A National Asthma Public Policy Agenda

A NATIONAL

ASTHMA PUBLIC

POLICY AGENDA

A set of public policy priorities for lawmakers, regulators

and advocates to reduce asthma morbidity and mortality

2022 Update

American Lung Association Page | 1

A National Asthma Public Policy Agenda

2022 Update

May 2022

55 W. Wacker Drive, Suite 1150 | Chicago, IL 60601

1-800-LUNGUSA | Lung.org

The update of the National Asthma Public Policy Agenda was supported by Grant Number

6NU38OT000292, funded by the Centers for Disease Control and Prevention. Its contents are solely the

responsibility of the American Lung Association and do not necessarily represent the official views of the

Centers for Disease Control and Prevention or the Department of Health and Human Services.

American Lung Association Page | 2

Table of Contents

Introduction ............................................................................................................................................................................... 3

Objective and Approach..................................................................................................................................................... 5

About the Update ................................................................................................................................................................... 6

Acknowledgements .............................................................................................................................................................. 6

Public Health Infrastructure and Surveillance ........................................................................................................... 7

Guiding Principles .......................................................................................................................................................... 7

Overview ............................................................................................................................................................................ 7

Policy Statements and Supporting Strategies ............................................................................................... 9

Outdoor Air ............................................................................................................................................................................... 13

Guiding Principles ........................................................................................................................................................ 13

Overview .......................................................................................................................................................................... 13

Policy Statements and Supporting Strategies .............................................................................................. 14

Healthcare Systems and Financing ........................................................................................................................... 20

Guiding Principles ...................................................................................................................................................... 20

Overview ........................................................................................................................................................................ 20

Policy Statements and Supporting Strategies .............................................................................................. 21

Homes ........................................................................................................................................................................................26

Guiding Principles .......................................................................................................................................................26

Overview .........................................................................................................................................................................26

Policy Statements and Supporting Strategies ............................................................................................. 27

Schools ..................................................................................................................................................................................... 34

Guiding Principles ...................................................................................................................................................... 34

Overview ........................................................................................................................................................................ 34

Policy Statements and Supporting Strategies ............................................................................................ 36

Workplaces ............................................................................................................................................................................ 44

Guiding Principles ...................................................................................................................................................... 44

Overview ........................................................................................................................................................................ 44

Policy Statements and Supporting Strategies ............................................................................................ 45

Conclusions and Call to Action .................................................................................................................................... 50

APPENDIX A. The Consensus Process....................................................................................................................... 51

APPENDIX B: Advisory Group Participants & Reviewers ................................................................................. 55

References ............................................................................................................................................................................. 59

American Lung Association Page | 3

Introduction

The burden of asthma in the United States is complex, multi-factorial, unequal and serious.

Efforts to address asthma must be equally significant and must look at the underlying systemic

causes of both the disease and the barriers to controlling it.

In 2009, the American Lung Association released the first National Asthma Public Policy

Agenda by bringing together a broad, multi-disciplinary group of asthma specialists, medical

professionals and public health and policy experts to agree on a set of public policy priorities

that, if implemented, could have the greatest impact on asthma morbidity and mortality. The

project established a blueprint for a national asthma policy on which lawmakers, regulators and

advocates could act. To be successful, the policy recommendations needed to be adopted by

multiple stakeholder groups at all levels.

In the subsequent decade, much has been accomplished to impact and hopefully improve the

quality of life for those living with asthma—including the passage of the Affordable Care Act

(ACA) in 2010, the adoption of stricter national air standards for particle pollution in 2012 and

ozone in 2015, the 2018 implementation of the U.S. Department of Housing and Urban

Development’s smokefree public housing policy, and the 2020 update of the National Asthma

Education and Prevention Program’s clinical guidelines. These and other changes in the policy

environment made it necessary to review, revise and update the National Asthma Public Policy

Agenda to chart a path for the public health community to follow in this next decade.

The stakeholders brought together by the American Lung Association to update the National

Asthma Public Policy Agenda met before the COVID-19 pandemic. The pandemic has exposed

many of the major challenges facing the nation’s public health and health systems

infrastructure, including a serious lack of robust, predictable, and sustained investments in

public health at the federal, state and local levels; depleted and understaffed workforces;

inadequate public health surveillance; and systemic inequities that create disparate health

outcomes. The recommendations included in the National Asthma Public Policy Agenda - 2022

Update are even more timely and urgent considering this global respiratory pandemic.

The Burden of Asthma Is Unequal and the Updated

Agenda Must Address These Disparities

Asthma makes breathing difficult for the 24.8 million Americans it affects, including 5.5

million children. Since 2001, asthma rates have increased 22% among adults while

decreasing 34% among children. While asthma affects people of all ages, races,

genders and segments of society, the burden is not equally shared across these

segments. Black individuals and American Indian/Alaska Natives have the highest rates

of current asthma compared with other races and ethnicities. Further, though asthma

rates are relatively low for Hispanics overall, Puerto Ricans in the continental United

American Lung Association Page | 4

States have the highest current asthma rate of any racial or ethnic group (14.0%

Finally, asthma rates were significantly higher among those with a family income below

the poverty threshold.

Of the 24.8 million Americans with a current diagnosis of asthma, 19.2 million were

adults and 5.5 million were children. Over half of children and adults with asthma

(52.7%) living below the federal poverty level reported an asthma attack in the past

year compared to 44.6% of those living at or above double the federal poverty

level,

which is an indication of poor asthma control. Children and people living below

the federal poverty level are among the groups most likely to have asthma, and to

suffer from severe asthma attacks, hospitalization and even death.

Healthcare

Asthma morbidity and mortality is disproportionably burdensome for Black individuals,

who are least likely to have access to adequate healthcare.

There are substantial gaps

between guidelines-based asthma care and coverage by state Medicaid programs. A

large percentage of children with asthma receive coverage through Medicaid and the

Children’s Health Insurance Program (47.6%).

Many Medicaid programs do not cover

the recommended categories of care and have inconsistent coverage across fee-for-

service and managed care plans within the same state, making it difficult for providers

and patients to understand coverage of asthma treatments and services.

While the ACA provides quality healthcare coverage for tens of millions more

Americans, including many with asthma, gaps in states that have not expanded

Medicaid and increasing challenges of affordability still leave millions more without the

coverage they need. Asthma’s multi-factorial and complex causes and triggers also

underscore that this disease will not be addressed by treatment alone; it also requires a

robust multi-sector response including public health and environmental responses.

Outdoor and Indoor Air Quality

A substantial body of evidence links asthma exacerbations to exposures to allergens

and irritants from outdoor sources and from indoor pollutants found where people live

go to school

or work.

Establishing asthma-friendly policies that eliminate or reduce

exposures to indoor and outdoor allergens, irritants, and pollutants where people with

asthma live, work, go to school and play is critical in the overall management of asthma.

Asthma self-management education, which includes education on reducing exposure

to asthma triggers, has been repeatedly shown to make a difference in patients’ ability

to maintain good control of the disease.

NHIS data from 2016-2018 was combined to acquire a large enough sample size to ensure an accurate

estimate for this population.

American Lung Association Page | 5

Climate change brings new challenges to people with asthma, such as increased

ozone pollution driven by heat; increased particle pollution from more wildfires;

increased pollen levels that can trigger allergic asthma; and mold from flooding and

extreme storms. Public policies focused on asthma must also recognize the

importance of addressing both the causes and impacts of a warming Earth and

climate.

Significant Financial Burden

People with asthma that have difficulty managing their disease can impact their

community in several ways, from lost productivity in the workplace to healthcare costs

to premature death. Asthma costs the nation $81.9 billion annually, including $50.3

billion in direct health care expenses and additional costs from loss of productivity,

absenteeism and mortality.

Contributing to the burden, asthma accounts for an

estimated 10.9 million missed workdays for people over 18 years of age and 7.9 million

missed school days.

Much of the overall health and economic burden of asthma is the

result of asthma not being well controlled; in addition to missing work or school, people

with asthma may require care in the emergency department or hospital for asthma

emergencies.

Objective and Approach

The American Lung Association with support from the U.S. Centers for Disease Control

and Prevention (CDC), National Center for Environmental Health reviewed the

recommended policies and strategies from the 2009 National Asthma Public Policy

Agenda, assessed the existing evidence for effective asthma policy interventions,

convened an interdisciplinary group of asthma experts and built consensus for an

updated, comprehensive and actionable national asthma public policy agenda.

American Lung Association Page | 6

About the Update

The consensus process resulted in 22 public policy recommendations grouped in six

major categories. The expert stakeholders determined the categories should remain

unchanged from the 2009 Agenda, but many of the policies and supporting strategies

within the categories were updated to reflect

the latest science.

Each policy category begins with a list of

“Guiding Principles.” The participants at the May

2019 conference decided to maintain the use of

the guiding principles from the original Agenda

and update them to reflect changes to the

policy recommendations. Each policy category

includes an overview of the importance of the

category, followed by the recommended policy

statements and support strategies. For each

policy, the authors described the existing

research and evidence of effectiveness. These

summaries are not intended as a comprehensive review of the issue but provide

context for including policies.

Acknowledgements

The American Lung Association is grateful to individuals that made this report possible:

Members of the 2019 National Asthma Public Policy Agenda Stakeholder Group and

Reviewers (see Appendix B) who shared their expertise and passion.

American Lung Association staff who dedicated their time and expertise to writing and

reviewing the report: Barbara Kaplan, Hannah Green, Thomas Carr, Laura Kate Bender,

Katherine Pruitt and Erika Sward. A special thanks Kenneth Rosenman, MD, for his

contributions to the workplaces section of the report.

A National Asthma Public Policy Agenda – 2022 Update was made possible with

support from the Centers for Disease Control and Prevention, National Center for

Environmental Health. The National Asthma Public Policy Agenda does not represent an

official position of the American Lung Association or the CDC. Rather, it represents a

broad agreement on policy from a multi-disciplinary group of stakeholders committed

to reducing asthma morbidity and mortality.

Public Policy Categories

• Public Health Infrastructure

and Surveillance

• Outdoor Air

• Healthcare Systems and

Financing

• Homes

• Schools

• Workplaces

American Lung Association Page | 7

Public Health Infrastructure and Surveillance

Guiding Principles

A strong public health infrastructure is essential to ensure adequate capacity and

training for community-based asthma strategies. An adequate public health

infrastructure should:

• Recognize that asthma is both a chronic and an environmental disease.

• Promote the establishment, maintenance or enhancement of surveillance

systems to monitor trends in asthma burden.

• Provide funding for comprehensive asthma programs and services that impact

morbidity and mortality.

• Identify cross-cutting risk factors that include addressing social determinants of

health and asthma management for underserved, disproportionally affected

populations.

• Address asthma management in multiple sectors, including health systems,

housing, workplaces, schools, and childcare facilities.

• Be prepared for and resilient to the impacts of climate change (e.g., adaptation,

planning, sustainable development, disaster response) to protect people with

asthma.

Overview

The COVID-19 pandemic has demonstrated how essential our nation’s public health

infrastructure is to the country’s well-being, and how important proper surveillance is to

help protect the public. The same concept holds true for other public health challenges

such as asthma and other chronic health conditions. Without comprehensive

surveillance nationally and in all 50 states, the District of Columbia and U.S. territories,

people working to reduce the burden of asthma are likely missing key information,

including about which communities are disproportionately impacted. In turn, a strong

public health infrastructure, including at the state and local level, is essential to

delivering the programs and services necessary to reduce the burden of asthma.

Essential to helping to strengthen the public health infrastructure to address asthma is

the Centers for Disease Control and Prevention’s (CDC) National Asthma Control

Program (NACP), created in 1999. Over the years, CDC has funded state and local

health departments, national non-governmental organizations and other agencies to

conduct asthma surveillance, implement evidence-based asthma interventions and

evaluate their effectiveness, and develop partnerships. Through the 2019 cooperative

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agreement “A Comprehensive Public Health Approach to Asthma Control through

Evidence-based Interventions,” the National Asthma Control Program currently

supports 25 state, local and territorial health departments in their efforts to enhance

public health infrastructure and leverage partnerships. The purpose of the cooperative

agreement is to reduce asthma morbidity, mortality and disparities by implementing

evidence-based strategies across multiple sectors.

Since 2002, CDC has demonstrated that adequately funded health departments

working on asthma can have a significant positive impact on their communities.

12, 13, 14, 15,

16, 17

Each grant cycle, CDC-funded state asthma programs have conducted asthma

surveillance and developed comprehensive state asthma plans. To have the greatest

impact on asthma morbidity and mortality, these grants should be extended to all 50

states, the District of Columbia and U.S. territories.

Asthma surveillance data are collected at the national and state levels. Surveillance

data are then analyzed to understand when, where and among whom asthma occurs.

