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quality of life for patients with asthma, but also decrease asthma-associated morbidity and mortality.
The NAEP's first major accomplishment was the development of an Expert Panel Report on the Diagnosis and Management of Asthma. The report was released to the medical and lay communities on February 5, 1991. It outlines the latest therapeutic regimens and patient education approaches available for managing and controlling asthma. The guidelines included in the report represent the collective medical wisdom of allergists, pulmonologists, nurses, and behavioral scientists. NAEP subcommittees have identified several activities that will support the goals of the program. With regard to professional education, these activites include the development of a clinician's guide to teaching patients about asthma self-management, a statement on peak flow monitoring, and an Executive Summary of the Expert Panel Report. Publications developed for patients and the public, include a pamphlet entitled "Facts About Asthma", an Asthma Quiz, and a booklet that outlines how patients can work with their doctors to receive the best asthma care. A number of products are being developed for schools that encourage school personnel to take an active role in asthma management.
NATIONAL HEART ATTACK ALERT PROGRAM
Question. Have you initiated the National Heart Attack Alert Program?
Answer. The Institute launched the National Heart Attack Alert Program (NHAAP) in January 1991. The goal of the NHAAP is to reduce premature morbidity and mortality from acute myocardial infarction (AMI), and sudden death through rapid identification and treatment. The objectives of the NHAAP are to: (1) increase awareness and knowledge of the symptoms and signs of AMI among those at increased risk and those around them, (2) promote immediate action by patients and those around them at the first symptoms and signs.of AMI, (3) promote immediate identification and treatment of patients with a suspected AMI or sudden death by health care professionals in pre-hospital and hospital emergency systems, (4) collaborate with other state and Federal agencies to promote the appropriate use of an enhanced emergency medical services system, and (5) consider, when the time is appropriate, a public education campaign to complement the objectives. Such efforts heighten the potential for an improved quality of life for patients, their relatives and friends.
Question. Who participates in it?
Answer. The NHAAP will be modeled after the four other NHLBI national educational programs. It is governed by a coordinating committee. Thus, while the NHLBI administers the program, its implementation is a collaborative
effort among all of the organizations. The NHAAP Coordinating Committee will
consist of members of professional and voluntary organizations and State and Federal governments who are committed to collaborative efforts to achieve the program's goal and objectives. The Coordinating Committee members will examine important issues related to early cardiac care and make recommendations concerning program direction and policies. Members will be encouraged to participate in appropriate activities and disseminate the educational materials of the program through their national networks and constituencies. Many of the NHAAP program activities will be conducted through Committee and subcommittee endeavors designed to invite and maximize active participation by all Committee members and their organizations. The NHAAP staff will also work closely with all individuals and organizations across the United States who are involved in early cardiac identification and care.
Question. Does the NHLBI provide the public with information on obesity and the need to control weight to reduce the risk of heart disease?
Answer. The Institute has recently begun the NHLBI Obesity Education Initiative. Obesity contributes to many cardiovascular risk factors and independently affects cardiovascular disease. The initiative allows the
Institute to begin a concerted effort to educate the public and health professionals of these relationships.
Up to now, obesity and weight control have been addressed only as they relate to high blood cholesterol, high blood pressure, and smoking through the existing National Cholesterol Education Program, National High Blood Pressure Education Program, and NHLBI Smoking Education Program. Both the NCEP and NHBPEP, in their expert panel reports on the detection, evaluation and treatment of high blood cholesterol and high blood pressure, respectively, emphasize the need for weight reduction among overweight individuals. Materials for patients also encourage people to reduce dietary fat, especially saturated fat, in order to reduce blood cholesterol levels and achieve weight loss in overweight individuals. For the general public, the NHLBI has assembled kits that include fact sheets addressing obesity, weight control, and exercise. Recently, an "IQ Quiz on Weight and Heart Disease" was developed to increase public awareness about the relationships between obesity and CVD risk factors and to clarify some public misconceptions regarding weight loss.
Because of its concern for minority health issues, the Institute sponsored a Conference on Obesity and Cardiovascular Disease in Minority Populations to examine the latest scientific information available and to provide directions for further research. The proceedings of the conference will be published in the June issue of the American Journal of Clinical Nutrition.
The NHLBI Obesity Education Initiative will integrate obesity-related issues as they evolve from the Institute's national education programs, and will allow for a more effective mechanism to address obesity as a separate health issue. The initiative will be directed by a group of experts who will consider the various scientific issues related to obesity and cardiovascular disease, identify issues where consensus opinions can and should be reached, convene expert ad hoc advisory panels to address certain issues, and recommend the types of educational messages that should he brought to the public and to health care professionals.
CLINICAL TRIAL ON ORAL IRON CHELATION THERAPY
Question. I understand that the NHLBI is considering a clinical trial on oral iron chelation therapy which will be useful in the treatment of Cooley's anemia. What is the status of this situation?
