Disparities found in children experiencing asthma emergencies from wildfire smoke
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Key takeaways:
- Hispanic/Latino children had the highest increase in asthma exacerbations.
- Children living in areas with greater poverty and less homeownership also saw in increase.
Racial and socioeconomic inequities were found among children impacted by wildfire smoke that caused asthma-related ED visits, according to a study published by Komodo Health.
“Though the effects of ambient air pollution on respiratory health outcomes in children are well established, much less is known about the impact of wildfire-associated air pollution on childhood asthma, the most prevalent childhood illness,” Marc Carmichael, PhD, clinical advisor at Komodo Health, told Healio.
“So, we wanted to understand how wildfire smoke waves are affecting asthma emergencies in children, specifically asthma exacerbations and asthma ED visits during an acute wildfire smoke event,” Carmichael continued.
Carmichael explained that the same components of ambient air pollution are also in wildfire smoke but at much higher levels. He also noted recent wildfire smoke events that affected regions at significant distances away from a wildfire epicenter, such as the summer of 2023 when smoke from Canadian wildfires affected air quality in New York City.
“By identifying the specific characteristics of populations most affected in a wildfire-prone region, we aimed to identify the populations of children most vulnerable to the adverse effects of climate change as it threatens to increase exposure to wildfire smoke,” Carmichael said.
Methods
Researchers identified 1.6 million pediatric asthma patients aged younger than 18 years with at least two asthma encounters within the San Francisco Bay Area as well as nearby counties that were directly affected by the 2018 wildfire in Northern California.
Health data from Komodo’s Healthcare Map were linked to data from the American Community Survey, the U.S. census and the EPA Air Quality System’s daily measurement of particulate matter smaller than 2.5 µm in diameter (PM2.5) at the zip code level to generate data on health, race and air pollution.
The main outcome measures of the study consisted of asthma exacerbations, which were defined as encounters during which an asthma diagnosis was given within a day of systemic steroid use, and asthma-related ED-visits, which were ED encounters with a resulting asthma diagnosis in 1 day.
To examine the impact of wildfire smoke on respiratory health, researchers compared the daily rates of asthma-related ED visits and exacerbations during the wildfire smoke-wave period (14 days) with the daily rates of an equal time length and season where no wildfires or elevated PM2.5 were observed.
The same comparison was performed to find out whether there were differential effects of smoke-wave exposure by race and ethnicity. Regional factors were also examined to see whether they had an effect.
Children were divided into tertiles determined by home ownership, education and poverty, as well as average annual daily PM2.5 levels.
Results
During the 2018 Northern California wildfire 14-day smoke wave, pediatric asthma exacerbations increased by 76% and asthma-related ED visits increased by 27%.
When data were stratified by ethnicity, the increase in asthma exacerbations was 95% for Hispanic/Latino children (P = .01), 75% for Asian American and Pacific Islander children (P = .05), 63% for Black/African American children (P = .05) and 55% for white children (P = .01).
Data also showed that the smoke wave effects on asthma-related ED visits were greater in areas with less home ownership (up to 51% greater risk; P < .01), lower education (45% greater risk; P < .001) and greater poverty (38% greater risk; P < .01).
Children living in areas with a high average annual daily PM2.5 level were up to 32% (P < .001) more likely to experience an asthma-related ED visit.
Carmichael noted that the research team expected there to be an increase in asthma exacerbations and asthma ED visits during a wildfire smoke event but when they examined the effects by race/ethnicity, they were surprised by how many more children of color were affected during the wildfire smoke wave.
“With further analysis, we found that the same social determinants of health that have been historically associated with racial disparities in health outcomes (eg, home ownership, education, poverty) were also at play, worsening the effect of a wildfire smoke wave on asthma emergencies,” he said.
Carmichael further explained that these findings suggest that the structural makeup of the zip code in which a child resides could exacerbate the health risks of an acute event like a wildfire smoke wave.
“The distribution of racial/ethnic subgroups with the worst outcomes during a wildfire smoke wave was consistent with the regions where the highest effects were observed,” Carmichael said. “Area-level poverty, housing instability, and lower education may explain the observed racial disparities in asthma exacerbations during a wildfire smoke wave.”
What can be done?
“Every patient with asthma should have an asthma action plan,” Carmichael said. “Our work suggests that providers may need to include information on how to prevent and manage asthma exacerbations during an acute wildfire smoke wave when developing an asthma action plan for patients and their families. However, this would only help patients who have a regular provider managing their asthma.”
Providers and health care organizations could be proactive about educating the populations that are most at risk for asthma emergencies during a wildfire smoke wave, as many underserved communities experience reduced access to care, according to Carmichael.