There are several surveys that can be used to obtain information to track the overall

burden of asthma and to identify disproportionately affected populations. Grantees

funded by the NACP typically use data from the Behavioral Risk Factor Surveillance

System and the Asthma Call-Back Survey to track asthma prevalence, activity

limitations, days of work or school lost, rescue and control medication use, asthma self-

management education, and self-reported healthcare use (physician office visits,

emergency department visits and hospitalizations) due to asthma. Another surveillance

tool introduced in 2009, the Environmental Public Health Tracking (EPHT) network,

connects environmental and health information. This information is used to target,

implement and evaluate interventions.

In 2018, CDC published the EXHALE technical package.

It represents a group of

strategies based on the best available evidence that can improve asthma control and

reduce health care costs. It is intended as a resource to inform decision-making in

communities, organizations and states. These strategies are complementary and are

intended to work in combination to reinforce each other. The hope is that multiple

sectors, including public health, health care, education, social services and non-

governmental organizations, will use this technical package to improve asthma control

in all age groups. Commitment, collaboration and leadership from numerous sectors

can maximize the impact of the strategies. As new evidence becomes available, the

strategies can be refined to reflect the current state of the science.

Since the publication of the 2009 National Asthma Public Policy Agenda, changing

climate patterns have increased the frequency and intensity of natural disasters and

severe weather, such as wildfires, droughts, floods and extreme heat events, which can

reduce both outdoor and indoor air quality.

People living with chronic lung diseases,

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such as asthma, face greater risks and need guidance and support to stay healthy.

The CDC provides planning resources for state and local governments, emergency

planners and responders, healthcare facilities and providers, businesses, and

individuals, families and communities.

Several national organizations including the

Allergy & Asthma Network,

American Lung Association,

and the Asthma & Allergy

Foundation of America

offer guidance and support tools for people with asthma

during natural disasters.

Policy Statements and Supporting Strategies

Every state and territory should have a comprehensive statewide asthma strategic

plan and adequately funded state asthma program to reduce asthma morbidity and

mortality.

• Statewide asthma programs and partners should develop a strategic plan to

document the problem, implement strategies and assess progress.

• Statewide asthma programs should follow best practices outlined in CDC’s

EXHALE Technical Package on implementing a comprehensive asthma program,

including access to guidelines-based asthma care, expanded asthma self-

management education in clinical and home visits, and environmental policies

and practices to reduce exposure to asthma triggers.

• Statewide asthma programs should partner with multiple sectors, including

health systems, housing, workplaces, schools and childcare facilities, when

implementing comprehensive asthma programs.

• Statewide asthma programs should implement the activities outlined in CDC’s

EXHALE Guide for Public Health Professionals.

• Statewide asthma programs should identify and ensure they address asthma in

underserved and disproportionately affected populations in their strategic plan

and activities.

About the evidence. Strategic plans represent a coordinated approach that targets

both clinical and environmental aspects of asthma. All CDC-funded state asthma

programs are required to develop and maintain a strategic asthma plan to assess the

burden of asthma and available asthma control services, outline major strategies and

activities, and identify resources and collaborations needed to accomplish these

goals.

Statewide asthma programs working in partnership with community-based

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partners that work directly with communities disproportionately impacted by asthma is

a strategy that is helping to improve asthma. Statewide and local partnerships increase

the capacity to enhance asthma surveillance, improve asthma management, reduce

exposure to environmental factors that exacerbate the risk of asthma, and ultimately

reduce disparities in asthma outcomes.

Over the past decade, congressional appropriations for the NACP have vacillated

between approximately $23 million and $30 million. The NACP received $30.5 million

for Fiscal Year (FY) 2022. This level of funding has allowed the NACP to provide grants

to 23 states, Puerto Rico, and Houston, Texas. To be able to fund comprehensive

asthma programs in all 50 states, the District of Columbia, and all U.S. territories, the

NACP would require approximately $65 million in funding from Congress. Federal

legislation known as the Elijah E. Cummings Family Asthma Act would authorize just this

amount. Ultimately, this level of funding is what is required to enable all individuals in the

United States to benefit from the impactful activities of a comprehensive asthma

program.

The federal government and states should institute a comprehensive, nationwide

asthma surveillance system that provides timely and relevant data.

• Asthma surveillance systems should include the collection of asthma data at

both the national and the state level.

• The asthma surveillance system should collect or coordinate with other

agencies/organizations to obtain data and report measures that are nationally

consistent by patients' age, sex, race, ethnicity, occupation, and socio-economic

status.

• The asthma surveillance system should track asthma prevalence, morbidity and

mortality, and coordinate with other data gathering efforts.

• The asthma surveillance system should explore obtaining data from non-

traditional sources, including federally qualified health centers (FQHC),

government (Medicaid or Children’s Health Insurance Program [CHIP]), private

insurance, hospitals, and schools.

About the evidence. National data is available on asthma prevalence, activity limitation,

days of work or school lost, rescue and control medication use, asthma self-

management education, physician visits, emergency department visits due to asthma,

and mortality due to asthma from National Center for Health Statistics’ (NCHS) National

Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS),

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National Hospital Ambulatory Medical Care Survey (NHAMCS) and the Vital Statistics

System. In addition, national data on asthma-related hospitalizations and emergency

department data for some states are from the Agency for Healthcare Research and

Quality’s (AHRQ) Healthcare Cost and Utilization Project survey (HCUP). At the state

level, adult and child asthma prevalence is available from the Behavioral Risk Factor

Surveillance System (BRFSS). BRFSS is a system of health-related telephone surveys

that collects information about prevalence of major behavioral risks associated with

adults ages 18 and older.

States may opt to include children in the survey. The

Asthma Call-back Survey (ACBS) adds considerable depth to the existing body of

asthma data. It addresses critical questions surrounding the health and experiences of

children and adults with asthma and provides data at the state and local level. The 2018

ACBS survey included 31 states and Puerto Rico. Any state can apply for funds to

conduct the ACBS. If more funding were available to states or territories, more states

could apply and improve the data set.

Asthma surveillance should also be able to track environmental and social factors

related to health disparities that contribute to high rates of poorly controlled asthma.

Some of the environmental factors associated with asthma exacerbations include

particulate pollution, pollen, mold, secondhand tobacco smoke, dust mites and

cleaning chemicals

as well as inhaling dusts, gases, fumes from chemicals or other

substances while at work.

Other factors that are attributed to health disparities in

asthma include social drivers such as poverty, where people live, age and quality of

housing, and access to quality healthcare services.

Federal, state and local governments’ natural disaster response plans and climate

resilience plans should address the needs of people with asthma.

• Federal, state and local governments should consider the current and future

impacts of natural disasters and climate change on air quality in their natural

disaster response plans and climate resilience plans.

• Federal, state and local governments should include air quality experts and

asthma control programs in their stakeholder engagement efforts when

planning and implementing natural disaster response plans and climate

resilience plans.

• Federal, state and local governments should ensure that natural disaster

response plans and climate resilience plans address populations with chronic

lung conditions that may be disproportionately impacted by poor air quality.

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About the evidence. Asthma and other chronic conditions can be worsened during

natural disasters as a result of disrupted access to asthma medicines and healthcare,

stress, or exposures to pollutants such as wildfire smoke or mold after flooding. Acute

respiratory infections and exacerbations of chronic lung conditions are common after

natural disasters, and preparedness and response efforts should be aware of and plan

for associated healthcare needs.

An increased focus on personal preparedness for

individuals, improvements in informatics and availability of healthcare records, and

increased capacity via standardized post-disaster treatment plans and first responder

training can help reduce the demand for care of chronic respiratory diseases in the

wake of a hurricane, wildfire or other disaster.

CDC is using its public health expertise to help state, tribal, local and territorial health

departments prepare for and respond to the health effects that a changing climate

may bring to their communities. CDC’s Climate-Ready States and Cities Initiative

(CRSCI) is helping grant recipients use the five-step Building Resilience Against Climate

Effects (BRACE) framework to identify likely climate impacts in their communities,

potential health effects associated with these impacts and their most at-risk

populations and locations.

The BRACE framework then helps these jurisdictions

develop and implement health adaptation plans and address gaps in critical public

health functions and services.

CDC’s Climate and Health Program recently released a new approach to climate

change-related health effects that expands CDC’s climate and health activities to build

capacity in communities to prepare for and respond to health impacts of climate

change.

Air quality is a key concern with preparing for and responding to the impacts

of climate change, as climate change may cause increased frequency and intensity of

wildfire events, high smog days, flooding events and extended pollen seasons, all of

which can have impacts on respiratory health.

For personal preparedness, CDC provides guidance on asthma management during

hurricanes and includes a guide on safe asthma medication use after natural

disasters.

This guidance emphasizes the need for a three-month supply of

medications, related equipment and documentation—such as an asthma action plan—

as well as getting the flu vaccine. Several national non-governmental organizations also

provide asthma-specific information to help individuals prepare for and recover from

hurricanes, wildfires and other disaster events.

36, 37, 38, 39

American Lung Association Page | 13

Outdoor Air

Guiding Principles

The following principles should be considered in implementing asthma policy

recommendations relating to outdoor air:

• Equitable protection from breathing outdoor air pollution should exist for people

with asthma throughout the country.

• Actions taken to reduce outdoor air pollution should include strategies that

reduce air and climate pollution caused by building infrastructure and emissions

from the energy and transportation sectors.

• Mitigating climate change by reducing greenhouse gases is critical to protecting

people with asthma.

• Many people face higher exposure to pollution because of pollution sources

near their residence or community, furthering health disparities. Communities

may face multiple sources of pollution that contribute to greater cumulative

harm. Stronger and/or targeted measures and investments will be needed to

reduce exposure and pollution levels.

Overview

Outdoor air pollution poses a wide range of public health challenges, especially for

people with asthma who face greater risks of negative health effects. Additional groups

who are at higher risk of health harm from air pollutants include children, older adults,

people of color, low-income populations, people with cardiovascular disease or

diabetes, people who work or exercise outdoors and people who live or work near

busy highways. Communities of color and low-income communities may be more

susceptible to air pollution because they are more likely to have power plants, industrial

facilities, major roads and other sources of air pollution nearby. Much of this inequity is

rooted in the long history of systemic racism in the United States, including the practice

of redlining, wherein discriminatory policies and practices around real estate have, in

practice, led to racially segregated neighborhoods. When people with asthma fall into

one or more of these additional at-risk groups, the potential for health impacts is even

greater.

The year 2020 marked the 50th anniversary of the federal Clean Air Act, which aims to

protect human health from dirty air by requiring the U.S. Environmental Protection

Agency (EPA) to set limits, called National Ambient Air Quality Standards (NAAQS), on

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certain air pollutants. Thanks to this law, the nation enjoys much cleaner air overall

today, but challenges remain. First, too many communities located near polluting

sources are still awaiting cleanup. And second, climate change is already adding to the

challenges of achieving clean, healthy outdoor air for all people. Rising temperatures

are leading to higher levels of ozone (“smog”) formation; hotter, drier conditions are

contributing to drought and wildfires that add to existing particle pollution; and the

changing climate is leading to longer, more intense allergy seasons. The health impacts

of climate change, driven in part by these impacts on air quality, are projected to

dramatically worsen without decisive action to reduce greenhouse gas emissions.

Climate change is driven by many of the same sources that emit other harmful air

pollution, including fossil fuel-fired power plants and gasoline- and diesel-powered

vehicles and equipment. A nationwide transition to zero-emission vehicles and clean,

non-combustion renewable electricity can reduce air pollutants that cause immediate

harm and reduce greenhouse gases at the same time, improving air quality for people

with asthma in both the short- and long-term.

Policy Statements and Supporting Strategies

Federal, state and local governments should support and implement the Clean Air

Act to reduce asthma risk from outdoor air pollution.

• U.S. Environmental Protection Agency (EPA) should adopt and implement strong

national measures to reduce emissions of outdoor air pollutants that cause or

worsen asthma and contribute to climate change.

• EPA should adopt strong, science-based National Ambient Air Quality Standards

(NAAQS) that provide an adequate margin of safety for people with asthma and

other more vulnerable populations.

• EPA, states and local governments should ensure reductions in emissions, so air

quality meets the NAAQS, and so that more local, community-level sources of

harmful pollution are addressed.

• Federal, state and local agencies should use Clean Air Act tools and other steps

to reduce air and climate pollution.

About the evidence. The Clean Air Act provides a suite of proven tools to improve air

quality. From 1980 to 2020, emissions of common air pollutants declined 73% while the

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nation’s gross domestic product (GDP) grew 173%.

However, there is still much work

to do to fully implement the law.

The NAAQS process laid out in the law requires that EPA set the national limits on

ozone, particulate matter and four other criteria pollutants at the level requisite to

protect the public health, with an adequate margin of safety, and that the agency

review the science regularly and update the NAAQS, if necessary. The evidence has

shown that ozone and particulate matter are more harmful than previously realized and

the current standards do not adequately protect people with asthma.