Answer. For over fifteen years, the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) have been supporting the development of improved therapies for Cooley's anemia. The NIDDK has been responsible for conducting animal toxicity studies of potential new iron chelators. In anticipation of a successful effort in this area, the NHLBI has prepared an initiative for a cooperative clinical trial for one or more of the new drugs that may emerge from the toxicity studies. However, to date, no non-toxic drugs have been identified. When a promising drug is eventually identified and Food and Drug, Administration approval is obtained, the NHLBI is prepared to begin human testing.
Question. Doctor, in your opening statement you briefly mentioned some recent progress that has been made in cystic fibrosis research. What were some of the other significant advances made in this area during the past year, and what are the clinical implications of these findings?
Answer. The discovery and cloning of the cystic fibrosis (CF) gene have together improved prospects for defining the pathogenesis of CF and determining the relationship between the CF gene product, called CFTR (for cystic fibrosis transmembrance conductance regulator), and the ion characteristic transport dysfunction of CF. A significant advance in this area is the recently reported finding that CFTR is probably a chloride channel. This discovery helps to explain the function of CFTR in lung cells
and why an aberrant form of the CFTR would stop chloride from moving normally through cell membranes. Because of the failure in chloride transport, CF patients cannot clear mucus from their lungs. As a result, CF patients are subject to numerous complications such as persistent bacterial infections, coughing, labored or fast breathing, and general weakness. This research is important because it provides insight into the function of CFTR and, combined with other ongoing research, will help us move closer to gene and/or protein therapy for CF.
Significant progress has also occurred in the area of cell surface receptor-ion transport regulation. Recently, specific receptors have been identified on human airway epithelial cells that express activities which place them in a crucial position for regulation of airway function. The receptors have been shown to be tightly coupled to the chloride channels that are defective in CF. Activation of these chloride channels in human airway cells leads to chloride secretion. Modulation of the receptors provides a new potential pharmacologic approach to regulate chloride secretion in CF patients.
Question. Doctor, we know the NHLBI is strongly committed to cystic fibrosis research, leading to an effective treatment and, hopefully the prevention of this disease. What has your Institute done this past year to help progress towards these goals?
Answer. Research efforts into the molecular basis of the cystic fibrosis (CF) defect, the mechanisms by which it causes the lung pathophysiology, and the development of new therapeutic modalities have been accelerated by the recent cloning of the CF gene. To ensure that dramatic strides continue to be made in the fight against CF, the Institute continues to promote a vigorous program of basic and clinical research, training, and education in CF. Although fiscal constraints necessitated reductions in many of our projects, I am happy to report that we were able to make an exception in the case of our three CF centers this past year. The Institute also provided funds to support four grants received in response to a solicitation entitled "Molecular Basis of Cystic Fibrosis," which was issued by the National Institute of Diabetes, Digestive, and Kidney Diseases. The goal of these grants is to define and characterize the molecular pathophysiology of CF and the membrane transport processes associated with the etiology and pathogenesis of CF. As part of our effort to foster transfer of knowledge in basic science to the clinical setting, the NHLBI recently held a conference entitled "Molecular and Cellular Biology of Cystic Fibrosis: Basic Concepts and Strategies for New Therapies." This conference assessed the current state of knowledge of the CF gene and the anticipated developments in the understanding and treatment of CF.
ASTHMA RESEARCH AND EDUCATION
Question. Dr. Lenfant, your Institute has been active in developing a National Asthma Education Program to help both children and adults with asthma. Can you tell us why you decided to initiate this program and what you hope it will accomplish?
Answer. Asthma is a serious, chronic condition, affecting approximately 10 million Americans, about one-third of whom are children. Each year, people with asthma experience well over 100 million days of restricted activity, and annual health-care costs for asthma exceed $4 billion.
Studies show that the prevalence of asthma is increasing. Between 1979 and 1987, the percentage of the population with asthma increased by about onethird. The increase occurred across all age, race, and sex groups. Hospitalization due to asthma is also increasing. From 1965 to 1983, hospital discharges for children younger than 15 years of age increased over three times. Deaths due to asthma are also on the rise. From 1979 to 1987, the number of deaths due to asthma nearly doubled, from 2,600 to 4,000. More Blacks than Whites die of asthma. This is particularly true for 10- to 19year-old Blacks, whose death rate from asthma is over three times the rate for Whites.
The past 10 years of NHLBI-funded research in asthma self-management demonstrate that emergency room visits and hospitalizations can be significantly reduced, and that school attendance and performance, as well as symptoms of asthma, can be significantly improved. The National Asthma Education Program is using the results of this research to guide present health education efforts. The overall goal is to develop a program and activities which will help people with asthma, particularly children, live fuller, more productive lives.
Question. Is asthma a public health problem in this country?
Answer. Asthma is a serious chronic disease with acute episodes that can be fatal. Asthma is receiving increased attention as a public health concern because of significant increases in frequency, number and rate of hospitalizations, and deaths. It is one of the leading medical causes of absenteeism among school children and a major cause of lost work days in the U.S. today. In 1988, there were almost 15 million visits to physicians for asthma.
