genomic data. Phenotype-based race/ethnicity information and data computed using AIMs often disagree. For example, self-reporting African Americans can have drastically different levels of African or European ancestry. Genetic analysis of individual ancestry shows that some self-identified African Americans have up to 99% of European ancestry, whereas some self-identified European Americans have substantial admixture from African ancestry. Similarly, African ancestry in the Latino population varies between 3% in Mexican Americans to 16% in Puerto Ricans. The implication of this is that, in African American or Latino populations, self-reported ancestry may not be as accurate as direct assessment of individual genomic information in predicting treatment outcomes. To better understand human genetic variation in the context of health disparities, we suggest using "ancestry" (or biogeographical ancestry) to describe actual genetic variation, "race" to describe health disparity in societies characterized by racial categories, and "ethnicity" to describe traditions, lifestyle, diet, and values. We also suggest using ancestry informative markers for precise characterization of individuals' biological ancestry. Understanding the sources of human genetic variation and the causes of health disparities could lead to interventions that would improve the health of all individuals.

Stress and asthma: novel insights on genetic, epigenetic, and immunologic mechanisms

In the United States the economically disadvantaged and some ethnic minorities are often exposed to chronic psychosocial stressors and disproportionately affected by asthma. Current evidence suggests a causal association between chronic psychosocial stress and asthma or asthma morbidity. Recent findings suggest potential mechanisms underlying this association, including changes in the methylation and expression of genes that regulate behavioral, autonomic, neuroendocrine, and immunologic responses to stress. There is also evidence suggesting the existence of susceptibility genes that predispose chronically stressed youth to both post-traumatic stress disorder and asthma. In this review we critically examine published evidence and suggest future directions for research in this field.

Asthma in Hispanics. An 8-year update

This review provides an update on asthma in Hispanics, a diverse group tracing their ancestry to countries previously under Spanish rule. A marked variability in the prevalence and morbidity from asthma remains among Hispanic subgroups in the United States and Hispanic America. In the United States, Puerto Ricans and Mexican Americans have high and low burdens of asthma, respectively (the "Hispanic Paradox"). This wide divergence in asthma morbidity among Hispanic subgroups is multifactorial, likely reflecting the effects of known (secondhand tobacco smoke, air pollution, psychosocial stress, obesity, inadequate treatment) and potential (genetic variants, urbanization, vitamin D insufficiency, and eradication of parasitic infections) risk factors. Barriers to adequate asthma management in Hispanics include economic and educational disadvantages, lack of health insurance, and no access to or poor adherence with controller medications such as inhaled corticosteroids. Although considerable progress has been made in our understanding of asthma in Hispanic subgroups, many questions remain. Studies of asthma in Hispanic America should focus on environmental or lifestyle factors that are more relevant to asthma in this region (e.g., urbanization, air pollution, parasitism, and stress). In the United States, research studies should focus on risk factors that are known to or may diverge among Hispanic subgroups, including but not limited to epigenetic variation, prematurity, vitamin D level, diet, and stress. Clinical trials of culturally appropriate interventions that address multiple aspects of asthma management in Hispanic subgroups should be prioritized for funding. Ensuring high-quality healthcare for all remains a pillar of eliminating asthma disparities.

Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families

OBJECTIVE

The current study sought to evaluate patterns of complementary and alternative medicine (CAM) use in a sample of Latino and non-Latino white (NLW) children with asthma to determine whether parental beliefs about conventional medications and barriers to obtaining these medications were related to CAM use and to assess whether CAM use was associated with decreased adherence to controller medications.

METHODS

Participants included 574 families of children with asthma from NLW, Puerto Rican (PR), and Dominican backgrounds from Rhode Island (RI) and from Island PR. All parents completed a brief checklist of barriers to medication use and an assessment of CAM approaches. A subsample of 259 families had controller medication use monitored objectively for approximately 1 month by MDILog (fluticasone propionate), TrackCap (montelukast), or dosage counter (fluticasone/salmeterol combination).

RESULTS

Prevalence of CAM use was high among Latino families. Perceived barriers to obtaining medication were related to increased CAM use in PR families from RI. Elevated medication concerns were positively associated with CAM use among NLW and Island PR families. CAM use was positively related to objective adherence within NLW families, and unrelated in other groups.

