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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


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?


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.


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.


Why is the prevalence of asthma increasing?


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. A major thrust of the guidelines is to encourage physicians to develop a partnership with their patients for better asthma management. As these guidelines are adopted, it is hoped that we can see a reversal of the increasing trends in asthma morbidity and mortality.


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.


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?

Answer. The Institute signed an interagency agreement with the Department of Education. Several of the materials and programs currently being developed for the school environment are a result of this agreement. The products will display the seals of both Departments. Initially, the materials will be targeted to school principals and outline the role that school personnel can play in managing asthma. A "Directory of Asthma Resources," which outlines a variety of asthma education resources, is also under development. Another product will be developed for school coaches. The NHLBI will work with the Department of Education to select schools to pilot test materials.



Senator HARKIN. Dr. Löe, we have your budget request for $160.9 million, which is about 8 percent more than last year. I am aware of your Institute's successful effort to complete its new long-range research plan, and we look forward to hearing about that and your statement. Welcome, and again, please proceed, Dr. Löe.

Dr. LÖE. Thank you, Mr. Chairman.

Last year at this time, a committee of experts convened by the Assistant Secretary for Health had engaged in the most comprehensive review of water fluoridation ever conducted by the Federal Government. As you recall, their review was prompted by studies in which four male rats, of those several hundred male and female rats and mice given high dosages of fluoride in drinking water, developed a rare bone cancer. The findings at that time were considered equivocal, which means that the results could have happened by chance alone.

The expert committee reviewed those experiments, along with other animal data, and more than 50 human demographic studies worldwide, and has now completed its report. Their conclusion is that optimal fluoridation of drinking water does not pose a detectable cancer risk to humans. The committee also confirmed that fluoride in water plays a central role in preventing tooth decay, providing improved oral health to all, rich and poor alike.

We at the NIDR are pleased that fluoride, which has been a cornerstone in dental disease prevention for the past 40 years, has received a clean bill of health. We hope that the new report will clear up some of the confusion on the part of the public, and we are eager to get on with the additional research that the committee has recommended.

This year NIDR is participating in a new and equally comprehensive review of the benefits or risks of dental amalgam, the mercury-containing silver fillings that have been in common use in dentistry for more than 150 years. The issue here is the possibility of mercury being toxic and that mercury is released from these restorations. Only a few years ago were we able to provide the technology to detect this small amount of mercury vapor from fillings. Actually, we believe that the amounts are too small to pose a threat, and that there is no need for panic at this time.

However, we are actively pursuing studies and tests to clarify this problem, and a report can be expected by the end of this year. Senator HARKIN. On the mercury issue.

Dr. LÖE. Yes, sir. Meanwhile, we are moving ahead in the development of new and improved materials which one day will substitute for both silver and gold.

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