Asthma is a serious chronic, inflammatory respiratory disease characterized by recurrent breathlessness coughing, chest tightness, shortness of breath, and wheezing.~( 1 )Asthma is one of the leading chronic childhood diseases affecting approximately 6.3?million or 8.4% of children under the age of 18?years in the United States~( 2 – 4 )and the third leading cause of hospitalizations among children under the age of 15?years. Parents and caregivers that have a child with asthma are often confronted with a myriad of problems, including unexpected emergency department (ED) and unscheduled physician office visits, missed school days and work absenteeism, daytime fatigue, reduced activity levels, emotional, and economic challenges.~( 2 , 5 , 6 ) Despite improvements in medication and treatment, the prevalence of asthma continues to increase worldwide, especially in children and young adults.~( 7 )In 2001, one in 14 persons were reported to have physician-diagnosed asthma in the United States compared with one in 12 in 2009.~( 4 )This increase may be partially due to underreporting and/or underdiagnosis, which may also lead to undertreatment. In addition to the emotional pain and suffering of asthma, the annual estimated financial cost burden of pediatric asthma from health care expenditures in the United States are estimated at 27?billion dollars.~( 8 ) The asthma burden in America is unevenly distributed within the population with race/ethnicity and socioeconomic status playing a major role.~( 9 )Poor, black, and Hispanic children living in households with incomes less than the federal poverty level are at twice the risk of asthma, have higher ED visits and hospitalization rates, and experience more deaths compared with white children.~( 10 , 11 )The reasons for these disparities and higher prevalence rates are complex but scientists agree that the differences cannot be attributed to genetics alone.~( 12 , 13 ) The root cause of asthma and continued increasing rates have been at the crux of research for decades. Several studies have pointed to children living in urban environments are more susceptible to asthma; however, the nature of this relationship is not well established.~( 14 )Other studies and theories suggest that contributing risk factors of asthma include lack of early childhood exposure to infectious agents,~( 15 )air pollution, microbial environment,~( 16 )biodiversity,~( 17 )and increased westernization (eg, diet, smoking).~( 18 )However, none of these concepts have established causality. Experts agree that asthma is multifactorial and likely the complex interplay between genetics and environment. However, until a cure has been recognized, health care providers (HCPs) must continue to follow national guidelines that focus on treatment, management, and control of symptoms for their patients with asthma.