CONCLUSIONS

CAM use is common among Latino families with asthma. Among some families, CAM use may be initiated as a way to cope with barriers to obtaining medication or when parents have concerns about conventional medications. Families who report CAM use do not appear to be substituting CAM for conventional asthma medication.

Socioeconomic and sociodemographic factors associated with asthma related outcomes in early childhood: the Generation R Study

Rationale

Few studies have analyzed the association of socioeconomic and sociodemographic factors with asthma related outcomes in early childhood, including Fraction of exhaled Nitric Oxide (FeNO) and airway resistance (Rint). We examined the association of socioeconomic and sociodemographic factors with wheezing, asthma, FeNO and Rint at age 6 years. Additionally, the role of potential mediating factors was studied.

Methods

The study included 6717 children participating in The Generation R Study, a prospective population-based cohort study. Data on socioeconomic and sociodemographic factors, wheezing and asthma were obtained by questionnaires. FeNO and Rint were measured at the research center. Statistical analyses were performed using logistic and linear regression models.

Results

At age 6 years, 9% (456/5084) of the children had wheezing symptoms and 7% (328/4953) had asthma. Children from parents with financial difficulties had an increased risk of wheezing (adjusted Odds Ratio (aOR) = 1.63, 95% Confidence Interval (CI):1.18–2.24). Parental low education, paternal unemployment and child's male sex were associated with asthma, independent of other socioeconomic or sociodemographic factors (aOR = 1.63, 95% CI:1.24–2.15, aOR = 1.85, 95% CI:1.11–3.09, aOR = 1.58, 95% CI:1.24–2.01, respectively). No socioeconomic or gender differences in FeNO were found. The risks of wheezing, asthma, FeNO and Rint measurements differed between ethnic groups (p<0.05). Associations between paternal unemployment, child's sex, ethnicity and asthma related outcomes remained largely unexplained.

Conclusions

This study showed differences between the socioeconomic and sociodemographic correlates of wheezing and asthma compared to the correlates of FeNO and Rint at age 6 years. Several socioeconomic and sociodemographic factors were independently associated with wheezing and asthma. Child's ethnicity was the only factor independently associated with FeNO. We encourage further studies on underlying pathways and public health intervention programs, focusing on reducing socioeconomic or sociodemographic inequalities in asthma.

Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults

BACKGROUND

Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers.

OBJECTIVE

To conduct a pilot study to assess feasibility, acceptability and preliminary evidence of effectiveness.

METHODS

A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a non-professional, modeled preparations for a medical visit, attended the visit and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid (ICS) adherence, asthma control, quality of life, FEV1, emergency department (ED) visits and hospitalizations. Mixed-effects models guided an intention-to-treat analysis.

RESULTS

100 adults participated: age 47 ± 14 years, 75% female, 71% African-American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p = 0.001) but not significantly in the PA group (p = 0.30). Both PA and MI groups demonstrated improved asthma control (p = 0.01 in both) and quality of life (p = 0.001, p = 0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups.

CONCLUSION

The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life.

A twin study of early-childhood asthma in Puerto Ricans

BACKGROUND

The relative contributions of genetics and environment to asthma in Hispanics or to asthma in children younger than 3 years are not well understood.

OBJECTIVE

To examine the relative contributions of genetics and environment to early-childhood asthma by performing a longitudinal twin study of asthma in Puerto Rican children ≤ 3 years old.

METHODS

678 twin infants from the Puerto Rico Neo-Natal Twin Registry were assessed for asthma at age 1 year, with follow-up data obtained for 624 twins at age 3 years. Zygosity was determined by DNA microsatellite profiling. Structural equation modeling was performed for three phenotypes at ages 1 and 3 years: physician-diagnosed asthma, asthma medication use in the past year, and ≥ 1 hospitalization for asthma in the past year. Models were additionally adjusted for early-life environmental tobacco smoke exposure, sex, and age.

RESULTS

The prevalences of physician-diagnosed asthma, asthma medication use, and hospitalization for asthma were 11.6%, 10.8%, 4.9% at age 1 year, and 34.1%, 40.1%, and 8.5% at 3 years, respectively. Shared environmental effects contributed to the majority of variance in susceptibility to physician-diagnosed asthma and asthma medication use in the first year of life (84%-86%), while genetic effects drove variance in all phenotypes (45%-65%) at age 3 years. Early-life environmental tobacco smoke, sex, and age contributed to variance in susceptibility.

