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The inner-city is a well-established and well-studied location that includes children at high risk for high asthma prevalence and morbidity. A number of intrinsic and extrinsic risk factors contribute to asthma in inner-city populations. This review seeks to explore these risk factors and evaluate how they contribute to increased asthma morbidity. Previous literature has identified risk factors such as race and ethnicity, prematurity, obesity, and exposure to aeroallergens and pollutants. Environmental and medical interventions aimed at individual risk factors and specific asthma phenotypes have contributed to improved outcomes in the inner-city children with asthma.

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.

BACKGROUND: Despite advances in asthma care, disparities persist. Black patients are disproportionally affected by asthma and also have poorer outcomes compared to White patients. OBJECTIVE: To determine associations between Black and White race and asthma-related healthcare utilization, accounting for complex relationships. METHODS: This study was completed as part of the National Heart, Lung and Blood Institute’s Severe Asthma Research Program (SARP), a prospective, observational cohort. Between November 2012 and February 2015, it enrolled 579 participants 6 years and older with one year of observation time and complete data. Inverse probability of treatment weighting was utilized to balance racial groups with respect to community and family socioeconomic variables and environmental exposure variables. The primary outcome was Emergency Department (ED) utilization for asthma. Secondary outcomes included inhaled corticosteroid (ICS) use, outpatient physician visits for asthma, and asthma–related hospitalization. RESULTS: Black patients had greater odds of ED utilization over one year (OR, 2.19; 95% CI, 1.43–3.35) but also differed in the majority (>50%) of baseline variables measured. After statistical balancing of the racial groups, the difference between Black and White patients with respect to ED utilization no longer reached the level of significance. Instead, in secondary analyses, Black patients were less likely to see an outpatient physician for asthma management (adjusted OR: 0.57; 95% CI: 0.38 – 0.85). CONCLUSIONS: The disparity in ED utilization was eliminated after consideration of multiple variables. Social and environmental policies and interventions tailored to Black populations with a high burden of asthma are critical to reduction (or elimination) of these disparities.

Asthma in the inner city contributes to high morbidity and mortality, and, in school children, reduced school attendance and alteration in academic performance. There is a need to improve asthma care in the inner city by reducing asthma exacerbations. Methods are currently available to predict and prevent seasonal exacerbations of asthma. In addition, new medications are being developed that will be effective in improving pulmonary function and reducing asthma exacerbations. School-centered asthma programs can also be helpful to assist children and clinicians in applying asthma treatment plans and assuring optimal adherence to these plans.

Objective: Asthma is one of the major causes of hospital readmissions in the South Bronx. The goal of this study was to assess the impact of asthma education provided by registered pharmacists with...

In 2014, the Request for Applications from the National Institutes of Health. (NIH) for continued funding of a multi-site clinical and mechanistic research. Network, Inner City Asthma Consortium (ICAC), called for “efficient IRB review. And approval for multi-center studies” and “IRB approval within 30 days from. Submission”. These requirements were precursors to the NIH policy of single. IRB review for multi-site studies. Here we share our challenges, implementation processes, results, and recommendations, using a single, independent IRB.

In this article, we review current understanding of the epidemiology and etiology of disparities in asthma. We also highlight current and emerging literature on solutions to tackle disparities while underscoring gaps and pressing future directions.Tailored, multicomponent approaches including the home, school, and clinician-based interventions show great promise. Managing asthma in disadvantaged populations can be challenging as they tend to have disproportionately worse outcomes due to a multitude of factors. However, multifaceted, innovative interventions that are sustainable and scalable are key to improving outcomes.

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

Children spend a significant amount of time in school. Little is known about the role of allergen exposure in school environments and asthma morbidity.The School Inner-City Asthma Study (SICAS) is a National Institutes of Health (NIH)-funded prospective study evaluating the school/classroom-specific risk factors and asthma morbidity among urban children.This article describes the design, methods, and important lessons learned from this extensive investigation. A single center is recruiting 500 elementary school-aged children, all of whom attend inner-city metropolitan schools. The primary hypothesis is that exposure to common indoor allergens in the classroom will increase the risk of asthma morbidity in children with asthma, even after controlling for home allergen exposures. The protocol includes screening surveys of entire schools and baseline eligibility assessments obtained in the spring prior to the academic year. Extensive baseline clinical visits are being conducted among eligible children with asthma during the summer prior to the academic school year. Environmental classroom/school assessments including settled dust and air sampling for allergen, mold, air pollution, and inspection data are collected twice during the academic school year and one home dust sample linked to the enrolled student. Clinical outcomes are measured every 3 months during the academic school year.The overall goal of SICAS is to complete the first study of its kind to better understand school-specific urban environmental factors on childhood asthma morbidity. We also discuss the unique challenges related to school-based urban research and lessons being learned from recruiting such a cohort.

