The September Asthma Epidemic? Part 1 of 2

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

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The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Every few years someone tells us pharmacists that a drug is so good, it should go into the water supply. When I graduated from pharmacy school, it was prozac. We were told that prozac was such a good antidepressant that if it was put in the water supply, not only would we cure depressed patients, the rest of us would be happier too. It was true that prozac was a lot better (and safer) than the existing antidepressants on the market at the time. However, it wasn’t for everyone, and like all medications it did have side effects in some people. The next miracle drug was a type of blood pressure pill called ACE inhibitors. I remember being at a talk by a kidney specialist when he said that ACE inhibitors were so good they should be in the drinking water. Now don’t get me wrong, ACE inhibitors are very good. Aside from treating blood pressure, they help some aspects of diabetes, some types of heart problems and some kidney conditions. But, as good as ACE inhibitors are, they aren’t perfect either. So you can understand why I was skeptical when I heard a drug rep suggesting that all asthmatic children go on singulair. It turns out he wasn’t talking about all asthmatic children going on singulair (montelukast) all the time. He was talking about a study that showed maybe they should be on it during the first 6 weeks of school. The study said it would help treat the “September Asthma Epidemic”.

So what is this “September Asthma Epidemic”? I was given a couple of medical articles when I asked. It seems that two bright researchers from Hamilton, Ontario, Malcom Sears and Neil Johston wrote “Understanding the September asthma epidemic” in the Journal of Allergy and Clinical Immunology in August 2007 and Neil Johnston and his team wrote “Attenuatin of the September Epidemic of Asthma Exacerbations in Children: A Randomized, Controlled Trial of Montelukact Added to Usual Therapy” in Pediatrics in September 2007. Long titles, but interesting reading. Don’t tell my six year old daughter, but the gist is that school makes kids sick.

The researchers first looked at health data from across Canada, and from around the world. They were specially looking at the number and timing of asthma related hospitalizations. The most childhood asthma hospitalizations happen in September every year. This happens in many Northern Hemisphere countries including the United States, Mexico, Israel, Finland, Trinidad, the United Kingdom and Canada. In Canada 20 to 25% of all childhood asthma hospitalizations happen in September.

It gets more interesting when you break down the numbers into age groups and apply it to a family, say mine. We’ll call me the adult (my wife would probably disagree), my daughter Emily is school aged (she’d six), and my son Eric is pre-school (he is three). Now give all of us asthma. Emily should be in the hospital first and have the worst asthma symptoms. Emily would go to the hospital September 19th. Eric (the pre-schooler) would have a less serious attack but would still end up in hospital September 21st. I would have an attack that wasn’t as serious as the kids but I should be admitted September 25th. It seems whatever causes this epidemic hits the school aged kids hardest and first. Then the school aged kids spread it to the pre-schoolers and the adults. (Again, don’t tell Emily she could literately be the cause of all my problems).

So what causes this increase in asthma in September? Well, it probably isn’t allergens or pollution in the air, or least not by themselves. Although amount of allergens in the air like pollens, does increase in the late summer/early fall, they should hit all asthmatics at the same time. School aged children shouldn’t have problems at a different time than adults. Viruses could be another possible culprit. Going back to school is a great time to get a virus. During the summer kids probably play with 3-4 other children at a time. Suddenly, they are in classrooms, school buses, etc with 30 or more other children. It doesn’t take long for that one sick kid to share his or her viruses. There is one virus that interested the researchers in particular. Rhinovirus infections have been associated with up to 80% of asthma attacks in school aged children. School aged children pass rhinovirus infections to their families 3 times more often than working adults do. Finally, rhinovirus infections do go up around September. When the researchers looked, they did seem to find more rhinovirus in the kids with asthma attacks in September. So rhinovirus is the culprit, right? Maybe the timing is too perfect.

The timing of the increase in hospital visits due to asthma is always 2 to 3 weeks after the start of school. The researchers looked at every September in Canada from 1990 to 2004. The peak number of hospitalizations was always at the same time. Rhinovirus infections go up in September, but the timing can easily change by a few weeks either way. There is another piece to the puzzle. That puzzle piece is school. As a bit of proof, the researchers checked other countries. In Canada and England most children go back to school the first week of September. In Scotland and Sweden, they go back in the third week of August. Large peaks in asthma hospitalization occur 2 to 3 weeks after the return to school in all four countries despite their different school start dates.

Next week we will look at why school is the missing link and what can be done about it.

As always if you have any questions or concerns about these products, ask your pharmacist.