CONCLUSION

Our longitudinal study in Puerto Rican twins demonstrates a changing contribution of shared environmental effects to liability for physician-diagnosed asthma and asthma medication use between ages 1 and 3 years. Early-life environmental tobacco smoke reduction could markedly reduce asthma morbidity in young Puerto Rican children.

Parental numeracy and asthma exacerbations in Puerto Rican children

BACKGROUND

Puerto Ricans share a disproportionate burden of childhood asthma in the United States. Little is known about the impact of low parental numeracy (a health literacy skill) on asthma morbidity in Puerto Rican children. Our objective was to examine whether low parental numeracy is associated with increased asthma morbidity in Puerto Rican children.

METHODS

This was a cross-sectional study of 351 children with asthma, aged 6 to 14 years, living in San Juan, Puerto Rico. Parents of study participants completed a modified version of the Asthma Numeracy Questionnaire. Multivariate linear or logistic regression was used to examine the relation between low parental numeracy (defined as no correct answers in the modified Asthma Numeracy Questionnaire) and indicators of asthma morbidity (severe asthma exacerbations, core measures of asthma exacerbations, and lung function measures). All multivariate models were adjusted for age, sex, household income, reported use of inhaled corticosteroids in the previous 6 months, and exposure to secondhand tobacco smoke.

RESULTS

Low parental numeracy was associated with increased odds of visits to the ED or urgent care for asthma (adjusted OR [aOR]=1.7, 95% CI=1.03-2.7, P=.04). The association between low parental numeracy and hospitalizations for asthma was significant only among children not using inhaled corticosteroids (aOR=2.8, 95% CI=1.4-5.6, P=.004). There was no association between low parental numeracy and use of systemic steroids or lung function measures.

CONCLUSIONS

Low parental numeracy is associated with increased asthma morbidity in Puerto Rican children.

Asthma care in resource-poor settings

Asthma prevalence in low- to middle-income countries is at least the same or higher than in rich countries, but with increased severity. Lack of control in these settings is due to various factors such as low accessibility to effective medications, multiple and uncoordinated weak infrastructures of medical services for the management of chronic diseases such as asthma, poor compliance with prescribed therapy, lack of asthma education, and social and cultural factors. There is an urgent requirement for the implementation of better ways to treat asthma in underserved populations, enhancing the access to preventive medications and educational approaches with modern technological methods.

The longitudinal relationship between parental reports of asthma and anxiety and depression symptoms among two groups of Puerto Rican youth

OBJECTIVES

This study aims to examine the relationship between parental reports of child asthma and levels and slopes of anxiety and depression symptoms among two contrasting groups of Puerto Rican youth, and to determine whether asthma is a special risk above and beyond parents' reports of other youths' medical conditions.

METHODS

Two probability samples of youth in San Juan and Caguas, Puerto Rico (n=673) and in the south Bronx, New York (n=598), and their caretakers were interviewed in three yearly assessments. Parental reports of their children's asthma during each assessment were used to indicate whether youth had intermittent (PR=34%, NY=23%) or persistent (PR=7%, NY=16%) asthma. Youths' depression and anxiety symptoms were assessed using self reports to the DISC-IV. Information on youths' medical comorbidity was gathered through parental reports.

RESULTS

Multilevel analyses adjusting for comorbid medical conditions indicated that parental reports of youths' intermittent and persistent asthma were related to higher levels, but similar slopes, of anxiety and depression among youth in New York. In Puerto Rico, youth with persistent asthma experienced less improvement in anxiety over time than youth without asthma, but no other associations were found.

CONCLUSION

Having asthma, based on parental reports, represents a risk factor for Puerto Rican youths' internalizing symptoms, even after adjusting for comorbid medical conditions. This risk is more pronounced among youth living in New York, which highlights the importance of considering the social context in which youth develop and minority status when examining associations between physical health risk factors and mental health.

Ethnic differences in caregiver quality of life in pediatric asthma

OBJECTIVE

The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican [PR] and Dominican) and non-Latino white caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.

METHOD

Seven hundred and eighty-seven children with asthma (7-16 years of age) and their primary caregivers participated in the study. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.

