Massachusetts Pursues the Primary Prevention of Asthma

Polly Hoppin
Co-coordinator of CHE’s Asthma Working Group

Massachusetts communities have high asthma rates, resulting in a substantial societal burden of human suffering, lost capacity and productivity, and direct fiscal costs. In 2010, 10.4% of adults in Massachusetts had asthma—one of the highest prevalence estimates in the nation. Current asthma prevalence among adults increased by 22.4% between 2000 and 2010. In 2009, 9.3% of Massachusetts children had current asthma [1]. And Massachusetts is not alone: asthma rates are increasing in states across the US.

As with other chronic diseases, far more resources focus on managing asthma in people who have it than on preventing the disease. Better compliance with medications, behavior modifications resulting from asthma education, and environmental interventions that reduce a person’s exposure to allergens and irritants are essential secondary prevention strategies that can reduce asthma attacks and keep people out of the doctor’s office, emergency room or hospital, often cost-effectively. Yet, there remains an urgent need to better understand the root causes of asthma and to develop strategies for reducing the rate of new cases.

A growing body of research documents associations between asthma onset and a range of risk factors, many of which are modifiable, such as exposure to contaminants and allergens in indoor air [2]; lack of breast feeding [3]; maternal health (including stress associated with poverty and racism, as well as obesity, and other factors [4]; and outdoor air pollution [5]. Evidence is also emerging that both adults and children living in close proximity to air pollution sources—for example traffic on busy roadways—are at higher risk than those living at greater distance [6]. Even higher rates of asthma onset are observed among children exposed to traffic who also experience significant stress in their lives [7]. Hundreds of specific chemicals have been associated with the onset of asthma in workers [8], and recent studies suggest that many of these same chemicals are found in household settings and may be associated with the onset of asthma in both children and adults [9]. A small but growing body of research has examined the impacts on asthma onset of specific interventions to reduce modifiable risk factors such as exposure to dust mites and other indoor allergens [10] as well as vitamin D deficits [11]. Several studies have demonstrated reduced rates of new onset asthma among recipients of an intervention to address multiple risk factors as compared to a control group [12]. A review of these studies suggests that a more systemic, multifactorial approach may be effective [13].

What could a state concerned about asthma prevalence do to reverse rates over time? For which risk factors is the weight of the evidence strong, indicating a known association between exposure and asthma onset? Where there remain uncertainties about the strength of the science, what other considerations might justify action to modify one or more risk factors? What kinds of interventions would align best with an understanding of asthma development as a complex, multifactorial process?

A two-day symposium on April 23-24, 2013, at the Massachusetts Medical Society will pursue these questions and feed recommendations into the next statewide strategic plan for asthma, which is in the early planning stages. Polly Hoppin and Molly Jacobs of the Lowell Center for Sustainable Production at the University of Massachusetts, Lowell, are convening the symposium, pursuing a goal they and others helped install in the current state strategic plan: “to develop….[with input from] a diverse group of professionals and individuals… a roadmap for better understanding the causes of asthma and the role of primary prevention in Massachusetts” [14]. The Symposium planning committee includes representatives of the Massachusetts Asthma Advocacy Partnership, a statewide asthma coalition; the regional offices of the American Lung Association; the US Department of Health and Human Services and EPA; the state Department of Public Health; the Asthma Regional Council of New England; the Boston Public Health Commission; hospitals and universities. CHE Science Director Ted Schettler has been instrumental in helping shape the agenda and is giving the opening presentation.

Ten years ago, research on the cost-effectiveness of home-based programs in reducing asthma symptoms was just emerging. New England organizations were leaders in synthesizing the research and convening public and private payers to discuss how to provide people with severe asthma home-based environmental interventions and asthma education to help bring their asthma under control. These activities played an important role in generating federal support for the delivery and financing of home visits for asthma. Organizers of the primary prevention symposium intend the April meeting to break comparably new ground in both the meeting processes used and its outcomes. A decade from now, we hope to be able to point to this gathering as an important first step in advancing understanding of the primary causes of asthma and action to address them.


[1] Massachusetts Behavioral Risk Factor Surveillance System, Massachusetts Department of Public Health, and US Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention, multiple years.

[2] e.g., Mendell MJ. Indoor residential chemical emissions as risk factors for respiratory and allergic effects in children: a review.  Indoor Air. 2007; 17(4):259-77; Jaakkola JJ, Knight TL. The role of exposure to phthalates from polyvinyl chloride products in the development of asthma and allergies: A Systematic Review and Meta-analysis. Environ Health Perspect 116(7):845-853; Chen YC, Tsai CH, Lee YL, et al. Early-life indoor environmental exposures increase the risk of childhood asthma. International Journal of Hygiene and Environmental Health. 2011;215:19-25.

