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Grunwell JR, Mutic AD, Ezhuthachan ID, Mason C, Tidwell M, Caldwell C, Norwood J, Zack S, Jordan N, Fitzpatrick AM. Environmental Injustice Is Associated With Poorer Asthma Outcomes in School-Age Children With Asthma in Metropolitan Atlanta, Georgia. J Allergy Clin Immunol Pract 2024; 12:1263-1272.e1. [PMID: 38378096 PMCID: PMC11081836 DOI: 10.1016/j.jaip.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Environmental justice mandates that no person suffers disproportionately from environmental exposures. The Environmental Justice Index (EJI) provides an estimate of the environmental burden for each census tract but has not yet been used in asthma populations. OBJECTIVE We hypothesized that children from census tracts with high environmental injustice determined by the EJI would have a greater burden of asthma exacerbations, poorer asthma control, and poorer lung function over 12 months. METHODS Children aged 6 to 18 years with asthma (N = 575) from metropolitan Atlanta, Georgia, completed a baseline research visit. Participant addresses were geocoded to obtain the EJI Social-Environmental Ranking for each participant's census tract, which was divided into tertiles. Medical records were reviewed for 12 months for asthma exacerbations. A subset of participants completed a second research visit involving spirometry and questionnaires. RESULTS Census tracts with the greatest environmental injustice had more racial and ethnic minorities, lower socioeconomic status, more hazardous exposures (particularly to airborne pollutants), and greater proximity to railroads and heavily trafficked roadways. Children with asthma residing in high injustice census tracts had a longer duration of asthma, greater historical asthma-related health care utilization, poorer asthma symptom control and quality of life, and more impaired lung function. By 12 months, children from high injustice census tracts also had more asthma exacerbations with a shorter time to exacerbation and persistently more symptoms, poorer asthma control, and reduced lung function. CONCLUSIONS Disparities in environmental justice are present in metropolitan Atlanta that may contribute to asthma outcomes in children. These findings require an additional study and action to improve health equity.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - Idil D Ezhuthachan
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Allergy and Immunology, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Carrie Mason
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Mallory Tidwell
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cherish Caldwell
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jalicae Norwood
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Sydney Zack
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Natalie Jordan
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. J Allergy Clin Immunol Pract 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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Mutic AD, Mauger DT, Grunwell JR, Opolka C, Fitzpatrick AM. Social Vulnerability Is Associated with Poorer Outcomes in Preschool Children With Recurrent Wheezing Despite Standardized and Supervised Medical Care. The Journal of Allergy and Clinical Immunology: In Practice 2022; 10:994-1002. [PMID: 35123099 PMCID: PMC9007879 DOI: 10.1016/j.jaip.2021.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/13/2021] [Accepted: 12/31/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Social determinants of health are associated with disparate asthma outcomes in school-age children. Social determinants have not been studied in preschool children with recurrent wheezing. OBJECTIVE We hypothesized that preschool children with recurrent wheezing at highest risk of social vulnerability would have more frequent symptoms and exacerbations when followed over 1 year, despite receiving standardized and supervised asthma care. METHODS A multicenter population of adherent preschool children receiving standardized and supervised care for wheezing was stratified by a composite measure of social vulnerability based on individual-level variables. Primary outcomes included days with upper respiratory infections and days with asthma symptom flares. Other outcomes included symptom scores during upper respiratory infections and respiratory symptom flare days, exacerbation occurrence, quality of life during the exacerbation, and hospitalization. RESULTS Preschool children at highest risk of social vulnerability did not have more frequent upper respiratory infections, respiratory symptoms, or exacerbations, but instead had more severe symptoms during upper respiratory infections and respiratory flare days, as well as more severe exacerbations with significantly poorer caregiver quality of life. Children at highest risk of social vulnerability also lived in poorer housing conditions with differing exposures and self-reported triggers. CONCLUSIONS Individual-level social determinants of health reflecting social vulnerability are associated with poorer outcomes in preschool children with recurrent wheezing despite access to supervised and standardized care. Comprehensive assessment of social determinants of health is warranted in even the youngest children with wheezing, because mitigation of these social inequities is an essential first step toward improving outcomes in pediatric patients.
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Affiliation(s)
- Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Pennsylvania State University, Hershey, Pa
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cydney Opolka
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Ga.