41,

Updated

NAAQS for these pollutants that reflect the current science would drive reductions in

emissions nationwide as states with unhealthy levels of these pollutants work to meet

the standards.

EPA also has the authority to require greater reductions in emissions for power plants,

the oil and natural gas industry and vehicles, including greenhouse gas emissions.

Stronger rules covering these sources are critical to driving a nationwide transition to

zero-emission electricity and transportation. The regulations resulting from the Clean

Air Act have the potential to improve health equity for people with asthma if they not

only drive down overall greenhouse gas emissions, but also maximize reductions in

localized sources of air pollution. EPA must also enforce regulations currently in place

to ensure that communities see the promised benefits of air pollution cleanup.

States and communities should reduce greenhouse gases to minimize climate

change, and prepare communities for hotter temperatures, more high-ozone days,

extreme weather, flooding, drought, wildfires and smoke to reduce risk for people

with lung disease.

• States and communities should minimize climate change by cleaning up major

sources of carbon pollution and other greenhouse gases, including power

plants, industrial facilities, cars, trucks, and other mobile sources. These policies

must:

o Adopt science-based targets to prevent global warming above 1.5° C.

o Maximize benefits to health by reducing carbon and methane pollution

while reducing other dangerous emissions from polluting sources.

o Ensure pollution is cleaned up in all communities, prioritizing those near

polluting sources who have historically borne a disproportionate burden

from air pollution.

American Lung Association Page | 16

o Leave the Clean Air Act fully in place. Any policy to address climate

change must not weaken or delay the Clean Air Act or the authority that it

gives EPA to reduce carbon emissions.

About the evidence. Action on climate change is needed at every level of society,

including from state, Tribal, local and community governments. Strong federal action

must be paired with additional actions at the state and local level to protect people with

asthma from the impacts of the changing climate. At the state level, most states have

adopted Renewable Electricity Standard or Clean Electricity Standard policies designed

to transition electricity production from fossil-fuel-powered to more clean or renewable

sources.

However, of these states, only 12 plus the District of Columbia require 100%

clean electricity by 2050 or earlier. The Clean Air Act also allows California to set

stronger motor vehicle emissions standards than the federal government and other

states to opt into California’s standards. As a result, 16 states have adopted California’s

vehicle regulations.

Opportunities abound for additional states to set or strengthen

policies to drive their transitions to zero-emission electricity and transportation.

Actions at the local level can also provide reductions of both greenhouse gases and

other dangerous air pollutants, and cities nationwide are taking steps to do so. For

example, the Climate Mayors coalition, a network of more than 470 mayors nationwide,

has compiled city-level climate actions, including city solar installations, bike share

programs, renewable energy purchases, energy efficiency measures in city facilities,

building codes that will require new construction be net-zero energy, and installation of

electric vehicle charging stations.

In addition, states and communities must address the health impacts of climate change

that cannot be avoided. CDC’s BRACE framework helps communities project the health

burden of climate impacts, assess interventions, and develop and implement plans to

protect the public.

The American Public Health Association offers additional

informational resources for local health departments on understanding and addressing

the inequitable health impacts of climate change, including air quality issues that

disproportionately affect people with asthma.

State and local governments should prioritize environmental justice through

community-informed and directed healthy air protections and investments in

disproportionately impacted communities.

• Implement environmental policies and best practices such as those outlined in

CDC’s “EXHALE Fact Sheet on Environmental Policies and Best Practices to

Reduce Asthma Triggers.”

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• Enhance publicly available air quality and health data through expanded

monitoring networks to identify major sources of pollution burdens at the

community level and inform targeted clean-up efforts in areas disproportionately

impacted by asthma.

• Reduce burdens caused by the fossil fuel industry through increased investment

in energy efficiency and zero-emission alternatives for transportation, energy,

home heating and cooking and other end uses to reduce asthma exacerbations.

• Make public funding for transportation projects conditional on verifiable emission

reductions and providing alternatives to driving by increasing pedestrian, bicycle

and transit infrastructure and service).

• Reduce harmful industrial and commercial practices that can exacerbate

asthma, including agricultural burning, oil and gas flaring and broadcast

applications of toxic pesticides.

• Transition to zero-emission technologies for on- and off-road vehicles and

equipment (cars, school buses, transit, trucks, port equipment), such as by

purchasing zero-emission school buses to replace diesel buses.

• Transition to zero-emission appliances for home heating and cooking to reduce

and eliminate health impacts caused by combustion.

• Reduce emissions of pollutants from fossil fuel-fired power plants, especially

sulfur dioxide and nitrogen oxide emissions, and transition to clean, non-

combustion renewable electricity.

• Prohibit or restrict outdoor wood boilers (outdoor hydronic heaters) and require

cleanup or retirement of existing units.

• Reduce agricultural sources of emissions, such as agricultural burning and diesel

trucks, tractors, pumps and other equipment.

• Adopt policies that reduce the use of motor vehicles, promote more compact

and walkable community development, and encourage transit use, bicycling and

walking that is safe and accessible to all communities, especially those that have

been historically under-invested in and impacted negatively by transportation

investments.

• Adopt or expand mass transit and other shared mobility options that reduce

emissions from motor vehicles and expand the benefits of healthier, less

polluting forms of travel.

• Adopt policies to transition to zero-emission vehicles, including investment in

infrastructure and programs that ensure equitable distribution of the health

American Lung Association Page | 18

benefits of zero-emission cars, school and transit buses, trucks and other

transportation sources.

• Implement policies and programs to reduce exposure to air pollution in

disproportionately burdened communities.

About the evidence. EPA defines environmental justice as “the fair treatment and

meaningful involvement of all people regardless of race, color, national origin or income

with respect to the development, implementation and enforcement of environmental

laws, regulations and policies,” and further says that fair treatment “means no group of

people should bear a disproportionate share of the negative environmental

consequences from industrial, governmental and commercial operations and

policies.”

Of course, the nation has much work to do before people in all communities

experience fair treatment. Currently, people of color, low-income and indigenous

communities experience disproportionate harms from pollution, including health harms,

which puts people with asthma in these communities at additional risk.

EPA offers states and communities resources to identify environmental justice

concerns, including EJSCREEN, a tool that overlays data on low-income populations

and people of color with several environmental health indicators, including outdoor

ozone and particle pollution levels. However, additional monitoring is critical to capture

specific and timely air quality concerns that affect people with asthma in communities

with environmental justice concerns. The White House Environmental Justice Advisory

Council (WHEJAC) issued recommendations for the federal government in 2021 that

include ensuring that each state adequately monitors pollution in frontline and fence-

line communities, including hyperlocal measurements in communities that lack these

data.

The use of combustion—whether of coal or natural gas at a power plant, of wood in an

outdoor boiler or residential woodstove, or of gasoline or diesel in vehicles and

equipment—creates harmful emissions and puts people with asthma at risk. Programs

that transition away from combustion and reduce demand for combustion-based

energy are critical for cleaning up air pollution at the community level. The WHEJAC

recommendations also include policies to incentivize community solar projects; invest

in battery storage; transition to clean energy; invest in transit hubs; electrify school

buses and sanitation trucks and provide job training in the renewable energy industry.

The agriculture industry is another source of local pollution and greenhouse gases due

to fossil-fuel powered equipment, erosion and tilling of soil, agricultural burning and

fertilizer use. EPA offers guides to understand the agricultural best practices to reduce

these impacts.

Pesticides have additional health risks associated with them, including

asthma and other lung problems, and pose a danger to the workers who apply them.

American Lung Association Page | 19

The National Pesticide Information Center offers guides to understand the risks and

reduce exposure.

The above steps to reduce emissions can be paired with additional measures that help

mitigate the harm of existing air pollution. For example, in areas prone to exposure to

wildfire smoke, residents may benefit from programs that provide access to

mechanical air filtration devices (air cleaners) to help them create a space in their home

in which it is safer to breathe during smoke events.

Important considerations include

focusing on effective devices that do not produce ozone or other additive technologies

and informing the public about key considerations for their use, including sizing of the

device relative to the room.

American Lung Association Page | 20

Healthcare Systems and Financing

Guiding Principles

The following principles should be considered in implementing asthma policy

recommendations relating to healthcare systems and financing:

• The healthcare system, in partnership with other sectors, should work to

address the medical needs and social determinants of health for people with

asthma, and communities with the highest burden.

• All patients should receive high-quality, culturally competent, guidelines-based

asthma care regardless of race, ethnicity, sex, sexual orientation and gender

identity, age, disability, immigration status, socioeconomic status or geographic

location.

Overview

Access to high-quality, affordable healthcare coverage is critical to improving the

health of people with asthma and reducing health disparities. Since the passage of the

Affordable Care Act (ACA) in 2010, historic progress has been made. Patients with pre-

existing conditions like asthma can no longer be denied coverage or charged more

because of their health status. The ACA also provides subsidies to purchase health

insurance, enables states to expand Medicaid coverage, and allows young adults to

stay covered by their families’ health insurance until age 26. As a result of these

changes, the number of uninsured individuals dropped from 46.5 million in 2010 to 26.7

million in 2016, with some of the largest coverage gains among low-income individuals

and people of color.

The past decade has also seen significant changes in where patients can access

healthcare services. In 2014, the Centers for Medicare and Medicaid Services (CMS)

reversed its free care policy, expanding the ability of school-based health programs to

provide services for individuals with Medicaid coverage.

This policy change, for

example, expands the ability of school health professionals to provide, and be

reimbursed for, self-management education for students with asthma. Additionally, as

a result of the COVID-19 pandemic, federal and state lawmakers have made temporary

and permanent policy changes to increase the number of patients who can access

healthcare services via telehealth, including care needed to manage asthma.

Despite this progress, many patients with asthma are still not getting the care that they

need from our nation’s healthcare system. Twelve states have failed to expand

Medicaid, leaving the most vulnerable people in those states without access to

healthcare.

The number of uninsured individuals has also increased from 2016 to

American Lung Association Page | 21

2019, and disparities in coverage still remain, with people of color more likely to be

uninsured than white individuals.

The passage of expanded financial assistance for

coverage through the American Rescue Plan Act, as well as new investments in

outreach and enrollment, appear to be helping to reverse this trend, with the number of

uninsured individuals once again falling in both 2020 and 2021.

Policy Statements and Supporting Strategies

All people with asthma should have comprehensive, affordable, and accessible

healthcare coverage to improve overall health and quality of life.

• Maintain and expand access to Medicaid, CHIP and other affordable health

insurance coverage options for eligible populations.

• Ensure that Medicaid and other payers include all asthma treatments and home-

based asthma services that reduce or eliminate environmental asthma triggers

recommended by national evidence-based guidelines in coverage policies.

• End policies that require patients to change medications when they are already

well controlled (non-medical switching) and other practices that interfere with

patients’ ability to control their asthma.

• Limit out of pocket costs for patients to support adherence to medications and

other treatments.

About the evidence. Medicaid remains an important source of coverage for patients

with asthma; for example, nearly half of children with asthma receive their coverage

through Medicaid or CHIP.

Research on the ACA’s Medicaid expansion highlights the

beneficial impact of Medicaid coverage on patients with asthma. For example,

Medicaid expansion is associated with a reduction in preventable hospitalizations for

asthma and other chronic conditions.

Another study found that Medicaid expansion is

associated with improvements in quality measures related to asthma management at

federally qualified health centers, an important source of care for patients with lower

incomes.

Recognizing the burden of asthma in the Medicaid population, with the support of CDC,

the American Lung Association launched the Asthma Guidelines-Based Care Coverage

Project in 2015 to track asthma guidelines-based care in state Medicaid programs. The

first peer-reviewed study from this project, published in Preventing Chronic Disease in

September 2018, found a lack of consistent and comprehensive coverage of

guidelines-based asthma care across state Medicaid programs as well as multiple

American Lung Association Page | 22

barriers to care.

Project data are updated annually and continue to show much room

for improvement in this area.

The 2009 National Asthma Public Policy Agenda recognized the burden that restrictive

formularies and high costs for care have on patients with asthma, problems that

unfortunately remain a decade later. Non-medical switching—where health plans

require patients to change their asthma medication to one that has preferred status on

their formulary, sometimes repeatedly—can have a long-term negative impact on

patients’ asthma control.

Additionally, high deductible health plans have grown

significantly over the past decade, and while the Internal Revenue Service updated

guidance in 2019 to clarify that inhaled corticosteroids for asthma management should

be covered by these plans as preventive care before patients hit their deductibles,

many medications, devices and other treatments to manage asthma are not subject to

this policy, leaving patients at risk for high costs.

According to a poll conducted by the Kaiser Family Foundation in 2021, 26% of

individuals report having trouble affording their prescription medications, and three in

10 adults report having not taken medications at some point in the previous year due to

cost.