~( 13 )One of the key recommendations from the guidelines that presents challenges for HCPs, is asking low-income children to avoid environmental “triggers” that can lead to an asthma attack. As further described below, the racial, ethnic and low socioeconomic health disparities found in asthma, confounded by factors such as, living in poor-quality neighborhoods and housing, stressors (eg, violence) and exposures from environmental pollutants, provide synergistic opportunities for increased respiratory symptoms and asthma exacerbations~( 19 – 22 )( Figure 1 ). Figure 1. Environmental factors associated with the social determinants of health that influence childhood asthma. Poverty Children living in poverty often face increased environmental exposures and other factors including being more likely to encounter family turmoil, violence; consuming more polluted air, water, noise; and living in lower quality homes that can threaten health and well-being. Air Pollution Low-income children with asthma face increased environmental respiratory exposures from ambient air quality exposure to ozone, particulate matter, sulfur dioxide, and nitrogen oxides.~( 23 )Outdoor air pollution studies often cite traffic-related air pollution in urban areas associated with asthma development, exacerbations, and morbidity.~( 24 ) Segregated Neighborhoods Where a person lives can have an impact on asthma. A study by Alexander and Currie~( 25 )clearly described the importance of residential segregation and neighborhoods in explaining racial asthma health disparities. Violence Low-income urban children with asthma who experienced community violence and violence exposure are more likely to report asthma symptoms but less likely to seek care for asthma.~( 26 , 27 ) Substandard Housing In North America, poor-quality ambient indoor air pollutants from poorly maintained heating and ventilation systems inside children’s homes and schools have been cited as a leading contributor to asthma exacerbations.~( 28 )Many common asthma allergen triggers can be found in poor-quality indoor environments, including secondhand tobacco and other
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机译:哮喘是一种严重的慢性炎症性呼吸系统疾病,其特征是反复出现的呼吸困难,咳嗽,胸闷,呼吸急促和喘息。〜(1)哮喘是一种主要的慢性儿童疾病,影响大约630万或8.4%的未成年人。美国的年龄为18岁〜(2-4岁),是15岁以下儿童住院的第三大主要原因。患有哮喘儿童的父母和照顾者经常面临无数问题,包括意外的急诊科(ED)和计划外的医生上门服务,缺勤的上课时间和缺勤,白天的疲劳,活动水平降低,情绪和经济挑战。〜(2,5,6)尽管药物和治疗有所改善,但全世界的哮喘患病率仍在上升,尤其是在儿童和年轻人中。〜(7)在2001年,据报道,每14个人中就有1个人被医生诊断出美国的哮喘病发生率与2009年的12分之一相比有所上升。〜(4)这种增加可能部分归因于报告不足和/或诊断不足,这也可能导致治疗不足。除哮喘引起的情感痛苦和痛苦外,美国每年因医疗保健支出而估算出的小儿哮喘的财务成本负担约为270亿美元。((8)在美国,哮喘的负担分布不均种族/民族和社会经济地位的人口起着主要作用。〜(9)生活在收入低于联邦贫困水平的家庭中的贫穷,黑人和西班牙裔儿童患哮喘的风险高两倍,急诊就诊率和住院率更高〜(10,11)这些差异和较高的患病率的原因很复杂,但科学家们同意,这种差异不能仅仅归因于遗传学。〜(12,13)。哮喘和持续增加的发病率一直是数十年来研究的关键。一些研究指出,生活在城市环境中的儿童更容易患哮喘。然而,这种关系的性质尚未得到很好的证实。〜(14)其他研究和理论表明,导致哮喘的危险因素包括儿童早期缺乏传染源,〜(15)空气污染,微生物环境,〜(16)。生物多样性,(17)和西化(例如饮食,吸烟)的增加。(18)然而,这些概念都没有建立因果关系。专家们认为哮喘是多因素的,可能是遗传和环境之间复杂的相互作用。但是,在未找到治愈方法之前,医疗保健提供者(HCP)必须继续遵循专注于哮喘患者症状的治疗,管理和控制的国家指南。(13)指南中的主要建议之一对HCP构成挑战的是,要求低收入儿童避免可能导致哮喘发作的环境“触发因素”。如下文进一步所述,哮喘中发现的种族,种族和社会经济状况不均,与生活在劣质社区和住房,压力源(例如暴力)和环境污染物暴露等因素相混淆,为增加哮喘的发病率提供了协同的机会。呼吸道症状和哮喘加重〜(19-22)(图1)。图1.与影响儿童哮喘的健康社会决定因素相关的环境因素。贫困生活在贫困中的儿童经常面临更多的环境暴露和其他因素,包括更容易遭受家庭动荡,暴力;消耗更多受污染的空气,水,噪音;以及生活在可能威胁健康和福祉的低品质房屋中。空气污染低收入的哮喘儿童由于环境空气质量受臭氧,颗粒物质,二氧化硫和氮氧化物的影响而面临更多的环境呼吸暴露。〜(23)室外空气污染研究经常引用与城市地区相关的交通相关空气污染并伴有哮喘的发展,恶化和发病率。〜(24)隔离的居民居住区域可能对哮喘有影响。 Alexander and Currie〜(25)的一项研究清楚地描述了居住区隔和社区在解释种族哮喘健康差异方面的重要性。暴力经历过社区暴力和暴力暴露的低收入城市哮喘儿童更有可能报告哮喘症状,但不太可能寻求哮喘治疗。〜(26,27)住房质量低下在北美,室内环境空气污染物的质量较差来自儿童家庭和学校内部供暖和通风系统维护不善的原因被认为是导致哮喘恶化的主要原因。〜(28)在劣质的室内环境(包括二手烟和其他)中,可以发现许多常见的哮喘致敏原。
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