Carmichael suggests direct community outreach, as well as creating community-based, multilingual resources that educate people about the health risks of wildfire smoke while also informing them of the opportunities they already have to prevent adverse outcomes during a smoke event.
For example, communities can be advised to take shelter at clean air facilities and use personal protective equipment, such as N95 masks, and portable air filters during these events
Public policy/future research
“We’ve seen a proliferation of studies examining the health risks of wildfire smoke within the past year. Still, there is a lot more we can do,” Carmichael said.
Carmichael also pointed out that the long-term effects of acute exposure to a smoke wave on a child’s health still remain unknown.
“As we are beginning to learn more about the health impacts of wildfire smoke, the results of this study and others suggest that prioritizing policies that address existing socioeconomic and educational disparities is a critical part of developing the infrastructure that could prevent the adverse effects of climate change from impacting the health of our communities,” Carmichael said.
When asked about future research, Carmichael told Healio that it should see if the findings of this study are generalizable across the nation. He suggested repeating similar studies for other wildfire smoke wave events that have occurred, particularly those affecting large metropolitan areas with diverse populations, such as the Canadian wildfires that affected the air quality in New York City in the summer of 2023 and in the greater Chicago area earlier this year.
“Future research should also explore other factors that could explain the racial disparities we see in our study,” Carmichael said. “For example, is there an access-to-care issue driving the racial disparities in asthma emergencies during a wildfire smoke wave? Or is it the lack of multilingual patient education resources for vulnerable communities where English might be a second language?”
No matter what the causes of these disparities may be, Carmichael continued, government agencies at the county, state and federal levels can use these and similar findings to ensure that resources have been effectively allocated to their most vulnerable populations.
“This same information can be used to ensure that regions with less home ownership have places for the public to shelter during wildfire smoke events when the air quality is extremely hazardous, especially for patients with pre-existing respiratory or cardiovascular conditions,” he said.
Reference:
- Impact of wildfire smoke waves on asthma emergencies in children: Insights into the pediatric subpopulations most vulnerable to the threat of climate change. https://www.komodohealth.com/hubfs/_2024/Komodo_Health_Asthma_and_Wildfires_Research_Brief_Aug_2024.pdf. Published Aug. 20, 2024. Accessed Aug. 28, 2024.
Perspective
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Stephanie Lovinsky-Desir, MD, MS
I think these findings are extremely important and significant, but not necessarily surprising. We know that poor air quality is bad for the lungs of children, preventing the lungs from growing to their fullest potential and making children susceptible to chronic illnesses such as asthma. We know that marginalized communities are at greater risk for exposure to and poor outcomes from environmental pollutants.
One of the great strengths of this study was the effort taken to understand specific components of disadvantage, such as home ownership, education and poverty, that are driving disparities in outcomes. These are the areas that we need to focus on when designing interventions that address health disparities.
On the east coast, where I practice, we have less exposure to wildfire smoke than on the west coast where this study was conducted. Nonetheless, we know that wildfire smoke travels very far and can still have an impact on our patients. A great example of that was last summer when New Yorkers experienced record-breaking poor air quality for days as a result of wildfire smoke drifting from Canada. On those days I had many patients with asthma that experienced an increase in their symptoms due to wildfire smoke exposure. That was a stark reminder of what our friends and colleagues experience on a more regular basis.
We need to make sure to educate parents and educators about the impact of wildfire smoke and make sure they are reducing outdoor play for our children during poor air quality days. I mentioned the record-breaking air quality alert days on the east coast in June 2023. I was shocked that my children’s school was planning on having an outdoor field day during this time before I spoke up about it. There are so many people outside of health care that can play a role in improving the health of our children. We need to make sure we spread this important message beyond our health care field.
The findings confirm what we know about the importance of avoiding outdoor exposure, particularly on poor air quality days like we experience during wildfire seasons. Clinicians should continue to warn their patients about the respiratory effects of wildfire smoke exposure, particularly for children and seniors. We also need to remind patients with chronic respiratory conditions to make sure prescriptions are current and filled so they can take rescue medication as soon as they are experiencing symptoms.
Government policies such as the Clean Air Act have led to remarkable gains in improving air quality across the country. We have seen how, over time, the smog-filled skies that used to cover many cities have cleared up. We have also seen decreasing trends in overall childhood asthma prevalence that may in part be attributed to air quality improvement.
One of my biggest concerns is that with increasing wildfire smoke exposure we are taking steps backward. Long-term exposure to wildfire smoke can place our children at risk for pulmonary and cardiac disease in adulthood. Thus, it is important that we continue to tackle this important air quality issue.
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