Research has shown that higher cost-sharing is associated with reduced

treatment for patients with asthma,

and even copayments as low as one to five

dollars can result in reduced use of necessary healthcare services by individuals with

lower incomes.

Private health insurance, Medicare and Medicaid should develop and implement

policies and payment systems to support the delivery of guidelines-based asthma

care, address social determinants of health and eliminate disparities.

• Implement activities such as those outlined in CDC’s EXHALE Guide for Medicaid

and Children’s Health Insurance Program (CHIP) Leaders or CDC’s EXHALE

Guide for Managed Care Leaders and Staff.

• Ensure that prescription formularies include a full range of medication options for

quick-relief and long-term control of asthma in accordance with the National

Asthma Education and Prevention Program (NAEPP) guidelines for diagnosing

and managing asthma.

• Develop and test innovative payment models that incentivize providers and

cover treatments and services to support the needs of people with asthma.

• Develop and implement coding, coverage and reimbursement policies for

payment for home-based asthma services, including environmental remediation.

American Lung Association Page | 23

• Develop and implement sustainable financing mechanisms to better integrate

services provided by community health workers into the healthcare delivery

system.

• Expand access to telehealth services.

About the evidence. The ACA expanded opportunities related to payment reform to

test new models that can decrease costs and improve patient care, a potential

pathway to translate innovations in clinical practice into public health advancements.

Institutions like the Medicaid and CHIP Payment and Access Commission (MACPAC)

are studying the implementation of value-based payment models in state Medicaid

programs, which will be important to ensure the innovations in this area reach the

underserved populations enrolled in these programs.

With regard to asthma specifically, stakeholders have increasingly focused on

achieving coverage and reimbursement for home-based asthma interventions that

have a strong record of improving asthma control as well as a positive return on

investment.

While the Asthma Guidelines-Based Care Coverage Project has shown

low uptake of these interventions by state Medicaid programs, many state asthma

programs are working to expand coverage in this area.

In 2021, the Centers for

Medicare and Medicaid Services (CMS) released guidance on opportunities in Medicaid

and CHIP to address social determinants of health, including interventions to address

triggers in the home environment for patients with asthma.

Efforts to expand

coverage and reimbursement for community health workers in state Medicaid

programs are closely related to efforts to expand coverage of home-based asthma

interventions, and a recent review found emerging evidence of a positive return on

investment from home-based asthma interventions led by community health workers

(CHW).

77, 78

Because of the critical role of CHWs in providing culturally competent care

in their communities, expanding and integrating their services into the healthcare

system could also be an important component of efforts to eliminate health disparities

among patients with asthma.

The COVID-19 pandemic has dramatically expanded the adoption of telehealth. Some

states have already moved to make temporary changes to expand access to telehealth

visits with providers permanent.

Some state asthma programs have worked to make

interventions like in-home environmental assessments for patients with asthma

available virtually or using hybrid models (in-person plus virtual visits).

Evaluations of

transitions to virtual implementation of home visit programs that include home

environmental assessments and self-management education will be key to building the

evidence-base for longer-term policy change related to the delivery of asthma services

via telehealth.

American Lung Association Page | 24

Provider teams should deliver services and treatments consistent with the National

Asthma Education and Prevention Program guidelines for the diagnosis and

management of asthma with appropriate care coordination.

• Implement the activities outlined in CDC’s EXHALE Guide for Healthcare

Professionals.

• Provide self-management education using evidence-based interventions by

trained professionals as a standard of care.

• Develop and use asthma action plans for all patients.

• Provide case management and care coordination, including home-based

asthma education, environmental assessment, remediation, and referrals to

other social supports or resources, for high-risk patients and those whose

asthma is not well controlled.

• Provide tobacco dependence treatment and pharmacological therapy to

smokers who have asthma or who have family members with asthma.

• Recruit and train a diverse workforce to care for patients with asthma, including

community health workers (CHW), pharmacists and other members of patients’

care teams.

About the evidence. Many of the strategies in this section were included in the 2009

National Asthma Public Policy Agenda and remain relevant today. In 2020, the National

Heart, Lung and Blood Institute released the 2020 Focused Updates to the Asthma

Management Guidelines: A Report from the National Asthma Education and Prevention

Program Expert Panel working group.

These updates have important implications for

asthma management, and it will be important to track their implementation to

determine whether additional strategies are needed to ensure providers teams are

equipped to deliver guidelines-based care.

The strategy about recruiting and training a diverse workforce recognizes the

increased focus on reducing health disparities in asthma policy work over the past

decade. Research has shown that patients benefit when receiving care from diverse

teams, with diversity defined by race, age, educational status, and other similar

factors.

CHWs have been well-documented in the literature to provide asthma home

environmental assessments and asthma education. Since the publication of the 2009

Agenda, CHWs delivered a range of home-based asthma services including home

environmental assessments, trigger reduction education, and asthma self-

management management education

and have improved outcomes (e.g., reduced

American Lung Association Page | 25

emergency department visits, hospitalization, and asthma symptoms) in underserved

communities.

85, 86

The healthcare system should develop and meet quality improvement goals that

improve outcomes for patients with asthma.

• Implement the activities outlined in CDC’s EXHALE Guide for Healthcare System

Executive Leaders.

• Revise, expand or develop national performance measures aligned with national

standards to better measure asthma control and quality of care.

• Provide comprehensive and consistent data that is reported across healthcare

systems, including through electronic health records, to improve asthma

surveillance and tracking of asthma outcomes and disparities.

About the evidence. There are multiple quality measures related to asthma, including

the asthma medication ratio (AMR), which measures level of control and, by extension,

the quality of the asthma care patients receive based on their medication use.

The

AMR is included in both the Child Core Set and Adult Core Set, measures that CMS

recommends state Medicaid programs report on. Beginning in 2024, all states will be

required to report on the Child Core Set of measures to CMS, including the AMR.

Moving to mandatory reporting will make the federal quality data set more robust and

should drive providers to deliver evidence-based care. However, some stakeholders

believe these measures are insufficient and have begun discussing other possible

measures that better capture the quality of patients’ asthma care.

For example, Green

& Healthy Homes Initiative collaborated with stakeholders to develop a standard set of

measures for the reimbursement of in-home environmental health services as part of

comprehensive asthma care.

Accessing and analyzing claims data and other sources of data are vital to evaluating

progress in asthma care. Without high-quality data, ineffective programs may be

difficult to identify and even harder to improve. Limitations and challenges exist with

respect to accessing or acquiring large administrative data files, data management,

data integration and, most importantly, data quality issues. Alternative sources of

asthma-related data (such as surveys) rely on patient self-reporting, which can be

unreliable. The need for high-quality, accessible data remains a significant challenge.

American Lung Association Page | 26

Homes

Guiding Principles

The following principles should be considered in implementing asthma policy

recommendations relating to homes:

• Policies for homes include all residential settings, including single and multi-unit

housing, group homes, shelters, institutionalized settings, etc.

• Housing codes are public health tools that can and should be used to improve

indoor environmental quality in homes of residents who have asthma.

• Harmful pollutants generated from the use of e-cigarettes and the combustion

of tobacco products, wood and fossil fuels for heating and cooking should be

eliminated from homes.

• “Green building” guidelines do not necessarily provide adequate protection from

asthma health concerns.

• People with asthma should have access to affordable, safe, healthy and climate-

resilient homes and neighborhoods.

Overview

The home is where most people spend much of their time, from infancy through old

age. There are many factors that affect the quality of the home environment and the

health of its residents, including the age and physical condition of the structure, the

materials used in the building and furnishings and the activities of the occupants.

Homes of all types often contain known triggers for asthma exacerbations, including

dampness and mold, dust mites, pests, secondhand smoke, cleaning chemicals,

pesticides, disinfectants and fragrances. Numerous studies have linked the indoor

environment with the development and exacerbation of asthma. Measures

recommended to reduce asthma triggers in the home include controlling humidity

levels and fixing water leaks, removing carpeting/rugs in bedrooms, vacuuming

carpets, area rugs and floors regularly using a vacuum with a HEPA filter, eliminating

cockroaches and rats, not using cleaning compounds or disinfectant that can

aggravate asthma, using special covers on mattresses and pillows, and reducing

indoor combustion, including smoking.

Since there are few policy approaches available that apply to private residences, most

control strategies for asthma triggers in homes are voluntary. Even in rental and multi-

unit housing, building owners and managers have a lot of autonomy when establishing

American Lung Association Page | 27

rules and practices for maintaining their properties. The three main types of state and

local laws that address the indoor environment in rental and multi-unit housing are

housing codes, landlord-tenant laws and laws or rules regulating specific indoor

pollutants, such as secondhand smoke.

The policy recommendations in this section have remained much the same as in the

original 2009 National Asthma Public Policy Agenda. One important addition is the

recognition that healthy housing will need to be made resilient to the effects of climate

change, including increasing temperatures, wildfires and flooding. Progress on policy

change in housing over the last 10 years has been for the most part slow, incremental

and localized. One significant exception has been the increase in the number of smoke

free laws and policies, especially in public housing.

Secondhand smoke is a serious health hazard causing or making worse a wide range

of diseases and conditions, including asthma. Children are particularly at risk as,

according to the U.S. Surgeon General, exposure to secondhand smoke causes more

frequent and more severe asthma episodes.

In the decade since this agenda was last

updated, the U.S. Department of Housing and Urban Development took a major step

forward when it finalized and implemented a rule requiring public housing agencies to

prohibit smoking in all public housing. This rule is expected to significantly reduce

exposure to secondhand smoke among public housing residents who are

disproportionately exposed.

Policy Statements and Supporting Strategies

Housing agencies should adopt housing codes that protect people with asthma

from exposure to indoor air pollutants, irritants and allergens.

• Adopt and proactively enforce healthy housing standards in state and local

housing codes.

• Use integrated pest management (IPM) techniques in multi-unit housing.

About the evidence. Housing codes are a set of tools used by states and

municipalities to set minimum standards for the maintenance of residential buildings.

Most U.S. cities, counties and states that adopt and enforce housing codes opt to base

them on model codes developed by the International Code Council. The purpose of

housing codes is to preserve a building’s structural and weather-resistant performance

and ensure a minimum level of safety and sanitation for residents and the community.

American Lung Association Page | 28

Many of the standard housing codes touch on issues that affect occupant health,

including peeling paint, mold and moisture and cockroach and rat control, but health is

not usually the primary focus. To better connect the housing and public health sectors,

the American Public Health Association and the National Center for Healthy Housing

published the National Healthy Housing Standard in 2014.

This evidence-based

Standard includes many provisions for maintaining healthy indoor air quality and

facilitating the environmental management of asthma. The Standard is written in

housing code language to complement the International Property Maintenance Code. It

is intended for use by housing advocates, public health professionals, elected officials,

code agency staff and community members interested in strengthening their local

codes.

As the evidence for the impact of housing on health has grown over time, more states

and municipalities have taken steps to address the problem of substandard housing

though code changes. In 2018, for example, the New York City Council passed a law to

amend the city’s housing maintenance code to require private landlords to prevent and

remediate indoor asthma triggers in their multi-unit residential buildings. The law lays

out detailed provisions for addressing mold and pests and is notable for its mandate to

use IPM practices to minimize the use of chemicals in controlling pests. IPM as defined

by the EPA is “an effective and environmentally sensitive approach to pest

management that relies on a combination of common-sense practices.”

However,

there is a need for additional state and federal funding opportunities for housing

agencies to address indoor environmental quality conditions in subsidized and public

housing.

State and local health departments and housing agencies should enforce housing

codes to protect people with asthma from exposure to indoor air pollutants,

irritants and allergens.

• Provide training for housing code enforcement officials on applying codes to

address indoor environmental quality problems.

• Provide proactive inspections of rental housing.

• Provide authority and capacity for local health departments to take legal action

to enforce indoor environmental quality-related codes and laws (including

nuisance laws).

• Provide capacity within state and local housing inspection agencies to offer

specialized services to identify and remedy indoor environmental quality

problems where families with asthma reside.

American Lung Association Page | 29

• Improve legal and other recourse for tenants to ensure enforcement of local

laws (including judicial education, increasing legal services and tenant

education) without risk of displacement.

• Provide capacity for state and local health departments to offer guidance to

property owners on identifying and remediating indoor environmental quality

problems, including information on smokefree policies.

About the evidence. Enforcement of housing codes has the potential to be a powerful

tool in the environmental management of asthma, but there are many challenges to

implementing it effectively. Just as housing codes are most often focused on basic

safety and sanitation, rather than health, so too are most code enforcement efforts. In

most places, inspection by code enforcement officers is based on complaints, rather

than being done systematically, so serious health and safety problems can be missed

until they become a crisis. Complaints about housing code violations are frequently

based on exterior conditions such as trash and peeling paint, rather than conditions

inside the home that affect occupant health. Tenants can be fearful of being displaced

if they complain about their living conditions. Therefore, enforcement of laws should

not put tenants at risk of displacement (e.g., raised rent, eviction).