[3] Kull I, Wickman M, Lilja G, et al. Breast feeding and allergic diseases in infants—a prospective birth cohort study. Archives of Disease in Childhood. 2002;87:478-481; Oddy WH, Hold PG, Sly PD, et al. Associations between breast feeding and asthma in 6 year old children: Findings of a prospective birth cohort study.  British Medical Journal. 1999;319:815-819.

[4] Wright RJ, Cohen S, Carey V, Weiss ST, Gold DR. Parental stress as a predictor of wheezing in infancy: A prospective birth-cohort study. American Journal of Respiratory & Critical Care Medicine. 2002;165:358–365; Mrazek DA, Klinnert M, Mrazek PJ, Brower A, McCormick D, Rubin B, Ikle D, Kastner W, Larsen G, Harbeck R, et al. Prediction of early-onset asthma in genetically at-risk children. Pediatric Pulmonology. 1999;27:85–94; Sternthal MJ, Coull BA, Chiu YH, et al. Associations among maternal childhood socioeconomic status, cord blood IgE levels, and repeated wheeze in urban children. Journal of Allergy and Clinical Immunology. 2011;128(2):337-345; Scholtens S, Wija AH, Brunekreef B, et al. Maternal overweight before pregnancy and asthma in offspring followed for 8 years. International Journal of Obesity. 2009 Sep 29. [Epub ahead of print]

[5] Künzli N, Bridevaux P-O, Liu L-J S, et al. Traffic-related air pollution correlates with adult-onset asthma among never-smokers. Thorax. 2009;64:664-670; Jerrett M, Shankardass K, Berhane K, et al. Traffic-Related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement. Environmental Health Perspectives. 2008;116:1433-1438; McConnell R, Islam T, Shankardass K, et al. Childhood incident asthma and traffic-related air pollution at home and school. Environmental Health Perspectives. 2010 Jul;118(7):1021-6; Clark NA, Demers PA, Karr CJ, et al. Effect of early life exposure to air pollution on development  of childhood asthma. Environmental Health Perspectives. 2009;118(2):284-290; Shankardass K, McConnell R, Jerrett M, et al.  Parental stress increases the effect of traffic-related air pollution on childhood asthma incidence. Proceedings of the National Academies of Science USA. 2009;106:12406-11.

[6] McConnell R, Islam T, Shankardass K, et al. Childhood incident asthma and traffic-related air pollution at home and school. Environmental Health Perspectives. 2010 Jul;118(7):1021-6.

[7] Shankardass K, McConnell R, Jerrett M, et al. Parental stress increases the effect of traffic-related air pollution on childhood asthma incidence. Proceedings of the National Academies of Science USA. 2009;106:12406-11.

[8] Malo J-L, Chan-Yeung M. Appendix: Agents Causing Occupational Asthma with Key References. In: Bernstein LI, Chan-Yeung M, Malo J-L, Bernstein DI (eds). Asthma in the Workplace. 3rd Ed. New York: Taylor & Francis, 2006.

[9] Mendell MJ. Indoor residential chemical emissions as risk factors for respiratory and allergic effects in children: a review. Indoor Air. 2007; 17(4):259-77.

[10] Maas T, Kaper J, Sheikh A, et al. Mono and multifaceted inhalant and/or food allergen reduction interventions for preventing asthma in children at high risk of developing asthma. Cochrane Database of Systematic Reviews. 2009; Jul 8;(3):CD006480.

[11] Litonjua AA. Vitamin D deficiency as a risk factor for childhood allergic disease and asthma.
Current Opinions in Allergy and Clinical Immunology. 2012 Jan 19. [Epub ahead of print]

[12] see Chan-Yeung M, Ferguson A, Watson W, et al.  The Canadian Childhood Asthma Primary Prevention Study: Outcomes at 7 Years of Age. Journal of Allergy and  Clinical Immunology. 2005 Jul;116(1):49-55.

[13] Maas T, Kaper J, Sheikh A, et al. Mono and multifaceted inhalant and/or food allergen reduction interventions for preventing asthma in children at high risk of developing asthma. Cochrane Database of Systematic Reviews. 2009; Jul 8;(3):CD006480.

[14] Strategic Plan for Asthma in Massachusetts, 2009-2014. Department of Public Health, Commonwealth of Massachusetts, 2009.

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