Question. Why is the prevalence of asthma increasing?
Answer. The prevalence of asthma is increasing for all age, race, and sex groups. The reasons for the increasing prevalence are unknown. However, it has been proposed that the increased prevalence may be due to an increase in allergens in our environment and an increase in the number of people with allergic sensitivity. Another hypothesis is that physicians are now more accurately diagnosing asthma and distinguishing it from infections, such as bronchitis, and smoking-related conditions such as chronic obstructive pulmonary disease.
Question. Are there new approaches for treatment?
Answer. The "new" approach to asthma therapy involves a stepped-care approach to asthma management in which the number of medications and their frequency of administration are increased as necessary. This approach recognizes that asthma is more than simply a constriction of overly sensitive airways. Inflammation is a key component and therefore asthma must be treated not only with a bronchodilator, a drug that provides relief to the patient, but also with an anti-inflammatory drug that reduces and prevents the inflammation from recurring. The major components of asthma treatment and control involves (1) patient education, (2) medications, (3) environmental control measures, and (4) objective measures of assessment.
One of the National Asthma Education Program's first major activities was the development of an Expert Panel Report on the Diagnosis and Management of Asthma. The report guidelines will be distributed widely to primary care physicians as well as specialists with up-to-date information on asthma practice. major thrust of the guidelines is to encourage physicians to develop a partnership with their patients for better asthma management. these guidelines are adopted, it is hoped that we can see a reversal of the increasing trends in asthma morbidity and mortality.
ASTHMA AND MINORITIES
Question. I have heard reports that asthma appears to be a bigger problem among Blacks than Whites. In fact, I am hearing that Blacks are twice as likely to be hospitalized and almost three times more likely to die from asthma. Is this true and if so, why is it happening?
Answer. Asthma prevalence has been increasing for all groups. The difference in prevalence is very small between Blacks and Whites. However, asthma seems to be more severe in Blacks and more Blacks are hospitalized and die from asthma than Whites. Recent reported data on hospitalizations for children ages 0 to 4 years show that Blacks are almost twice as likely to be hospitalized. In 1987, the mortality rate for Blacks for asthma was almost three times the rate for Whites. Research has shown that the greatest mortality from asthma is centered in four geographic urban areas around the country with strikingly high rates in New York and Chicago's Cook County.
reasons for the high mortality is not known. However, current hypotheses focus upon access to care, poverty, lack of a usual source of primary care, and lack of adequate health insurance. Control of environmental factors that trigger, asthma attacks in inner cities is another major concern.
Question. Is the National Heart, Lung, and Blood Institute doing anything to tackle the problem of helping minorities control their asthma?
Answer. The Institute has initiated several research and educational activities to address the increasing asthma problem in minority populations. Five projects totalling over $9 million were awarded to develop effective intervention strategies for controlling asthma in minority children. projects, which target both Black and Hispanic children, are being carried out at the University of New Mexico; Washington University, St. Louis; the University of Texas Health Sciences Center; Columbia University; and Howard University, Washington, D.C. The results of these demonstration and education research projects will be used to develop innovative materials and approaches designed to reach Blacks and Hispancics. In addition, the NHLBI is working with nine emergency departments in large urban areas to develop a treatment protocol and appropriate health education materials that can be used nationwide.
Question. What initiatives are planned by the National Asthma Education Program related to asthma in minorities?
Answer. The NHLBI plans to continue efforts and initiate new programs to develop culturally sensitive patient and public education materials, including target radio public service announcements. In addition, the NHLBI has established working relationships with the print media that service the Black community (JET, Ebony, Emerge, Black Elegance, and Black Enterprise) to provide information on asthma to the Black community. The NHLBI now plans to meet with Black network television.
ASTHMA IN THE SCHOOLS
Question. I am interested to learn that children with asthma lose so many days from school. What can be done about this?
Answer. Asthma is a common disease among children. Of the estimated 10 million persons with asthma in the United States, one-third are children. The disease is responsible for a large proportion of activity limitation and school absenteeism. School children, their families and school personnel must develop a partnership to manage asthma. Research has demonstrated that school absenteeism can be reduced and performance improved with proper asthma education. Many schools exclude children with asthma from routine activities, especially physical education and sports, because of their disease. School personnel need to know that in almost all cases, these children can participate in virtually all school activities if they are under appropriate asthma therapy. School personnel need skills to deal more effectively with children who have signs and symptoms of asthma.
Question. Are there plans to introduce asthma education programs in the
Answer. The NAEP has established a school asthma subcommittee whose purpose is to investigate and recommend asthma education approaches, "ctivities and materials to be used in the school environment. This subcommittee is composed of organizations involved in education, including the National Association of School Nurses, the Associations of Elementary and Secondary School Principals, the National School Boards Association and the Department of Education. The NAEP will develop appropriate materials and programs.
Question. Last year we were advised of your cooperation with the Department of Education; would you please give us an update on this?