To ensure that housing is safe and healthy, municipalities need a range of enforcement

tools, including detailed, enforceable health-based code language, financial support to

hire and train enforcement officers and community support for and cooperation with

the program. Cross-agency collaboration is critical to ensure that all the various

government agencies with enforcement authority in residential buildings are

coordinating their efforts and services. The health department managing a home

asthma program, for example, should be able to share information with housing

inspectors to address a mold problem.

Making code enforcement less punitive and more collaborative has been shown to

increase community support and compliance.

Alameda County in California adopted

a cooperative compliance model, in which code enforcement officers work

cooperatively with property owners to help them understand the elements of healthy

housing, the importance of code compliance and how to bring the property into

compliance. The code enforcement officer is also able to provide information about

available resources to improve housing conditions and promote health. The Boston

Public Health Commission’s Breathe Easy at Home program is a web-based referral

system that allows healthcare professionals to refer patients to receive a home

inspection that is conducted by the Boston Inspectional Services Department (ISD).

The ISD inspectors work with property owners to address poor housing conditions for

people with asthma.

American Lung Association Page | 30

Multi-unit housing, including public and other federally supported housing, should

be smokefree.

• Pass state and local laws and regulations to require smokefree multi-unit

housing, including e-cigarettes and marijuana.

• Expand policy with the U.S. Department of Housing and Urban Development

(HUD) to require all federally supported multi-family housing to be smokefree.

• Develop and disseminate guidance on best practices for enforcement of

smokefree policies while minimizing displacement and eviction.

• Provide resources and services to support smokers wishing to quit.

• Collaborate with tenants’ rights and other community-based organizations to

develop and implement policies and best practices.

About the evidence. According to the U.S. Surgeon General, secondhand smoke has

been causally linked to a number of diseases and conditions, including lung cancer,

heart disease and stroke in adults and respiratory symptoms, including impaired lung

function, lower respiratory illness, and sudden infant death syndrome among children.

Children with asthma exposed to secondhand smoke have more severe and more

frequent asthma attacks.

The Surgeon General has also declared that aerosol coming

from e-cigarettes is “not harmless.”

In addition, secondhand marijuana smoke

contains many of the same toxins and carcinogens found in directly inhaled marijuana

smoke, in similar amounts if not more.

Therefore, e-cigarettes, marijuana smoking and

vaping can be harmful to lung health.

Children have a higher prevalence of secondhand smoke exposure than adults,

especially children age 3 to 11, and most exposure among children occurs in the

home.

In 2019, an estimated 25.3% of middle and high school students reported

secondhand smoke exposure in the home. Exposure is even higher for children living in

multi-unit housing. Among children who live in homes in which no one smokes indoors,

those children living in multi-unit housing such as apartments or condos have 45%

higher cotinine levels than children living in single-family homes.

100

Disparities in secondhand smoke exposure also persist despite overall declines in the

number of people exposed to secondhand smoke, especially for Black individuals and

people who live below the federal poverty level.

101

The disparities for Black people are

particularly stark—50.3% of Black people who do not smoke are exposed compared to

approximately 20% of white people and individuals of Mexican descent.

102

In addition,

while secondhand smoke exposure among U.S. youth in homes and vehicles

significantly declined from 2011 to 2018, exposure among Black youth did not change.

103

American Lung Association Page | 31

On July 31, 2018, an important rule from HUD took effect that required public housing

agencies to prohibit smoking in all public housing. Specifically, the rule prohibited the

smoking of most tobacco products in all public housing living units and interior areas,

including but not limited to hallways, rental and administrative offices, community

centers, day care centers, laundry centers, and similar structures, as well as in outdoor

areas within 25 feet of public housing and administrative office buildings.

104

The rule,

unfortunately, does not include e-cigarettes, but individual public housing authorities

can extend their policies to include them.

This rule is expected to reduce exposure to secondhand smoke for close to 2 million

public housing residents and reduce episodes of asthma accordingly. Although not the

main intent of the rule, it is also expected to reduce cigarette consumption and

increase smoking cessation rates. One study of public housing residents in Milwaukee,

Wisconsin, showed a decrease in secondhand smoke exposure after implementation

of the rule.

105

Another study measuring air quality in Norfolk, Virginia, found that

secondhand smoke exposure initially dropped one month after the rule’s

implementation, then increased relative to the previous year’s exposure level several

months later.

106

Both studies point to the need for ongoing implementation support,

including ongoing education of public housing authority residents and staff, and

thoughtful enforcement for the benefits of the rule to be fully realized. HUD, the

American Lung Association, and many other organizations assembled implementation

and smoking cessation resources based in part on previous voluntary adoption of

smokefree housing policies by public housing authorities, and some organizations

provided direct implementation support in the 18-month period between when the rule

was finalized and implemented.

107,

108

At present, no efforts are underway to extend the smokefree policy to other federally

subsidized housing, but that could be considered in the future to further reduce

exposure to secondhand smoke among populations disproportionately exposed to

secondhand smoke and e-cigarette aerosol.

Uptake of state or local laws prohibiting smoking in multi-unit housing has been much

less widespread, with only a few communities in California adopting such laws. Over 10

states do explicitly prohibit smoking in the common areas of multi-unit housing as part

of their laws prohibiting smoking in public places and workplaces. Efforts in certain

communities to encourage voluntary adoption of smokefree multi-unit housing policies

have been much more widespread, with programs existing or having existed in the

majority of states.

American Lung Association Page | 32

State and local agencies should incorporate best practices for healthy and climate-

resilient homes through construction, rehabilitation and repair of housing, including

public and other federally supported housing.

• Identify substandard public and other federally assisted housing buildings and

renovate according to best practices for healthy indoor environmental quality.

• Green building guidelines should incorporate healthy housing standards.

• Housing authorities should incorporate financing tools, including grants, loans

and tax credits, to ensure safe and healthy properties.

• Ensure that federal policies for the funding of housing rehabilitation encourage

following best practices for improving indoor environmental quality for housing

rehabilitation and weatherization.

• Housing authorities should incorporate climate resilience into building

construction, rehabilitation and repair with considerations of siting of residential

buildings and flood protection; materials; heating, cooling and ventilation; energy

sources; and zero-emission vehicle fueling infrastructure.

About the evidence. Much progress has been made in the last 10 years in identifying

best practices in building and maintaining healthy and climate resilient homes.

Research has shown that applying these practices can reduce asthma morbidity,

including in public and federally subsidized housing.

109, 110

Climate change is affecting buildings and indoor environments as well as outdoor

environments. Wildfires and extreme storms can cause extensive structural damage

and leave toxic residue behind. Buildings can be modified not only to reduce their

contributions to the fossil fuel use that drives climate change, but also to enhance their

resilience in the face of climate impacts.

111

Changes made to homes to improve their energy efficiency are important to reduce

demand for electricity that comes from polluting sources. Indoor air quality

considerations must be incorporated into green building practices to ensure that

measures that reduce airflow between the indoors and outdoors to reduce heating and

cooling costs, for example, do not contribute to air quality problems.

112

EPA offers

guidelines for energy upgrades in multi-unit and single family homes designed to

inform contractors and environmental professionals for voluntary adoption by state,

Tribal and local weatherization assistance programs, federally funded housing

renovation programs and others.

113

Initial considerations in single-family homes, for

example, include ensuring that combustion appliances are properly vented, that

exposure to building materials that may contain volatile organic compounds is

American Lung Association Page | 33

minimized, that flooring is water-resistant in areas prone to moisture, and that mold

problems are remediated before buildings are upgraded.

114, 115

Additionally, EPA offers a compendium of green building codes and identifies which

include indoor environmental quality factors.

116

The American Society of Heating,

Refrigerating and Air-Conditioning Engineers (ASHRAE) offers a guide to ensuring

healthy indoor air quality in design, construction and commissioning, including

adequate air filtration.

117

Federal, state and municipal governments and nonprofit organizations offer a

patchwork of funding programs to help landlords and low-income homeowners with

home repairs. HUD has several loan and grant programs to address housing-related

health hazards, including asthma. USDA Single Family Housing Repair Loans and Grants

provide funds to elderly and very-low-income homeowners to remove health and

safety hazards, perform necessary repairs and make homes more energy efficient.

Some communities use their HUD-funded Community Development Block Grants for

housing code enforcement programs and housing rehabilitation efforts. Unfortunately,

these funding programs are not available consistently across the country, and can be

difficult to find and apply for, which limits the accessibility of proven best practices,

especially for the most vulnerable populations.

American Lung Association Page | 34

Schools

Guiding Principles

• Closer coordination between schools and the healthcare system is critical to

improve health outcomes for children with asthma.

• Provision of adequate health services requires creative solutions including

private/public partnerships, use of health technicians, etc. Links between

schools, private/public partnerships and other community services should be

aggressively pursued and used.

• Although these policy recommendations focus on schools, children with asthma

in all institutional settings, including childcare and residential programs, should

receive similar protections.

Overview

Asthma is one of the most common chronic childhood illnesses in the United States,

affecting 5.5 million children. Although common, asthma can be difficult to manage,

and its impact on the well-being of children and families ripples through communities

nationwide. In 2018, 44% of children with asthma reported missing at least one day of

school due to asthma.

118

Additionally, the average annual rate of children visiting the

emergency room for asthma in 2016-2018 was 88.1 per 10,000, much higher than the

rate for adults at 41.1 per 10,000.

119

A student’s health status can directly affect their

attendance and academic achievement and may impact a parent’s ability to go to

work. For example, asthma is linked with chronic absenteeism, and students that miss

fifteen or more school days a year are at an increased risk of dropping out of school.

120

Schools face several issues directly related to asthma—providing a healthy school

environment, potential asthma emergencies, absenteeism, student and teacher

productivity, health office visits, and access to life-saving asthma medications. Often,

schools are not prepared to manage these issues, resulting in a school environment

that may cause or worsen asthma symptoms and impede a student’s learning.

In 2014, the Association of Supervision and Curriculum Development (ASCD) and the

CDC launched the Whole School, Whole Community, Whole Child (WSCC) model.

WSCC is an expansion of the CDC’s Coordinated School Health model. The WSCC

model does not replace the Coordinated School Health model, but rather expands on it

and builds on the lessons learned through its implementation. It uses a collaborative

approach to improve learning and health in schools across the country. The model

American Lung Association Page | 35

encourages engagement of the community, creating opportunities for schools to

facilitate linkages to healthcare providers and other social services.

Over the last 10 years, some of the biggest advancements in school districts and

schools that directly impact children with asthma have come from the adoption of

policies that allow schools to stock quick–relief asthma medication, the use of Every

Student Succeeds Act (ESSA) funds to improve school buildings, and opportunities

through the reversal of the free-care rule for schools to receive Medicaid

reimbursement to manage chronic conditions.

121, 122, 123, 124, 125

In 2015, Congress passed

the School-Based Allergies and Asthma Management Program Act. This law

incentivizes states to require schools to have trained nursing or other personnel on

staff, as well as require each student with asthma or allergies to have a personalized

action plan.

ESSA replaced the “No Child Left Behind Act” in December 2015. ESSA is a law that

governs school and school districts’ education policy for K-12. ESSA includes several

provisions that support student health, such as: adding chronic absenteeism as a

required indicator to school report cards for Title I schools; supporting school nursing

services as a part of the Title 1 Schoolwide Program Plans; restructuring Title IV, Safe

and Healthy Students, to require that eligible school districts conduct a needs

assessment to identify the health and safety needs of their students; and recognizing

both health education and physical education as part of a well-rounded education.

126

ESSA also requires states to include a measure of school quality or student

engagement and over 30 states use chronic absence as that measure.

127

Schools

eligible for ESSA funds could apply financial resources to develop school asthma

management plans. An optimal asthma management plan for schools is one that

supports a healthy school environment and implements appropriate policies and

procedures to manage the medical aspects of students with asthma.

The opportunities presented by ESSA implementation for supporting healthy schools

and student health and wellness can help to transform education to better support

healthy schools and student health and wellness and address key health issues, such

as asthma, that impact students’ ability to learn.

School health services are delivered primarily by the school nurse. School nurses play a

pivotal role in the health and well-being of students with asthma. The school nurse is

responsible for many critical components, including ensuring that quick-relief

medication is at school for each student with asthma; implementing a student’s asthma

action plan; administering medication or supervising the administration of medications;

monitoring the student’s condition, and often providing asthma education to the rest of

the school staff. School nurses are uniquely able to identify students whose asthma is

not well controlled and to work with the family and the student’s asthma care clinician

American Lung Association Page | 36

to identify and implement the right control measures. Since the publication of the 2009

Agenda, there has been an increase in the number of School-based Health Centers

(SBHCs) with over 2,500 now available in underserved communities.