Asthma morbidity and mortality are disproportionately high in low-income minority populations. Variations in environmental exposures, stress, and access to appropriate health care all contribute to these disparities. The complex nature of asthma with strong contributions from environmental, psychosocial, and biological factors suggest that community-based approaches focused on the unique needs of high-risk populations may be effective. The few previous randomized trials suggest that case management with professionals and/or community health educators may reduce asthma morbidity. Health-educator programs should be lodged in stable infrastructures with training and funding for community health workers to obtain long-term sustainability. Factors not amenable to individual intervention, however, such as poor condition of homes, outdoor pollution, and lack of access to appropriate care, will require collaborative efforts of community groups, academic professionals, public agencies, and health-care providers.

For children living in the inner city, asthma tends to be more frequent and severe. Although the causes for this heightened severity of asthma are not clearly established, environmental allergens likely play a major role. To characterize, understand, and treat children with asthma living in the inner city better, the National Institutes of Allergy and Infectious Diseases of the National Institutes of Health established an Inner City Asthma Program in 1991. Over the past 15 years, 3 separate inner-city asthma research networks have been formed and funded by this institute. The work from these programs has led to important observations including evidence that environmental allergens, particularly cockroach, are important for sensitization and severity of asthma of the affected children. Furthermore, reductions in the allergen load can lead to improved asthma control. The most recent program, the Inner City Asthma Consortium, was formed in 2002 with a goal to develop immune-based therapy for children with asthma in the inner city and to determine mechanisms of these therapies as well as immunopathogenesis of asthma in these high-risk children. This article reviews these programs and how they have begun the effort to understand and treat children with asthma who live in inner cities better and what their findings mean in relationship to unique features of asthma in inner city children.

Asthma exacerbations are important components of asthma morbidity. The Inner-City Asthma Consortium was established in the early 1990s to identify risk factors for and to evaluate treatments to reduce asthma symptoms and exacerbations. Early studies identified atopy and inadequate treatment as important drivers of asthma morbidity. Later studies demonstrated that good adherence to guidelines-based asthma care could virtually eliminate symptoms and reduce but not eliminate exacerbations. Looking at exacerbations by season, risk factors were found to vary across the different seasons. Of the 7 factors identified, allergic status and pulmonary functions were found to be important for exacerbations in all seasons, but allergy had its strongest effect in the fall season. Therefore, additional therapy directed at reducing the role of allergy was evaluated and found to significantly reduce exacerbations even in participants with good symptom control when receiving guidelines-based therapy. Despite this year around aggressive therapy, exacerbations remain albeit at a lower level and with less seasonal variation. Another strategy, the short term use of therapy aimed at reducing the role of allergy begun before the fall season and focused on individuals at high risk for exacerbations, was found to be an effective approach to minimize exacerbations and to limit the amount of therapy necessary.

Asthma is the most common chronic illness of childhood and inner city residents suffer a disproportionately high rate of asthma diagnosis and asthma morbidity. The School Inner City Asthma Study investigates the school classroom based environmental exposures that may lead to asthma morbidity in inner city school children with asthma. Within this cohort, we investigated the role of methylation at the promoter region of the beta-2-adrenergic receptor in relation to asthma morbidity. We found that high levels of methylation in the region studied was significantly associated with decreased report of dyspnea and trended towards significance for lower levels of asthma symptoms and airway obstruction. This Research Highlight discusses the findings of the recent study and the investigators’ active research endeavors.

