Identifying Students with Asthma in Schools

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Identifying Students with Asthma in Schools

• Bindi Gandhi
• Division of Adolescent and School Health
• National Center for Chronic Disease Prevention
  and Health Promotion

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the apparent logic

• Know there is undiagnosed wheezing and chronic
  coughing
• Know there is diagnosed but poorly controlled
  asthma
• Know that people are screened for asthma in the
  clinicians office
• Seems reasonable to implement asthma screening in
  the community

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Some key terms definitions

• Case Identification
• Individual Case Detection
• Population-based Screening
• Population-based Case Detection
• Population-based Surveillance

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Case Identification

• Uses existing information, usually from standard
  school forms, to identify students with diagnosed
  asthma (or RAD, wheezy bronchitis or AHR, etc.).

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Individual Case Detection

• Occurs when students who do not have a diagnosis
  of asthma present to health rooms with symptoms
  of the illness

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Population-based Screening

• Uses tests, examinations, or other procedures
  applied rapidly to populations to identify
  apparently well (asymptomatic) persons who
  probably have asthma.

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Population-based Case Detection

• Uses surveys, tests, examinations, or other
  procedures to rapidly identify students with
  symptoms who may have asthma but not be diagnosed

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School-based Screening vs. School-based
Surveillance

• Surveillance ongoing, systematic collection,
  analysis and interpretation of health data
  essential for planning, implementing, and
  evaluating public health practice.
• Focus is on group information (s), not
  individual detection
• Goal is clear with the community

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CDCs Recommendation

• Strategies for Addressing Asthma Within a
  Coordinated School Health Program recommends Case
  Identification.
• Schools should examine their current case ID
  system.
• Focus students with significant asthma morbidity
  (ex frequent absences,

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CDC also recommends Individual Case Detection for
any student exhibiting signs of significant
morbidity (ex school nurses documenting repeated
episodes of undiagnosed wheezing in a health
appraisal).
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What CDC does not recommend

• Population-based asthma screening it does not
  currently meet AAP or WHO guidelines
• Lack of evidence that early treatment of
  currently asymptomatic people who later could
  develop asthma improves their health
• Experts do not agree on an appropriate screening
  test

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What CDC does not recommend

• Population-based case detection Is feasible but
  no study has confirmed that identifying these
  students ultimately improved their health.
• Effectiveness for prevention and
  cost-effectiveness of such case detection remains
  unknown.
• School-based health centers may provide
  appropriate sites for population-based case
  detection

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Recent Research Findings

• Gerald (Journal of Pediatrics, 2002)
• Can screen with spirometry and step-test
• Most were previously know to have asthma
• Yawn (Annals of Allergy, Asthma Immunology
  2003)
• Case detection surveys did not increase the
  diagnosis of new cases of asthma
• Letters to parents of students with asthma who
  remain symptomatic increased asthma visits and
  med changes

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Recent Research Findings

• Joseph (Journal of Pediatrics, 2005)
• A small percentage of students detected with
  surveys have moderate or severe disease and these
  improve with an intervention
• 85 students detected have mild asthma
• Many undiagnosed asthma students are diagnosed
  with RAD, wheezy bronchitis, asthmatic
  bronchitis, etc. and/or take prescription asthma
  meds.

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Summary of CDC Recommendations

• Focus on case identification
• Provide individual case detection
• Help students with asthma receive good quality
  medical care, ex collaborate with community
  partners
• Consider participating in well-designed research
  projects
• Look for new research findings

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CASE STUDIESWhen is case detection appropriate?

• Appropriate
• Follow-up care is ensured (ex SBHC or child has
  insurance and healthcare provider) and improves
  asthma control
• Research setting

• Not appropriate
• Limited resources
• Large of students with diagnosed asthma have
  significant morbidity
• No linkages with community healthcare provider
  groups

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Scenario 1

• Central City Elementary School
• Local doc wants to do spirometry on all students
• School objective ID 3-5th grade students for
  Open Airways classes who need it most
• Emergency cards for nearly 100
• Include check box for asthma and EIA
• Parents complete the cards

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Scenario 2

• Hillside Community
• Community objective-apply for adolescent asthma
  grant funds
• Hospitalization and ED data indicate possible
  higher asthma prevalence than surrounding
  communities

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Scenario 3

• Unified Senior High-School-based health Center
• School objective-improve control for students
  with asthma
• 750/800 students enrolled in SBHC
• Very few health cards returned by parents

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Contact Information BGandhi_at_cdc.gov [phone]
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Scenario4

• Valley Middle School
• School objective Ensure that students who need
  them have quick-relief inhalers at school.
• Emergency cards for nearly 100
• Include check box for asthma and EIA
• Parents complete the cards

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Scenario 5

• Mountain Middle School
• School objective-prevent asthma episodes after
  mile run
• 50 students with asthma on health card
• 10 more have quick-relief meds at school
• 3 more had episodes last year
• Very few take pre-exercise meds