128

In August 2015,

the Community Preventative Services Task Force recommended “the implementation

and maintenance of SBHCs in low-income communities to improve education and

health outcomes.”

129

Communities with SBHCs have demonstrated decreases in

asthma morbidity, emergency room visits and hospitalizations for asthma.

130

The

National Association of State Boards of Education (NASBE), through its State Policy

Database, tracks state health policies. NASBE tracks several state policies related to

school-based health services, including policies that address on-campus health

centers or clinics. Eighteen states and the District of Columbia have policies that

address on-campus health centers or clinics.

131

Policy Statements and Supporting Strategies

Every state should put in place laws and regulations to improve asthma

management in schools.

• Establish laws to authorize stocking of asthma medication in schools.

• Provide funding to support school nurses in every school.

• Expand Medicaid programs to allow school districts to bill Medicaid for all

Medicaid eligible services delivered to Medicaid enrolled students.

• State Boards of Education should create and disseminate standards or

recommendations for healthcare services and alternative methods for providing

care in schools in the absence of school nurses.

• State Departments of Health and State Departments of Education should

coordinate activities to support asthma policies and practices in schools.

• States should use funding from and implement procedures recommended by

ESSA to improve school buildings.

About the Evidence. When children with asthma go off to school, their safety and the

management of their condition becomes the shared responsibility of the family, their

healthcare providers and school personnel. Every state and the District of Columbia has

passed a law allowing students with asthma to self-carry their asthma inhalers.

However, there is still a range of policies and practices in place that create barriers to

appropriate access to these potentially lifesaving medicines during the school day. In a

2014 issue brief, “Improving Access to Asthma Medications in Schools: Laws, policies,

American Lung Association Page | 37

practices and recommendations,” the American Lung Association identified six barriers

to optimal access to asthma medications in schools, including local control, parental

engagement, assessing a student’s readiness to self-carry, availability of back-up

medication, protection from liability, and penalties that limit access to life-saving

medication.

132

Currently, 15 states have laws or state administrative guidelines allowing

schools to stock quick-relief medications.

133

However, there is still much work that

needs to be done in communities to fully implement the law. Once a law has been

established, it is important for school districts and schools to put protective policies

and practices into place, such as obtaining medication and supplies, training

designated school staff in administering stock quick-relief asthma medication, and

implementing a communication strategy to inform students, parents, staff, and the

larger community. An American Thoracic Society policy statement, published in

September 2021, provides a comprehensive guide for passing and implementing laws

pertaining to stock asthma medication in schools.

134

Every state should provide funding for school nurses in every school. CDC estimates

that 40% of school-aged children and adolescents have at least one chronic health

condition.

135

The National Association of School Nurses and the American Academy of

Pediatrics recommends at least one full-time school nurse per school.

136, 137

However,

there are no federal laws regulating school nurse staffing, and the Department of

Education does not monitor the number of school nurses at the state or local level. For

schools without a school nurse, state boards of education should intervene by

providing guidance for schools to address health. ESSA funds could help to support

school nursing services.

School nurses serve an important role in asthma treatment, including monitoring

asthma, medication delivery and care coordination.

138, 139

Studies have demonstrated

that full-time school nurses reduce illness-related absenteeism. All states have a

school Medicaid program that allows school districts to bill for certain Medicaid-eligible

services, including nursing services. As of March 2022, 16 states have expanded their

school Medicaid programs through the free care policy reversal to allow school

districts to bill for additional services delivered to Medicaid enrolled students.

140

than half of public schools (51.1%) bill for Medicaid reimbursement; however,

reimbursements differ by state.

141

Schools eligible for ESSA funds could also apply financial resources to develop school

asthma management plans. An optimal asthma management plan for schools is one

that not only manages the medical aspects of students with asthma but also

implements appropriate policies and procedures to support a healthy school

environment. A number of policies, programs and maintenance activities to ensure

healthy indoor air at school can also help to protect students with asthma.

American Lung Association Page | 38

Approximately 87% of districts use integrated pest management, defined as an

approach to pest control that seeks to minimize the use of pesticides. Integrated pest

management uses methods that focus on preventing pests by eliminating pest access

to food, water, and shelter in and around the school.

All educational facilities should adopt and implement policies and procedures for

the medical management of asthma that are based on current research and best

practices.

• Implement recommended strategies such as those outlined in CDC’s EXHALE

Guide for Schools on coordination of care and educate all students with asthma

and their caregivers on asthma self-management.

• Ensure that all students with asthma who are not well controlled are provided

case management by a school nurse or other designated school personnel.

• Educate all educational personnel (especially health services, physical education

teachers, coaches and athletic trainers) about asthma, including how to identify

and respond to students at risk for a respiratory emergency.

• Establish and implement emergency protocols for students in respiratory

distress.

• Designated school health staff should identify and track all students with a

healthcare provider diagnosis of asthma and assess and refer students who

may be at risk for asthma or have asthma that is not well controlled based on a

nurse assessment for clinical diagnosis and treatment.

• Obtain and ensure the use of an asthma action plan for all students with asthma

in all settings.

• Ensure students with asthma have immediate access to quick-relief medications

by establishing protocols to define students’ assessment of readiness for self-

carry and by stocking medication in school.

• Schools should identify alternative options for care when school nurses are not

present, such as School-based Health Centers (SBHCs), community health

workers or telehealth.

About the evidence. Children with asthma can experience symptoms that can lead to

a life-threatening scenario while at school. School health services policies should

ensure that the school nurse or other designated school personnel (for schools without

American Lung Association Page | 39

a school nurse or school nurses with limited availability) has a list of students with

asthma; has an asthma action plan on file for each student; documents each visit to the

school health office for medication use; and can quickly intervene when a child is in

respiratory distress. In 2016, 76.2% of school districts reported having polices or

practices in place for a school-based management program to manage chronic

conditions. In addition, 66% of schools had procedures in place to provide instruction

on self-management of chronic conditions, such as asthma.

142

School nurses play a critical role in the management of asthma in schools. According to

the 2016 School Health Policies and Programs Survey (SHPPS), from 2000 to 2016,

school nurses employed by the school district have decreased from 93.7% to 79.7%,

and only 33.7% of school districts have a policy stating that each school will have at

least one full-time school nurse.

143

Furthermore, the National Association of State

Boards of Education (NASBE) state policy database identifies only two states (Delaware

and Vermont) that require a full-time nurse in every school. School nurse availability in

school buildings across campus and at all grade levels is addressed in policies in the

remaining states but school nurse availability is limited.

144

In the absence of a school

nurse, schools and school districts should consider alternate sources of care. School-

based health centers can serve as an important source of asthma care particularly in

schools that are in low-income communities.

145

Regardless of the availability of a school nurse, students with asthma need immediate

access to quick-relief asthma medication. Even though every state and the District of

Columbia have passed a law allowing students with asthma to self-carry their asthma

inhalers, only 91.2% of districts had adopted policies that some students may carry and

self-administer a prescribed quick-relief inhaler.

146

More can be done to educate

schools and school districts to ensure that all children have immediate access to life-

saving quick-relief asthma medication. Schools can add permissions to asthma action

plans allowing students to self-carry, which becomes a shared decision between the

child, parents, healthcare provider and school. In addition, schools can adopt policies to

stock back-up quick-relief asthma medication to prevent emergencies for children that

do not have medication available. Adopting standardized emergency procedures can

benefit both diagnosed and undiagnosed students with asthma during unexpected

respiratory distress.

After-school programs, youth serving organizations and licensed childcare

systems should adopt and implement policies and procedures for the

management of asthma that are based on current research and best practices.

American Lung Association Page | 40

• Communities should educate and train personnel from after-school programs,

youth serving organizations and licensed childcare systems about effective

asthma friendly policies and practices to improve childhood asthma.

• After-school programs, youth serving organizations and licensed childcare

systems should implement emergency protocols for students in respiratory

distress.

About the evidence. Over 10 million children participate in after-school programs.

147

Like schools, staff employed by licensed childcare centers, Head Start programs and

out-of-school time programs (e.g., before- and after-school care, camps) should adopt

asthma-friendly policies and practices. These out-of-school time programs often serve

low-income, minority populations that have high rates of asthma. Additionally, CDC

reports that about one in 10 preschool-aged children have an asthma diagnosis and

this age group is twice as likely to end up in the emergency room or hospitalized

because of their asthma.

148

Licensed childcare providers can implement effective

interventions like the “Asthma Basics for Children” program which educates families

and daycare providers to reduce asthma episodes including medication management

and steps to improve the environment by removing asthma triggers.

149

These programs

can educate parents and children about asthma, require asthma action plans on file for

each child with asthma, conduct training about asthma to enable staff to recognize

symptoms of asthma and respond to a child in respiratory distress, and implement

policies and practices that improve the physical environment. Research has

demonstrated that educating preschool staff in asthma while simultaneously providing

at-home asthma education to parents can significantly improve asthma control, reduce

hospitalizations and reduce oral corticosteroid use.

150

Similar to schools, after-school programs, youth-serving organizations and licensed

childcare providers need to be trained to recognize a child in respiratory distress, have

access to asthma medication, be able to assist the child in administering quick-relief

asthma medication and call emergency services if necessary.

All educational systems should adopt and implement environmental assessment

and management protocols that are based on current research and best practices.

• Develop, implement and sustain an indoor air quality program as detailed in U.S.

Environmental Protection Agency’s Indoor Air Quality Tools for Schools.

American Lung Association Page | 41

• Educational systems should strive to have ventilation systems that meet the

minimum guidelines of American Society of Heating, Refrigerating and Air-

Conditioning Engineers (ASHRAE).

• Educational systems should follow work practices to reduce exposure to

cleaning agents and disinfectants that cause or aggravate asthma as

recommended by EPA’s “Safer Choice” program.

• Require schools, grounds, facilities, vehicles and sponsored events to be 100%

tobacco-free, including e-cigarettes.

• Schools should minimize students’ exposure to outdoor air pollutants on days

with unhealthy levels of air pollution, including using ventilation/filtration and

other strategies to reduce exposures while inside school buildings.

• Schools should adopt zero-emission technology for school buses, and policies

to prevent school bus and personal car idling on school grounds.

• Schools should develop and implement a disaster response plan that addresses

exposure to indoor and outdoor pollutants (e.g., mold, wildfires), access to

asthma medication and cleaning up schools.

About the evidence. For more than three decades, the U.S. Environmental Protection

Agency (EPA) has been working with school districts to create asthma management

plans. IAQ management plans address dampness problems, mold contamination,

maintenance and repairs, cleaning, integrated pest management and other factors. An

asthma management plan includes four components: using EPA’s indoor air quality

(IAQ) Tools for Schools, identifying students with asthma, providing school-based

asthma education programs, and communicating with parents. Through years of

implementation, EPA’s IAQ Tools for Schools program addresses six common issues

that schools face: maintaining Heating, Ventilation and Air Conditioning (HVAC) systems

for proper ventilation and filtration; inspecting and mitigating for mold and moisture;

implementing integrated pest management (IPM) techniques; cleaning and

maintenance practices; selecting low-emitting products; and eliminating sources of

indoor pollutants by using and storing chemicals properly. School districts from urban,

suburban and rural districts that have implemented the IAQ Tools for Schools program

have demonstrated strategies to overcome barriers and improve student health.

151

School environments can expose both children and staff to indoor and outdoor air

pollution. The health effects of indoor and outdoor air pollutants, including asthma, are

well established. Schools should choose asthma-friendlier cleaning products that clean

and disinfect without serving as a respiratory irritant. The EPA’s “Safer Choice”

program

152

or the Cleaning for Asthma Safe School project by the California

American Lung Association Page | 42

Department of Public Health

153

helps consumers, businesses, and institutional buyers

identify cleaning and other products that perform well, are cost-effective and are safer

for the environment. On the positive side, IAQ management programs in schools

increased in 2006-2016. Specifically, the percentage of districts that had a specific

policy or practice related to indoor and outdoor air quality increased from 35.4% to

48.9%.

154

However, less than half of school districts implementing policies and

practices to protect the school community is not sufficient. In addition, only 39.3% of

districts had an IAQ program based on best practices provided in the EPA’s IAQ Tools

for Schools program.

Research has shown that schools can reduce tobacco use among school-aged youth

when school tobacco-free policies are clearly and consistently communicated, applied

and enforced. The Public Health Law Center identified that, “while smoking is prohibited

within school buildings under the clean indoor air laws of most states, local school

policies vary as to whether all tobacco use, or just smoking, is prohibited on school

property; whether tobacco use is also prohibited in outdoor areas on school grounds;

and whether tobacco use is prohibited at off-campus school functions.”