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Fitzpatrick AM, Mutic AD, Mohammad AF, Stephenson ST, Grunwell JR. Obesity Is Associated with Sustained Symptomatology and Unique Inflammatory Features in Children with Asthma. J Allergy Clin Immunol Pract 2022; 10:815-826.e2. [PMID: 34688962 PMCID: PMC8917992 DOI: 10.1016/j.jaip.2021.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Obesity complicates the clinical manifestations of asthma in children. However, few studies have examined longitudinal outcomes or markers of systemic inflammation in obese asthmatic children. OBJECTIVE We hypothesized that obese children with asthma would have: (1) poorer clinical outcomes over 12 months, (2) decreased responsiveness to systemic corticosteroid administration, (3) greater markers of systemic inflammation, and (4) unique amino acid metabolites associated with oxidative stress. METHODS Children 6 to 17 years of age (lean, N = 257; overweight, N = 99; obese, N = 138) completed a baseline visit and follow-up visit at 12 months. Outcome measures included asthma control, quality of life, lung function, and exacerbations. A subset received intramuscular triamcinolone and were re-evaluated at 7(+7) days. Leptin, adiponectin, C-reactive protein, total cholesterol, interleukin (IL)-1β, IL-6, IL-17, interferon gamma, tumor necrosis factor alpha, monocyte-chemoattractant protein-1, and amino acid metabolites were also quantified in plasma as potential biomarkers of outcomes in obese children. RESULTS Obesity was associated with more symptoms, poorer quality life, and more exacerbations that persisted over 1 year despite greater medication requirements. Obese children also had minimal clinical improvement in asthma control and lung function after intramuscular triamcinolone. Leptin, C-reactive protein, and amino acid metabolites associated with glutathione synthesis and oxidative stress differed in obese children. Within the obese group, lower concentrations of arginine-related metabolites also distinguished uncontrolled from controlled asthma at 12 months. CONCLUSION Obesity is associated with poorer asthma outcomes and unique systemic inflammatory features that may not be adequately modified with conventional asthma therapies. Novel approaches may be needed given increased symptoms and unique inflammation and oxidative stress in obese children with asthma.
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Affiliation(s)
- Anne M. Fitzpatrick
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia,Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Abby D. Mutic
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Ahmad F. Mohammad
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia
| | - Susan T. Stephenson
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia
| | - Jocelyn R. Grunwell
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia,Children’s Healthcare of Atlanta, Atlanta, Georgia
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Mutic AD, Mix JM, Elon L, Mutic NJ, Economos J, Flocks J, Tovar-Aguilar AJ, McCauley LA. Classification of Heat-Related Illness Symptoms Among Florida Farmworkers. J Nurs Scholarsh 2017; 50:74-82. [PMID: 29024370 DOI: 10.1111/jnu.12355] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Farmworkers working in hot and humid environments have an increased risk for heat-related illness (HRI) if their thermoregulatory capabilities are overwhelmed. The manifestation of heat-related symptoms can escalate into life-threatening events. Increasing ambient air temperatures resulting from climate change will only exacerbate HRI in vulnerable populations. We characterize HRI symptoms experienced by farmworkers in three Florida communities. METHODS A total of 198 farmworkers enrolled in 2015-2016 were asked to recall if they experienced seven HRI symptoms during the previous work week. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between selected sociodemographic characteristics and reporting three or more symptoms. Latent class analysis was used to identify classes of symptoms representing the HRI severity range. We examined sociodemographic characteristics of the farmworkers across the latent classes. RESULTS The mean age (±SD) of farmworkers was 38.0 (±8) years; the majority were female (60%) and Hispanic (86%). Most frequently reported symptoms were heavy sweating (66%), headache (58%), dizziness (32%), and muscle cramps (30%). Females had three times the odds of experiencing three or more symptoms (OR = 2.86, 95% CI 1.18-6.89). Symptoms fell into three latent classes, which included mild (heavy sweating; class probability = 54%), moderate (heavy sweating, headache, nausea, and dizziness; class probability = 24%), and severe (heavy sweating, headache, nausea, dizziness, muscle cramps; class probability = 22%). CONCLUSIONS Farmworkers reported a high burden of HRI symptoms that appear to cluster in physiologic patterns. Unrecognized accumulation of symptoms can escalate into life-threatening situations if untreated. Our research can inform interventions to promote early recognition of HRI, on-site care, and appropriate occupational health policy. Administrative or engineering workplace controls may also reduce the manifestation of HRI. CLINICAL RELEVANCE This study advances the current knowledge of HRI symptoms in farmworkers and moves beyond reporting individual symptoms by utilizing latent class analysis to identify how symptoms tend to co-occur together in this population. It acknowledges multiple symptoms occurring as a result of occupational heat exposure and highlights the importance of symptom recognition.
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Affiliation(s)
- Abby D Mutic
- Iota, Certified Nurse Midwife, Doctoral Candidate, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Jacqueline M Mix
- Postdoctoral Fellow, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Lisa Elon
- Senior Associate, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nathan J Mutic
- Project Manager, Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Jeannie Economos
- Pesticide Safety and Environmental Health Project Coordinator, Farmworker Association of Florida, Apopka, FL, USA
| | - Joan Flocks
- Director of Social Policy and Associate Professor, Center for Governmental Responsibility, Levin College of Law, University of Florida, Gainesville, FL, USA
| | | | - Linda A McCauley
- Alpha Epsilon, Dean and Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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Abstract
Human exposure to endocrine disrupting chemicals (EDCs) has become common as a result of widespread application of these chemicals to the food supply, environmental contamination, and occupational exposures (Caserta et al., 2011). However, relatively little is known about the effects of EDCs such as ethylene thiourea (ETU) in developing fetuses and the lasting implications of this disruption on human development from birth through adulthood. Of highest concern are chronic, low-dose exposures among industrial and agricultural workers. Current knowledge regarding the significance of endocrine thyroid signaling on normal human development raises serious concerns about the possible deleterious effects of EDCs in the developing fetus, children, and mature adults. Occupational health nurses are critical in identifying women and families at increased risk of ETU exposure and mitigating early exposures in pregnancy.
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