RESULTS

Ethnic and site differences were found on total QOL scores (ΔF(1,783) = 29.46, p < .001). Island PR caregivers reported worse QOL scores than Rhode Island (Rl) Latino and non-Latino white caregivers; Rl Latino caregivers reported significantly worse QOL scores than non-Latino white caregivers. In Rl Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with one or more emergency department visits.

CONCLUSION

Latino caregivers may be experiencing a greater level of burden related to their child's asthma than non-Latino white caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.

Body mass index and mortality rate among Hispanic adults: a pooled analysis of multiple epidemiologic data sets

OBJECTIVE

To evaluate the association between body mass index (BMI, kg m⁻²) and mortality rate among Hispanic adults.

METHODS AND PROCEDURES

Analysis of five data sets (total N=16,798) identified after searching for publicly available, prospective cohort data sets containing relevant information for at least 500 Hispanic respondents (≥18 years at baseline), at least 5 years of mortality follow-up, and measured height and weight. Data sets included the third National Health and Nutrition Examination Survey, the Puerto Rico Heart Health Program (PRHHP), the Hispanic Established Population for Epidemiologic Studies of the Elderly (HEPESE), the San Antonio Heart Study (SAHS) and the Sacramento Area Latino Study on Aging.

RESULTS

Cox proportional hazards regression models, adjusting for sex and smoking, were fit within three attained-age strata (18 to younger than 60 years, 60 to younger than 70 years, and 70 years and older). We found that underweight was associated with elevated mortality rate for all age groups in the PRHHP (hazard ratios [HRs]=1.38-1.60) and the SAHS (HRs=1.88-2.51). Overweight (HRs=0.38 and 0.84) and obesity grade 2-3 (HRs=0.75 and 0.60) associated with reduced mortality rate in the HEPESE dataset for those in the 60 to younger than 70 years, and 70 years and older attained-age strata. Weighted estimates combining the HRs across the data sets revealed a similar pattern.

CONCLUSION

Among Hispanic adults, there was no clear evidence that overweight and obesity associate with elevated mortality rate.

Mouse allergen, lung function, and atopy in Puerto Rican children

Objective

To examine the relation between mouse allergen exposure and asthma in Puerto Rican children.

Methods

Mus m 1, Der p 1, Bla g 2, and Fel d 1 allergens were measured in dust samples from homes of Puerto Rican children with (cases) and without (controls) asthma in Hartford, CT (n = 449) and San Juan (SJ), Puerto Rico (n = 678). Linear or logistic regression was used for the multivariate analysis of mouse allergen (Mus m 1) and lung function (FEV₁ and FEV₁/FVC) and allergy (total IgE and skin test reactivity (STR) to ≥1 allergen) measures.

Results

Homes in SJ had lower mouse allergen levels than those in Hartford. In multivariate analyses, mouse allergen was associated with higher FEV₁ in cases in Hartford (+70.6 ml, 95% confidence interval (CI) = 8.6–132.7 ml, P = 0.03) and SJ (+45.1 ml, 95% CI =  −0.5 to 90.6 ml, P = 0.05). In multivariate analyses of controls, mouse allergen was inversely associated with STR to ≥1 allergen in non-sensitized children (odds ratio [OR] for each log-unit increment in Mus m 1 = 0.7, 95% CI = 0.5–0.9, P<0.01). In a multivariate analysis including all children at both study sites, each log-increment in mouse allergen was positively associated with FEV₁ (+28.3 ml, 95% CI = 1.4–55.2 ml, P = 0.04) and inversely associated with STR to ≥1 allergen (OR for each log-unit increment in Mus m 1 = 0.8, 95% CI = 0.6–0.9, P<0.01).

Conclusions

Mouse allergen is associated with a higher FEV₁ and lower odds of STR to ≥1 allergen in Puerto Rican children. This may be explained by the allergen itself or correlated microbial exposures.

Cut points for Asthma Control Tests in Mexican children in Orange County, California

BACKGROUND

The Childhood Asthma Control Test (C-ACT) and the Asthma Control Test (ACT) are validated measures of asthma control in which a score of 19 is defined as uncontrolled according to published reports. However, different cut points may exist in different ethnic populations.

OBJECTIVE

To determine the cut point for uncontrolled asthma in a Mexican descent population from Orange Country, California, compared with an age- and asthma severity-matched non-Hispanic cohort.