155

Comprehensive tobacco-free policies not only prohibit tobacco products on school

property, including school-sponsored events, but they also include practices to

educate students and staff about the dangers of tobacco products. While many

schools have adopted tobacco-free campus policies, with the surge of e-cigarette use

among youth, schools need to update tobacco-free campus policies to include e-

cigarettes. E-cigarettes are being used by teens more than any other tobacco product,

which led to the U.S. Surgeon General declaring e-cigarette use among youth an

epidemic.

156

In addition, state departments of education and school districts should

adopt comprehensive tobacco-free policies. Close to 15 states require tobacco-free

campus policies, including e-cigarettes, by state law or regulation.

Indoor air is not the only source of pollution in a school setting. Children playing outside

on high pollution days can be exposed to unhealthy levels of outdoor air pollution,

which is an established asthma trigger. School buses are frequently used to transport

children to school, but diesel exhaust, a known cause of asthma episodes, from buses

can concentrate in the bus cabin, exposing children to a hazardous lung irritant. Idling

diesel school buses also increase the exposure to children, and the exhaust can

infiltrate the school building itself. Fewer than half (49.2%) of districts implement a

school bus anti-idling program.

157

Modifying older diesel engines of school buses to run

more cleanly reduces air pollution and has been shown to reduce airway inflammation,

improve lung growth over time and reduce absenteeism.

158, 159

Zero-emission, electric

school buses present an additional opportunity for health benefits for students and

staff. The Infrastructure Investment and Jobs Act’s passage made available $2.5 billion

American Lung Association Page | 43

in funding for the transition to electric school buses, which will help schools clean up

diesel pollution.

Over the last decade, the United States has seen an increase in the frequency of

wildfires, hurricanes and flooding. Because these natural events can occur at any time,

even when children and staff are in school, schools need to develop a disaster

management plan. Disaster management plans may be especially important to children

with asthma and should take into consideration access to quick-relief asthma

medication and cleaning practices after the disaster to minimize exposure to asthma

triggers. SchoolSafety.gov offers emergency planning resources for schools.

160

American Lung Association Page | 44

Workplaces

Guiding Principles

Workplaces should reduce or eliminate conditions that cause or exacerbate asthma.

Many people work in situations that place them at risk of developing work-related

asthma, but also may be discouraged from seeking assistance. Policies to identify and

manage asthma in the workplace should recognize that critical issues must be

addressed, including:

• Every worker has the right to a safe workplace. Immigrants, people of color and

low-wage earners are especially vulnerable and should not face discrimination

nor denial of these rights.

• Every worker should have access to comprehensive, affordable healthcare

coverage for themselves and their family members to manage asthma.

• Every worker should be eligible for workplace accommodations to minimize the

effect of the workplace on their asthma symptoms.

• Every worker is eligible to receive workers’ compensation for asthma caused or

aggravated by work.

Overview

The 2009 Agenda called for establishment of surveillance mechanisms to document

levels of work-related asthma (WRA) and to establish national guidelines for the

management of WRA. CDC’s National Institute for Occupational Safety and Health

(NIOSH) funds states “to assess the extent and severity of workplace injury, illness,

disability, and death and identify worker populations and occupations at greater risk.”

161

Massachusetts and Michigan have consistently monitored work-related asthma since

the program began in 1988, with California following in 1993. Additional states have

conducted surveillance and developed resources related to work-related asthma,

including New Jersey, New York, Washington and Wisconsin. However, more studies

are needed to evaluate the effectiveness of approaches to prevent and manage work-

related asthma. Also, national guidelines do not exist for states to prevent and manage

WRA.

Consensus documents from the American Thoracic Society conclude that 16% of

asthma in adults is caused by exposures at work

162

and that 21.5% of adults with

asthma have aggravation of their asthma by work.

163, 164

There are three types of work-

related asthma (WRA): 1) asthma caused by an immunological reaction to a wide variety

of substances such as animals (e.g., veterinarians or workers handling mice/rats in

American Lung Association Page | 45

research labs), plants (e.g., bakery workers, or workers in grain mills), or chemicals (e.g.,

workers making car seats from isocyanate foam, or construction workers using epoxy

glues); 2) asthma caused by a marked exposure to an irritant (e.g., janitorial workers

exposed to a mixture of bleach and acid or bleach and ammonia); 3) aggravation of

pre-existing asthma (e.g., workers in offices with poor ventilation and/or housekeeping).

Moreover, a large proportion of new onset cases in surveillance data are associated

with chronic irritant exposures, as opposed to Reactive Airways Dysfunction Syndrome

(RADS).

165

The diagnosis of WRA is based on the presence of asthma symptoms that

occur/increase in relationship to work, history of exposure to substances that cause

work-related asthma, and medical tests (e.g., breathing tests that show worsening in

relationship to work and sometimes allergy testing). CDC’s National Institute for

Occupational Safety and Health (NIOSH) guidelines include questions to be asked and

recommended medical tests to be undertaken to diagnose WRA.

166

There are approximately 300 substances present in the workplace that have been

shown to cause WRA from an immunological reaction. There are thousands more

substances in the workplace that can aggravate pre-existing asthma or cause new

asthma from an irritant exposure. Consultation with an occupational medicine

specialist, pulmonary specialist or allergist may be useful to assist in both diagnosis and

identification of the causal agent.

Early diagnosis of WRA along with removal from exposure to the causal agent(s) is

extremely important. Early diagnosis and together with cessation of exposure to the

agent(s) causing WRA increases the likelihood of complete resolution of symptoms or

at least the reduction of the severity of symptoms.

The importance of early diagnosis has led to recommendations that individuals who

work with known causes of WRA be provided medical surveillance, to promptly

recognize individuals who develop asthma from their work. Surveillance should, at the

minimum, include a respiratory questionnaire about breathing symptoms.

Many organizations have developed recommendations for health care providers and

approaches to reduce use/exposure to workplace causes of asthma (e.g., OSHA Fact

Sheet or the Cleaning for Asthma Safe School project by the California Department of

Public Health).

167, 168

Policy Statements and Supporting Strategies

American Lung Association Page | 46

The federal government should update Occupational, Safety, and Health

Administration (OSHA) standards to make them comprehensive standards that

include air levels set low enough to prevent work-related asthma and provide

education and medical surveillance to exposed workers.

About the evidence. Agents that are known to cause work-related asthma do not

have comprehensive standards, so there are no requirements to educate workers

about the risks nor requirements for medical surveillance to ensure early diagnosis.

OSHA standards have not been promulgated to prevent work-related asthma.

Examples include flour, which is regulated as a nuisance dust, or disinfectants, which

have no regulatory air standard. Additionally, exposure to some causes of work-related

asthma such as isocyanates can occur after skin exposure, and OSHA regulations do

not require skin protection.

Even in the absence of changes in OSHA regulations, employers who use substances

known to cause work-related asthma should undertake voluntary efforts to lower

exposure to known causes of work-related asthma, educate their employees and

provide periodic medical testing.

Employers should identify and eliminate exposures to hazards that put workers at

risk for developing asthma or causing asthma symptoms.

• Identify work processes that expose workers to substances that cause or make

asthma worse and control these exposures by eliminating their use, substituting

safer substances and employing engineering controls (such as ventilation).

• Establish 100 percent tobacco-free workplaces, including e-cigarettes.

• Implement fragrance-free policies.

• Provide tobacco cessation programs.

• Adopt cleaner equipment (e.g., loaders, tractors) or vehicle technology (e.g.,

transition to zero-emissions technology).

About the evidence. Employers should use the National Institute for Occupational

Safety and Health (NIOSH) “Hierarchy of Controls” as a basic method to protect

workers from risk of illness or injury. The hierarchy includes five stages of effectiveness:

elimination (physically remove the hazard), substitution (replace the hazard),

engineering controls (isolate people from the hazard), administrative controls (change

the way people work) and personal protective equipment (Figure 1).

169

American Lung Association Page | 47

While elimination and substitution of

the agent are the preferred

preventative methods, they may also

be the most difficult. A good

example of the substitution method

is healthcare professional use of

powdered latex gloves. By

substituting powder-free latex

gloves, hospitals and health systems

were able to reduce occupational

allergy and asthma in healthcare.

170

Sometimes elimination and

substitution are not feasible, and

employers have to resort to less effective methods. Ventilation is a good example of an

engineering controls method. All employers should ensure that ventilation in their

facilities meets the minimum guidelines of American Society of Heating, Refrigerating

and Air-Conditioning Engineers (ASHRAE) specific for their type of workplace (e.g.,

office, laboratory, retail store).

171

In addition, all employers can address issues related to

cleaning agents/disinfectants, tobacco smoking, fragrances and other allergens.

NIOSH provides guidelines on work-related asthma, including useful information that

can help employers and employees develop and maintain a worksite safe from asthma

triggers.

172

Similarly, the American Lung Association’s “Guide to Control Asthma at

Work” details a set of measures to eliminate sources of unhealthy air in the workplace

by using safer disinfectant and cleaning products whenever possible, using chemicals

and machinery according to manufacturer instructions, and establishing tobacco-free

policies eliminating smoking, secondhand smoke and e-cigarette aerosols.

173

The COVID pandemic has increased the use of disinfectants, many of which are known

causes of work-related asthma (e.g., bleach and quaternary ammonium chloride

compounds). EPA’s “Safer Choice” program helps consumers, businesses and

institutional buyers identify cleaning and other products that perform well, are cost-

effective and are safer for the environment.

174

A list of cleaners that meet EPA

standards can be found by searching for SAFER Choice Products. The American Lung

Association has a sample fragrance-free policy that employers can use to help reduce

asthma that is exacerbated by exposure to personal care and cleaning products.

175

While reducing exposures to hazards in the workplace is critical to prevent WRA, there

are several strategies that employers can implement to make workplaces safer. For

example, all employers should make sure their health insurance includes a

comprehensive tobacco cessation benefit for all employees. The Affordable Care Act

Figure 1. Hierarchy of Control (NIOSH)

Figure 1. Hierarchy of Controls (NIOSH, 2015)

American Lung Association Page | 48

(ACA) requires employee-sponsored health insurance to cover smoking cessation. A

benefit that covers all treatments recommended in the 2008 U.S. Public Health Service

Guideline, including all seven medications and three forms of counseling, would give

smokers the best chance to become tobacco-free.

176

The critical part to prevent WRA is making workplaces safe. When establishing

workplace wellness programs, employers should consider a comprehensive approach

that includes smoking cessation. One such program is the American Lung

Association’s Freedom From Smoking® program, which has over 35 years of

experience helping hundreds of thousands of people quit smoking for good.

Outdoor workers or construction workers may be exposed to air pollutants and diesel

exhaust from heavy equipment. Mobile sources are major contributors to air pollution

because they emit air pollutants including nitrogen oxides (NOx), hydrocarbons (HC),

particulate matter (PM), toxics and greenhouse gases. Diesel exhaust from on-road

vehicles (cars, trucks buses), farm and construction equipment, locomotives, marine

vessels and aircraft is a major contributor to air pollution. The California Air Resources

Board (CARB) 2020 Mobile Source Strategy promotes advancing the use of zero-

emission technologies.

177

States should adopt and implement surveillance mechanisms to track work-

related asthma, identify asthma hazards, follow trends and facilitate interventions.

• Establish a surveillance system for work-related asthma using data from

healthcare providers, clinics, emergency departments, hospitals, workers’

compensation databases and poison control centers.

• Promote interventions that investigate and reduce exposures associated with

work-related asthma.

About the evidence. NIOSH maintains a clearinghouse for work-related lung disease

data, including State-Based Occupational Respiratory Disease Surveillance asthma

data that contributes to NIOSH epidemiological research.

178,

179

Since 1988, NIOSH has

funded several states to collect surveillance data on WRA including Massachusetts,

Michigan, New Jersey, California, Washington, Wisconsin and New York. These

surveillance projects have identified new causes of work-related asthma and, more

importantly, have shown that follow-up with the workplaces identified through the

surveillance programs can prevent work-related asthma in fellow workers of the index

case, as well as in other similar workplaces.

180

State health departments should

encourage healthcare professionals to report all diagnosed or suspected cases of

asthma that are caused by or exacerbated by workplace exposures or conditions,

and/or use existing data sources such as emergency or hospital discharge data,

American Lung Association Page | 49

workers’ compensation data, and poison control center data for case-finding.

Expansion of surveillance systems in additional states would increase reported cases

and help to report trends in WRA.

National clinical guidelines on the diagnosis and management of work-related

asthma, including primary and secondary prevention, should be adopted by

healthcare providers and healthcare systems.

• National guidelines should be implemented by healthcare providers to assess

work-related asthma and should include education and clinical decision support

tools.

• Healthcare providers should ask their adult asthma patients about their

workplace, positions and job tasks, including associated exposures and timing

of symptoms.

About the evidence. The American College of Chest Physicians published a

consensus statement on work-related asthma in 2008.