Background Despite growing evidence of the importance of exposure to fungi as an environmental risk factor for asthma, few data have been reported on the exposure to airborne fungi of asthmatic children living in US inner cities. Objective We sought to examine the spectrum and concentration of fungi in the air inside and outside of the homes of mold-sensitive children with asthma living in US cities. We also analyzed the relationship of the concentration of fungi in indoor air to home characteristics. Methods We performed a home environmental survey and measured the concentrations of culturable airborne fungi inside and outside the homes of 414 mold-sensitive children with asthma in 7 urban communities. Results The airborne fungi encountered indoors generally paralleled those found outdoors, and the similarities between communities were more striking than the differences. Indoor fungal concentrations were correlated with outdoor concentrations measured on the same day, suggesting the need to adjust for the outdoor concentration in analyses by using the indoor concentration as an indicator of the relative moldiness of a home. The concentration of fungi in indoor air in excess of outdoor air—that is, the indoor-outdoor difference—was significantly related to home characteristics, including dampness, having a cat, and cockroach infestation. Conclusion Mold-sensitive children with asthma living in urban communities across the US are exposed to airborne fungi in indoor and outdoor air. The concentrations of fungi are higher in homes with dampness problems, cockroach infestation, and cats. The indoor-outdoor difference in the concentration of airborne fungi may provide a valuable metric for investigations of the role of fungal exposure as a risk factor for asthma.

Explanatory models (EMs) for asthma among inner-city school-age children and their families were examined as a means of better understanding health behaviors. Children and parents were interviewed about their concepts of asthma etiology, asthma medications, and alternative therapies. Drawings were elicited from children to understand their beliefs about asthma. Nineteen children with 17 mothers from a variety of cultural backgrounds were interviewed. Among children, contagion was the primary EM for asthma etiology (53%). Twenty-five percent of children reported fear of dying from asthma, while fear of their child dying from asthma was reported by 76% of mothers. Mothers reported a variety of EMs, some culturally specific, but the majority reported biomedical concepts of etiology, pathophysiology, and triggers. Although 76% of mothers knew the names of more than one of their children's medications, 47% thought their child's medications all had similar functions. Thirty-five percent of families used herbal treatments and 35% incorporated religion into asthma treatment. Seventy-one percent of families had discontinued medications and 23% reported currently not giving anti-inflammatory medication. Reasons for discontinuing daily medications included fears of unknown side effects (53%), addiction (18%), tachyphylaxis (18%), and feeling that their child was being given too much medicine (23%). The traditional focus of asthma education is not sufficient to ensure adherence. Asthma education for children should address their views of etiology and fears about dying from asthma. Conversations with parents about their EMs and beliefs about medications and alternative therapies could assist in understanding and responding to parental concerns and choices about medications and help achieve better adherence.

Study objective: Inner-city asthma is a growing problem, and concerns remain about the role of exposure to multiple indoor allergens. Because of the increasing problems of rat infestation in New York and other cities, we sought to determine the frequency of sensitization to rat among inner-city children with asthma living in homes infested with cockroaches, and whether rat sensitization is associated with increased symptoms. Design/Setting/Participants: As part of the Columbia Intervention to Reduce Indoor Allergens Study, 37 Latino and African-American children age 5–18 years with asthma and determined to have positive skin tests to cockroach were evaluated for the presence of sensitization to rat by skin test and anti-rat-IgE levels. Clinical course was assessed by questionnaire. Results: We found that 43% had positive skin tests to rat, and 43% had an elevated anti-rat-IgE level. Anti-rat-IgE levels correlated with anti-cockroach-IgE levels (r =. 37, p =. 02) and mouse-IgE levels (r =. 72, p =. 001). O...

The rate of asthma has increased dramatically in the past 20 years, both in the United States and worldwide [1]. Data collected by the Centers of Disease Control and Prevention over the last 4 decades show large and unexplained increases in asthma prevalence, hospitalization rates, and mortality in the United States [2]. Between 1980 and 1994, asthma prevalence rose from 3.1% to 5.4% [2]. This asthma epidemic caused heavy increases in health expenditure; direct and indirect monetary costs related to asthma were estimated at approximately $12.7 billion in 1998 [3]. Childhood asthma is the most frequent health-related cause of school absenteeism, accounting for more than 10 million missed school days annually. Asthma is the most common admitting diagnosis for children [2,4,5], accounting for 159,000 annual hospitalizations with an average length of stay of 3.4 days. The largest increase in asthma hospitalizations has occurred in the youngest of children. From 1979 to 1980, the number of children aged 4 years and younger who were hospitalized for asthma was 34.3 per 10,000 population, but this number escalated to 58.3 per 10,000 in 1990 to 1992 and remained high at 49.7 per 10,000 in 1993 to 1994 [2]. In comparison, hospitalizations for children aged 5 to 14 years have remained relatively stable, with rates of 15.9, 20.6, and 18.0 per 10,000 population for the same respective time periods [2]. Asthma rates vary between regions, states, cities and neighborhoods. From 1988 to 1994, the Northeast region of the United States had more asthma hospitalizations than did the Western and Southern regions across all age groups. During that same time period, asthma hospitalizations increased in the Northeast region but decreased in the Midwestern and Western regions. By 1993 to 1994, age-adjusted hospitalizations were higher among persons residing in the Northeast