METHODS

The C-ACT (in children 6-11 years old) and ACT (in children 12-17 years old) scores were collected from 151 children of Mexican descent and 48 non-Hispanic controls with mild-to-moderate asthma who lived in Orange County. Physicians were masked to C-ACT and ACT scores while assessing control based on National Asthma Education and Prevention program guidelines. The receiver operating characteristic method was used to examine the screening accuracy of the tests to detect uncontrolled asthma. The optimal cut points were selected by maximizing the total sensitivity and specificity.

RESULTS

Cronbach α values for the C-ACT (0.76) and the ACT (0.80) confirmed that both tests were reliable in our study population. The C-ACT and ACT scores were statistically higher in children of Mexican descent than non-Hispanic children (P = .008). A cut point of 22 was optimal to detect uncontrolled asthma in children of Mexican descent 6 to 11 years old (group 1: sensitivity, 0.74; specificity, 0.86; area under the curve [AUC], 0.83) and children 12 to 17 years old (group 3: sensitivity, 0.78; specificity, 0.68; AUC, 0.79). For non-Hispanic controls, a cut point of 20 were optimal to detect uncontrolled asthma in children 6 to 11 years old (group 2: sensitivity, 0.70; specificity, 0.91; AUC, 0.86) and children 12 to 17 years old (group 4: sensitivity, 0.83; specificity, 0.87; AUC, 0.91).

CONCLUSION

In this cross-ethnic validation study, children of Mexican descent in Orange County seem to underreport asthma symptoms compared with a non-Hispanic population and may require higher C-ACT and ACT cut points to detect uncontrolled asthma.

Paediatric asthma hospital utilization varies by demographic factors and area socio-economic status

OBJECTIVES

Associations of emergency department (ED) visits and hospital admissions for asthma in children with demographics and area socio-economic status (SES) were examined to evaluate long-term trends and identify vulnerable populations.

STUDY DESIGN

Retrospective population-based trend and cross-sectional analyses.

METHODS

Asthma hospital admissions (2000-2007) and ED visits (2005-2007) for children aged 0-14 years living in Orange County, California were linked with zip-code-level SES data (2000 US Census). Annual population estimates were obtained to calculate age-specific admissions and ED visit rates. Average annual percentage changes (AAPC) were calculated with joinpoint analyses. The risks of ED visits and hospital admissions were estimated from SES indicators with negative binomial regression.

RESULTS

Rates of asthma hospital admissions and ED visits were highest among children aged 0-4 years, males and African Americans, and lowest among Asian/Pacific Islanders. African Americans and Hispanics/Latinos were more likely to be uninsured. Asthma admissions decreased significantly for all age groups over the study period. The greatest declines per 100,000 were among children aged 0-4 years (AAPC: -15.3%, 95% confidence interval -17.0% to -13.4%). Rates of hospital admissions and ED visits were significantly higher in low-SES groups. Hospital admission rates were 30-60% higher and ED visits were 80-90% higher in zip codes in the lowest tertile of median household income compared with the highest tertile of median household income.

CONCLUSIONS

Paediatric asthma hospitalizations and ED visit rates are declining in Orange County. However, certain groups are disproportionately affected, including those living in areas with low SES. This information will help in targeting intervention strategies to children at highest risk for severe asthma episodes.

Exposures to fine particulate air pollution and respiratory outcomes in adults using two national datasets: a cross-sectional study

BACKGROUND

Relationships between chronic exposures to air pollution and respiratory health outcomes have yet to be clearly articulated for adults. Recent data from nationally representative surveys suggest increasing disparity by race/ethnicity regarding asthma-related morbidity and mortality. The objectives of this study are to evaluate the relationship between annual average ambient fine particulate matter (PM2.5) concentrations and respiratory outcomes for adults using modeled air pollution and health outcome data and to examine PM2.5 sensitivity across race/ethnicity.

METHODS

Respondents from the 2002-2005 National Health Interview Survey (NHIS) were linked to annual kriged PM2.5 data from the USEPA AirData system. Logistic regression was employed to investigate increases in ambient PM2.5 concentrations and self-reported prevalence of respiratory outcomes including asthma, sinusitis and chronic bronchitis. Models included health, behavioral, demographic and resource-related covariates. Stratified analyses were conducted by race/ethnicity.

