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By Taylor Knopf

When a 10-year-old boy died of asthma complications a few years ago, Goldsboro pediatrician David Tayloe said the medical community was embarrassed.

The boy was being treated for asthma through his school clinic, managed by Goldsboro Pediatrics. He had a sad home life and had been mentally and physically abused, Tayloe said.

At the time of his death, he was living with his father who didn’t give his son the medication sent home by the clinic, leading to his death.

Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. illustration courtesy: United States-National Institute of Health: National Heart, Lung, Blood Institute

“We were all very embarrassed,” Tayloe said. “We would have given more medicine at the school if we knew he wasn’t getting the medicine at home.”

“There needs to be a responsible caretaker,” Tayloe emphasized.

Noncompliant guardians can be a challenge when treating children with asthma. And when it comes to asthma and its flare ups, a number of factors are at play, including race, poverty and environmental triggers.

A new study found that the rate of asthma-related emergency department visits is highest in rural eastern North Carolina. And an increasing number of 5- to 9-year-olds are impacted by the respiratory disease.

Experts say this isn’t surprising given the lack of health care access in rural North Carolina. And they say nationally asthma rates are highest in poor, minority communities, such as those in eastern N.C.

The study, led by East Carolina University Public Health Professor Gregory Kearney, examined asthma-related emergency department visits from 2010-2014 from all North Carolina counties, using data collected by N.C. Department of Public Health’s NC DETECT.

Kearney said he’s been looking at asthma among children in eastern N.C. for about seven years and was anxious to get his hands on data that would compare his part of the state to the rest of North Carolina.

Rural, tier one counties

From 2010-2014, there were a total of 329,119 asthma-related ED visits, and the overall state rate was 66.2 asthma ED visits per 10,000 people.

The study divides the state into three regions: eastern, Piedmont and western. The eastern region of the state consistently had the highest rates with an average of 85.1 ED admissions for every 10,000 people. That rate increased to 93.5 per 10,000 by the end of 2014.

From the study “Asthma-Related Emergency Department Visits in North Carolina, 2010–2014”

Kearney noted in the study that the majority (92 percent) of asthma-related ED visits took place in rural counties.

“It confirmed what we were already thinking,” he said. “We thought we would have higher rates here. After going through the data, we made that clear in the end. Rural, tier one counties have the highest rates in the state.”

While people age 45 to 64 had the highest percent of ED visits for asthma (22 percent), kids between 5 and 9 years old had the greatest increase (14 percent) in asthma-related ED visits.

Kearney said further research is needed to explore why people are using the emergency department instead of primary care physicians. By law, the emergency department is open to everyone and often acts as a safety net.

Additionally, it’s been well-documented that rural North Carolina has a lack of physicians, including specialists such as asthma educators.

These high rates warrant “increased public health concern,” Kearney wrote in his paper. Data on race and ethnicity were not available, but the highest rates of asthma were also found in the poorest counties with the highest percentage of African Americans.

Triggers

There are a number of triggers that can cause asthma symptoms to flare up. But what is it about eastern North Carolina that could be worsening the problem?

Kearney suggested that the substandard housing could be a factor.

“Poor housing conditions are presumably likely to contain numerous asthma allergen triggers (eg, mold from leaking roofs) that can pose unfortunate exposure opportunities for someone with allergic asthma,” Kearney wrote.

There is also a decent amount of literature that points to cockroaches as a cause of allergies and worsening asthma symptoms.

In an entomology lab at NC State, researchers keep cases and cases of German cockroaches for study, separated by gender. These are males, the black dots are the feces. Photo credit: Rose Hoban

Kearney also noted in his study that exposure to secondhand smoke is an irritant for those with asthma. In 2016, the North Carolina Behavioral Risk Factor Surveillance System data found that about 19 percent of adults in North Carolina smoke.

Goldsboro Pediatrics, which serves about 45,000 patients in eastern N.C., did a survey a few years ago and found that 31 percent of respondents lived in a home with a smoker, according to Tayloe.

Darryl Zeldin, scientific director at the National Institute of Environmental Health Sciences based in Raleigh, has studied the environmental causes of asthma for a long time.

“Individuals who live in older homes and homes in disrepair may be exposed to irritants at higher levels,” he said.

When it comes to strictly environmental triggers, Zeldin said the agricultural industry in eastern N.C. could play a role in triggering asthma symptoms.

“Endotoxin is a product of bacteria that can cause and exacerbate inflammation in airways and can lead to increased asthma attacks,” he said. “Endotoxin is common in rural environments, particularly around livestock.”

Zeldin emphasized that worsening asthma rates are not solely a problem caused by the environment.

Intervention and education

“It’s not surprising that the rates are higher there. Environmental factors are entirely different than the health care access issue,” he said.

Some people lack insurance or access to a primary care physician, so they use the emergency department as default.

Then there is what he calls “environmental justice.”

“Poor people, in general, are the ones that are disproportionately afflicted, live in environments where exposure is higher,” Zeldin said.

There need to be targeted interventions to people who need it the most in order to change the socioeconomic factors at play, he said.

“Sometimes it’s more than giving the kid a drug to deal with the asthma, but going into the home and educating the family,” Zeldin said.

Tayloe said unlike a large portion of eastern N.C., the physicians in his practice are much more knowledgeable about asthma. His first medical partner was somewhat of a national asthma champion. He educated everyone at the practice and Tayloe said that education has continued.

His practice conducts annual lung function testing for kids with allergies and asthma. He said they are also able to connect patients with specialists out of Greenville if necessary.

Goldsboro Pediatrics has case management specialists who will work with the housing authority to improve the conditions of children’s homes and get things like air conditioning installed, which makes a big difference for those with allergies.

“We have a culture of quality when it comes to asthma that you might not see in other practices, especially due to primary care shortage in eastern North Carolina,” Tayloe said.

Taylor Knopf

Taylor Knopf covers rural and mental health news. She previously wrote for The News & Observer as a politics and general assignment reporter. Before that, she worked at a small daily newspaper in southern...