JL Friedlander, WJ Sheehan, SN Baxi. J Allergy Clin Immunol Pract. 2013;1(5):479–484 The goal of this study was to investigate the relation between food allergy and asthma morbidity in inner-city students with asthma. A total of 300 elementary school students with physician-diagnosed asthma were enrolled over a period of 6 years in the School Inner-City Asthma Study in the northeastern United States. Subjects were eligible if they had wheezing, used controller medications, or had unscheduled health care visits for asthma in the previous 12 months. This population was primarily a nonwhite (>95%), impoverished cohort …

Objective: The purpose of this study was to evaluate the effects of a recently implemented disease management programme [Asthma Control and Education Program (ACE)] on patient outcomes (clinical and functional) and on resource utilisation in socio-economically disadvantaged (and largely Hispanic) individuals with asthma treated at Hartford Hospital. Design and Setting: Using standardised measures (i.e. the Health Status Questionnaire [HSQ] and the Center for Epidemiologic Studies Depression Scale) and conducting serial assessments the investigators determined: 1. functional status at intake and follow-up; 2. change in the level of illness severity over time; 3. patients' acquisition of self-management skills; and 4. the type and frequency of acute care services utilised pre- and post-enrolment in ACE. Patient Population: The study participants consisted of consenting individuals, aged 18 years or older, enrolled in ACE from 1 January 1997 to 30 September 1998. Each individual had a comprehensive intake interview (data collected included clinical and financial status) followed by 3 educational sessions. Results: While only 34.7% (n = 282) of the 813 patients referred from Hartford Hospital to physicians or emergency department services elected to participate in the programme, 60% of participants completed the educational sessions. 73% of these enrollees returned for the 3-month follow-up. On the HSQ, the mean Physical Composite Summary (PCS) scores increased from 33.3 +- 10.01 at baseline to 41.6 +- 11.48 at the 3-month follow up and 45.3 +- 10.30 at the 6-month follow-up. In an analysis using only those patients (n = 50) with HSQ scores at baseline and 3- and 6-month follow-ups, there were statistically significant increases in both the PCS and the Mental Composite Summary scores (p

Objectives: Our objective was to compare two different teaching methods used to educate patients in the use of a breath actuated inhaler (BAI) and to assess the impact of its continued use on their metered-dose inhaler (MDI) technique. Design: Prospective, randomized, controlled trial. Setting: Adult Pulmonary/Asthma clinic of Cook County Hospital, Chicago, IL. Patients: Diagnosed, stable asthmatics. Intervention: The patients were randomized into two groups. The experimental group received verbal instructions and demonstration on breath actuated inhaler technique while the control group received written instructions only on BAI use. The metered dose inhaler technique of both groups of patients was also evaluated. Measures: A checklist evaluating the key aspects of proper BAI and MDI inhalation techniques was used to assess the use of both types of inhalers at entry into the study and upon postintervention follow-up at 8 to 20 weeks. Results: At baseline, 97% of patients in the experimental group and 83% of patients in the control group were initially able to demonstrate BAI inhalation technique correctly. Upon follow-up, 82% of the control group and 68% of the experimental group were able to use the BAI correctly, which was a statistically significant deterioration in the experimental group. In both of these groups, there was a statistically significant improvement in MDI technique. Conclusions: Written instructions alone may be an adequate teaching tool for proper inhalation technique of BAI. Continued BAI use appears not to impact adversely on proper MDI technique.

We performed a five-year retrospective study on the impact of a monthly inner-city allergy clinic (AC) on emergency room (ER) visits, hospital admissions, and medication use of asthmatic children. Forty-three AC patients (cases) were matched to 32 asthmatic controls who attended a general pediatrie clinic. The matching criteria are age, sex, medication score, and ER visits. For each case and its matched control, variables were compared before and after an exact date that corresponds to the date of the first AC visit of that case. Follow-up at the AC had no impact on the ER visits, as the frequency of visits significantly declined for both the cases (p 0.05). The AC group also had a significant decline in hospital admissions for asthma (p 0.05).