RESULTS

Of nearly 110,000 adult respondents, approximately 8,000 and 4,000 reported current asthma and recent attacks, respectively. Overall, odds ratios (OR) for current asthma (0.97 (95% Confidence Interval: 0.87-1.07)) and recent attacks (0.90 (0.78-1.03)) did not suggest an association with a 10 μg/m3 increase in PM2.5. Stratified analyses revealed significant associations for non-Hispanic blacks [OR = 1.73 (1.17-2.56) for current asthma and OR = 1.76 (1.07-2.91) for recent attacks] but not for Hispanics and non-Hispanic whites. Significant associations were observed overall (1.18 (1.08-1.30)) and in non-Hispanic whites (1.31 (1.18-1.46)) for sinusitis, but not for chronic bronchitis.

CONCLUSIONS

Non-Hispanic blacks may be at increased sensitivity of asthma outcomes from PM2.5 exposure. Increased chronic PM2.5 exposures in adults may contribute to population sinusitis burdens.

Bronchial hyperresponsiveness, word descriptors, and ethnicity: women with mild asthma

BACKGROUND

Few studies have examined the ethnic differences in symptom reporting and airway hyperresponsiveness (AHR) for women with mild asthma during a methacholine (McH) challenge.

OBJECTIVE

The purpose of this sub-analysis was to determine: (1) whether AHR to McH varied by the ethnicity of women with mild asthma and (2) whether ethnic word descriptors (EWDs) varied by the ethnicity during induced bronchoconstriction.

METHODS

Specific inclusion criteria included the following: FEV(1) (forced expiratory volume in 1 second) ≥ 70% predicted normal, PC(30) ≤ 8 mg/McH, β(2) inhaler only, and self-reported ethnicity of African American (AFAM), Mexican American-Hispanic-Latino (MexAMLat), Asian-Pacific Islander (Asian PI), or white. Serial pulmonary function testing (PFT) and Borg, visual analogue scale (VAS), and EWDs were collected.

RESULTS

A total of 44 women, mean age of 31.3 years old, with a mean baseline FEV(1) of 2.85 L comprised this sub-analysis. Ethnic-racial diversity included: 12 AFAMs, 5 MexAMLat, 13 Asian-PIs, and 14 whites. All had atopy ≥ 2 pinprick responses of 3 mm. At PC(30), Asian-PI women required a significantly (p < .05) smaller mean dose of McH 1.9 mg/mL. MexAMLat women required an McH dose of 1.6 mg/mL. At PC(30), McH dose was 2.9 mg/mL for AFAMs and 3.0 mg/mL for whites, respectively. Asian-PIs who used only upper airway EWDs at PC(30) vere itchy throat, itchy chin, and constricted throat (p < .001). AFAMs significant EWDs were itchy throat, itchy chin/face, and tight throat (p < .01). Lower airway EWD was used by both MexAMLat and whites. Significant EWD for Whites were tight chest (p < .01) and hard to inhale/lungs tight (p < .001).

CONCLUSION

Asian-PI women required a significantly smaller dose (p < .05) of McH to induce a PC(30). AFAM and whites required a comparable dose of Mch at PC(30). Asian-PI and AFAM women used only upper airway EWD. Asian-PI women may be at a greater risk for acute asthma episodes that are not recognized or treated due to their upper airway symptom reporting.

Socio-demographic disparities of childhood asthma

Childhood asthma is particularly prevalent among disadvantaged children and is associated with greater functional consequences. This study described factors associated with childhood asthma in a sample of Latino and non-Latino children. Data were from baseline measures of 791 parent and child dyads involved in a childhood obesity prevention study. Parents completed a self-administered survey assessing childhood factors, demographics, acculturation and child asthma diagnosis. Multivariate mixed effects logistic regression analyses tested for correlates of child asthma and ethnicity interactions. Children were 4-10 years old, half were female, 86.0 percent were US-born and 45.7 percent were overweight or obese. The prevalence of childhood asthma was 11.5 percent. In multivariate analyses, the odds of childhood asthma were greater among children of non-Latino descent (OR = 4.1, CI: 1.8, 9.2), who had health insurance (OR = 11.1, CI: 2.7, 46.4), were male (OR = 1.8; CI: 1.1, 3.1) and born pre-term (OR = 3.0, CI: 1.4, 6.3). This study supports socio-demographic disparities in childhood asthma and evidence of their independent effects.