181

Early diagnosis is extremely

important in work-related asthma, because the sooner work-related asthma is

diagnosed after the onset of symptoms and measures are taken to eliminate/reduce

causal exposures, the greater the likelihood that the disease will be halted from further

progression.

The most common reason for missing the diagnosis of work-related asthma is failure

of the healthcare provider to ask about work exposures among their adult patients with

asthma. OSHA produced a fact sheet that healthcare providers and adults can use to

assess for work-related asthma.

182

The fact sheet outlines the key questions and

process that healthcare providers may use in the diagnosis of WRA. A study from

Michigan, Minnesota and Oregon reported that only 21% to 25% of adults who thought

their asthma was caused by a job had discussed with their doctor the possibility their

asthma was work-related.

183

Healthcare providers and employers can play a key role in

raising awareness about WRA and use tools like the OSHA Fact Sheet in addition to

others.

Prevention and control of WRA starts with a workplace assessment, followed by a

discussion between the employer, employee and workplace health and safety

professional on appropriate strategies to minimize or eliminate exposure. Industrial

hygienists play a critical role in identifying workplace hazards and helping to mitigate or

control them through appropriate measures. When WRA is suspected, the healthcare

system including healthcare providers can engage with industrial hygienists to further

American Lung Association Page | 50

investigate the exposure and help develop exposure control plans to prevent additional

exposures.

Conclusions and Call to Action

Public policy has the potential to make a tremendous impact on the health and quality

of life of those living with asthma. The evidence detailed throughout this Agenda

demonstrates that tools such as disease surveillance and smokefree multi-unit housing

can help reduce the burden of asthma. The policy recommendations and priorities

addressed in this Agenda reflect the consensus of a broad, multi-disciplinary group of

leaders and experts. These public policy priorities, if implemented, could greatly

improve asthma morbidity and mortality. As such, this Agenda establishes a blueprint

for national asthma policy that lawmakers, regulators, and advocates can use to guide

policy development and enact positive change at the federal, state and local levels.

American Lung Association Page | 51

APPENDIX A. The Consensus Process

Below is a description of the consensus process.

Small Group Orientation Call

In April 2019, the Lung Association convened Advisory Group members to help prepare

for the one-day conference. During the call, Lung Association project staff provided an

overview of the expectations of advisory group members, the asthma policies in the

2009 National Asthma Public Policy Agenda, the review process, and the planned

agenda for the May 16, 2019, meeting.

Online Assessment of Existing Policies

The Lung Association team distributed a feedback form to Advisory Group members to

assess the National Asthma Public Policy Agenda on what is currently being done, what

policy approaches appear to be most successful, and where gaps exist. Participants

were asked to rate the policy statements and supporting strategy in topic areas where

they had the most expertise. The categories included Keep, Edit, Delete, Don’t Know

and Unsure. Participants were then asked to recommend additional supporting

strategies for each policy statement, new policy statements and to include evidence to

support the new policy statements or supporting strategies.

In-Person Meeting with Experts

A nationwide group of asthma stakeholders gathered in Arlington, Virginia, on May 16,

2019, to discuss policies and strategies to improve asthma morbidity and mortality. This

meeting was made possible by a grant from the U.S. Centers for Disease Control and

Prevention, National Center for Environmental Health.

Capitalizing on the unique opportunity to have so many esteemed asthma stakeholders

gathered, a robust agenda was crafted to accomplish one clear and direct objective—

to review, discuss and reach consensus on policies and supporting strategies that will

improve asthma morbidity and mortality.

In addition, meeting attendees were charged with challenging past assumptions and

exploring new pathways while seeking to identify policies that were achievable and

based on evidence. Attendees were also asked to consider how outcomes will be

tracked and measured along with who should be charged with accomplishing specific

policies and strategies.

The day began with an opportunity for meeting attendees to network and get

acquainted with one another before each was tasked with identifying three things,

either positive or negative, that have made the most significant changes on the burden

of asthma this past decade. Answers to these questions were placed on charts labeled

American Lung Association Page | 52

with each policy area—outdoor air, healthcare systems and financing, public health

infrastructure and surveillance, homes, schools, and workplaces.

Topic area table facilitators then grouped responses to identify trends and key themes

to anchor table discussions scheduled later in the morning. Following this exercise,

Barbara Kaplan, MPH, presented the group with an overview of the assessment results

gathered from pre-meeting feedback provided by meeting attendees to begin

identifying which current policies should be revised, deleted or expanded. This

presentation was followed by a robust, moderated discussion before each attendee

was assigned to their respective topic breakout table.

Breakout Groups

Each attendee was assigned to a group charged with focusing on a specific policy

section of the agenda, which as noted earlier are:

• Public Health Infrastructure and Surveillance

• Outdoor Air

• Healthcare Systems and Financing

• Homes

• Schools

• Workplaces

Initially, each group was assigned an ice breaker activity to build cohesion and acquaint

those who may not have had the opportunity to meet before this gathering. Each group

was also asked to identify a notetaker and presenter. The Lung Association also

provided a staff member with subject matter expertise to moderate table discussions.

First Consensus Exercise

Before diving into their specific topic areas, the larger group was challenged to agree

upon definitions for the terms policy and strategy. In its simplest terms, policy was

agreed to mean specific goals and transformative actions while strategies would serve

as the tools to implement stated policies.

Table Brainstorming

With clarity on the aforementioned key terms, each group was asked to begin by

discussing their topic area’s findings identified during the charting success exercise

where everyone was asked to identify positive or negative actions or influences that

have most impacted the burden of asthma this past decade. Building on this exercise,

each group was asked to determine which current policies still effectively address

American Lung Association Page | 53

these issues while also identifying new policies or strategies that need to be

considered in light of this initial feedback.

Each group was then asked to move the discussion forward by determining whether

any current policy statements need to be revised or combined. Groups were then

charged with beginning to fine-tune language and modify for clarity or conciseness

based on the instructions and format examples noted below.

Think in terms of what should be done to impact asthma morbidity and mortality. Begin

by identifying who should take the recommended action and follow with a clear

statement of what must be done and conclude with a clear statement of how the

implementation is to occur when applicable.

Sample: Every county in every state should attain the national ambient air quality

standards as expeditiously as possible.

Sample: All school systems should adopt and implement a comprehensive plan

for the management of asthma based on current research and best practices.

Each group worked on fine-tuning their respective topic area policies through lunch

and then presented their working drafts for feedback and discussion with the larger

group. With the larger group’s feedback, the group members reconvened and spent

the remainder of the afternoon preparing their policy statements and brainstorming

strategies.

While no policies were finalized, most groups made significant progress and noted that

they would only need one or two more meetings to reach consensus.

Small Group Expert Follow-up Calls

Following the May 16 meeting, each group reconvened again for a 90-minute phone

conversation to continue to finetune guiding principles, policies and supporting

strategies. Asthma experts who were unable to attend the in-person meeting or who

had a desire to provide feedback in other topic areas were assigned accordingly.

Each facilitated call lasted 90 minutes allowing each of the six groups to further narrow

and refine their recommendations while also taking time to consider if the

recommended actions adhered to the proof check listed below.

1. Have we recommended policies that are clear, actionable and measurable?

2. Is what we’ve recommended feasible?

3. Who will be in charge of implementing each recommended policy and tactic?

4. How will we know success has been achieved?

5. Do the policies address social determinants of health or health equity?

American Lung Association Page | 54

6. Are the policies evidence based? Do you know where the data comes from to

support each policy statement? If not, can you cite who knows where to find this

information?

Following this series of calls, each table facilitator then incorporated the group’s

comments into the revised strategy and policy documents providing one last round of

feedback and review to occur through email.

Following the development of the National Asthma Policy Agenda, each participant will

have the opportunity to review the document in its entirety and provide final feedback,

ensuring that the revised policy guidance is a clear and transparent reflection of 26

leading public health organizations and more than 30 nationally recognized asthma and

public health policy experts that participated in the convening process.

American Lung Association Page | 55

APPENDIX B: Advisory Group Participants & Reviewers

This list includes Advisory Group members and reviewers, all of whom made invaluable

contributions to the project. Individuals with a [P] by their names participated in the

May 16, 2019, meeting and those with an [R] by their names participated after the

meeting as external reviewers. The participation of an individual does not imply the

support of their institution, organization or agency for the policy recommendations as

stated in this report, nor should such support be inferred.

Allergy & Asthma Network

Charmayne Anderson [P] [R]

Director of Advocacy

American Lung Association

Laura Kate Bender [R]

National Assistant Vice President, Health Air Campaign

Thomas Carr [P] [R]

National Director, Policy

Hannah Green [P] [R]

National Senior Director, Health Policy

Barbara Kaplan, MPH [P] [R]

National Director, Asthma Programs

Janice Nolen [P]

National Assistant Vice President, Policy

Katherine Pruitt [R]

National Senior Director, Policy

Erika Sward [R]

National Assistant Vice President, Advocacy

Cindy Trubisky, MS Ed, AE-C [P]

National Senior Director, Asthma Programs

Association of Asthma Educators

Michael Bowman, PhD, MD [P]

President

American Lung Association Page | 56

Asthma & Allergy Foundation of America

Jenna Riemenschneider [P]

Director of Advocacy and Special Projects

California Department of Public Health, Occupational Health Branch

Justine Lew Weinberg, MSEHS, CIH [R]

Industrial Hygienist

Jennifer Flattery, MPH [R]

Research Scientist

Children’s Environmental Health Network

Kristie Trousdale [P]

Deputy Director

Environmental Law & Policy Center

Janet McCabe, JD [P]

Senior Law Fellow

Environmental Law Institute

Tobie Bernstein, JD [P]

Senior Attorney, Director, Indoor Environments & Green Buildings Program

George Washington University Milken Institute School of Public Health

Katie Horton, RN, MPH, JD [P]

Research Professor, Department of Health Policy

Green & Healthy Homes Initiative

Michael McKnight [P] [R]

Vice President of Policy and Innovation

Healthy School Campaign

Rochelle Davis [P] [R]

President & CEO

Alexandra Mays [R]

Senior National Program Director

Massachusetts Department of Public Health, Occupational Health Surveillance

Program

Elise Pechter, MPH, CIH [P]

American Lung Association Page | 57

Industrial Hygienist

Michigan State University

Kenneth Rosenman MD, FACE, FACOEM, FACPM [R]

Professor of Medicine

Chief of the Division of Occupational and Environmental Medicine

Missouri Department of Public Health

Peggy Gaddy, RRT, MBA [P]

Asthma Program Coordinator

National Association of School Nurses

Piper Largent [P] [R]

Director, Government Affairs

National Institute of Environmental Health Sciences

Stavros Garantziotis, MD [P]

Medical Director, NIEHS Clinical Research Unit and Principal Investigator

Regional Asthma Management & Prevention, Public Health Institute

Joel Ervice [P] [R]

Associate Director

Anne Kelsey Lamb, MPH [R]

Director

Brandon Kitagawa, MS [R]

Senior Policy Associate

Rhode Island Department of Public Health

Julian Rodriguez-Drix, MPH [P]

Asthma Program Manager

Saint Louis University Center for Health Outcomes Research

Eric Armbrecht, PhD [P]

Associate Professor; Director consulting practice

U.S. Department of Housing and Urban Development

Peter Ashley, DPH [P] [R]

Division Director, Policy and Standards Division, Office of Lead Hazard and

Healthy Homes

American Lung Association Page | 58

U.S. Environmental Protection Agency, Indoor Environments Division

Tracy Enger [P]

Program Manager

U.S. Centers for Disease Control and Prevention

Pamela Collins, MPA, MSA [P] [R]

Deputy Branch Chief, Asthma and Community Health Branch, Division of

Environmental Health Science and Practice, National Center for Environmental

Health

Zanie Leroy, MD, MPH [P] [R]

Medical Officer, School Health Branch, Division of Population Health, National

Center for Chronic Disease Prevention and Health Promotion

Kanta Sircar, PhD, MPH, PMP [P] [R]

Epidemiology Team Lead, Asthma and Community Health Branch, Division of

Environmental Health Science and Practice, National Center for Environmental

Health

Emily Gardner, MPH [R]

Public Health Analyst, Asthma and Community Health Branch, Division of

Environmental Health Science and Practice, National Center for Environmental

Health

Joy Hsu, MD, MS, FAAAAI [R]

Medical Officer, Asthma and Community Health Branch, Division of

Environmental Health Science and Practice, National Center for Environmental

Health

Carol A. Johnson, MPH [R]

Epidemiologist, Asthma and Community Health Branch, Division of Environmental

Health Science and Practice, National Center for Environmental Health

Paige Welch [R]

Public Health Advisor, Asthma and Community Health Branch, Division of

Environmental Health Science and Practice, National Center for Environmental

Health

National Institutes of Occupation Safety & Health, Respiratory Health Division

Jacek Mazurek, MD, PhD [P]

Surveillance Branch Chief

American Lung Association Page | 59

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