Background: The Inner City Asthma Intervention (ICAI) was a national multi-center implementation of an evidence-based intervention to reduce asthma morbidity. Objective: This study describes mitigating behaviors and reported outcomes in families with asthma who completed the intervention and a post-intervention survey at one of the ICAI sites. Results: Eighty percent (0.72- 0.88, 95% confidence interval) of these families made five or more changes to mitigate exposure to environmental asthma triggers. The majority of families (0.84-0.96, 95% confidence interval) reported an improved awareness of asthma symptoms and less school absences, limitations of activity, unplanned doctor visits, and asthma related sleep disruption.

Background: Animal models that mimic the pulmonary features observed in human asthma are important tools to study the mechanism(s) of allergen-induced asthma. Cockroach and dust mite allergens are two common allergens found in the ‘inner city’ environment. In this study, we examined the interaction between recombinant cockroach (r Bla g 2) and dust mite (r Der f 1) allergens in inbred mouse strain (A/J). The tested hypothesis was that there are enhanced effects of exposure to r Bla g 2 and r Der f 1 allergens in the airway inflammatory response in A/J mice. Methods: Five groups of mice (male, 6–8 weeks) were examined: vehicle (saline) controls; adjuvant (alum) controls; r Bla g 2 immunized (0.01–10 µg/mouse), r Der f 1 immunized (0.01–10 µg/mouse), and combined immunization with r Der f 1 (0.05 µg/mouse) and r Bla g 2 (0.0 5 µg/mouse). Mice were immunized at days 0 and 7, challenged by oro-tracheal inhalation with r Der f 1 and/or r Bla g 2 allergen at day 14, and were studied and sacrificed on day 17. Airway hyperreactivity was measured by peak airway pressure and airway pressure time index (APTI). Differential cell analysis and total proteins in bronchoalveolar lavage returns were used to assess airway inflammation and epithelial injury. Results: Dose-related statistically significant increases in peak pressure, APTI, total cells, eosinophils, epithelial cells, but not total proteins, were induced by r Bla g 2 challenge in r Bla g 2-immunized mice. Similar allergen-induced dose-related increases in airway total cells, eosinophils, epithelial cells and total proteins were observed in r Der f 1 immunized mice. Compared to either allergen alone, enhanced airway inflammation and epithelial damage, but not airway reactivity, were detected in the combined group. Conclusion: This novel mouse model will allow investigation of the immunopathogenesis of human asthma and should provide insight into the common form of ‘inner city asthma’.

The article by Scott et al entitled ‘‘Achieving and maintaining asthma control in inner-city children’’ in this month’s issue of the Journal demonstrates that, through the use of mobile schoolbased clinics, guidelines-based asthma care can and is being delivered regularly and effectively to children known to have the highest degree of asthma-associated morbidity: those who reside in our inner cities. This finding is a very encouraging one because regular receipt of quality asthma care, which is often difficult in these populations, is known to be critically necessary in achieving long-term asthma control.

Asthma morbidity and mortality continue to increase especially in the inner cities despite medical advances in disease management.To investigate the clinical outcomes of inner city asthma patients treated in an allergy clinic.Phase 1 involved random review of medical records of 100 asthma patients treated in an allergy clinic for 2 consecutive years, assessing the frequency of hospitalizations, emergency room visits (ERV) and asthma severity during three periods; 1 year prior to initial visit (year 0) and during the first (year 1) and second (year 2) years of intervention. Phase 2 involved administration of quality of life (QOL) survey to 23 patients volunteered from allergy clinic (group I), and 21 patients volunteered from emergency room (group II), treated by primary care or emergency room physicians during the previous year.The frequency of hospitalizations and ERV significantly declined over time (P.001) with greatest declines during year 1. Disease severity of all patients significantly declined over time (P.001); good compliers had significant improvement over poor compliers (P.023). Quality of life scores were significantly lower for both groups than for the general population; and although the scores were higher in the allergy clinic group than in the non-allergy clinic group, significant differences were achieved only in mental health and social functioning domains.Patients treated in an allergy clinic demonstrate superior clinical outcomes.