For most people, Vermont’s scenic beauty comes with the promise of fresh, clean, mountain air. Yet in reality, many Vermonters have trouble breathing. The state, it turns out, suffers from one of the highest asthma rates in the country.
“While Vermont has been rated the second healthiest state in the nation, the rising prevalence of asthma remains a problem,” says Jane Wolforth, MPH, manager of the Vermont Asthma Program, under the state Department of Health’s Division of Health Promotion and Disease Prevention. “Historically, New England asthma rates have been high, and since 2007 the current asthma rate among Vermont adults has been significantly higher than the U.S. average and in recent years it has been among the highest in the country.”
Vermont’s Asthma Rates
Asthma inflames and narrows the airways and causes wheezing, coughing, shortness of breath, and tightening in the chest. It is one of the most common chronic diseases in the United States and in Vermont and a leading cause of absenteeism among schoolchildren. The condition costs the country more than $56 billion annually to treat, according to the U.S. Centers for Disease Control (CDC). In Vermont, asthma-related emergency room visits and hospitalizations cost more than $7 million annually.
Asthma currently affects 11 percent of all adult Vermonters, and that rate has not changed since 2011, according to the latest data from the annual Vermont Behavioral Risk Factor Surveillance System (BRFSS). The U.S. rate is 9 percent. Asthma rates are even higher in the Rutland and Springfield areas.
However, no one knows what causes asthma, or why Vermont — and, in turn, Rutland County – has a higher asthma rate. Instead, public health officials know only which populations tend to suffer from asthma and which allergens and irritants promote asthma attacks.
Who Has Asthma?
According to the state’s Department of Health’s report on The Burden of Asthma in Vermont, asthma is more prevalent among women; those with household incomes below 125 percent of the federal poverty level (in the most recent guidelines, that would be about $29,813 for a family of four); those who did not graduate from high school; those who reported they were unable to work; and those who reported they were unemployed.
“The main biologic risk factor among adult Vermonters with asthma was the existence of co-occurring chronic conditions,” according to the report. “Adults with current asthma were significantly more likely to report having multiple chronic conditions than those without asthma,” the report states. “A third of those with three or more coexisting chronic conditions had severe persistent asthma. This is significantly higher than the proportion seen among those with one or less co-occurring chronic conditions.”
Specifically, the report notes that:
- “Vermonters with current asthma were nearly three times as likely to report having depression” than Vermonters without asthma.
- Vermonters with current asthma were “five times more likely to report chronic obstructive pulmonary disease (COPD) than Vermonters without asthma.”
- “Adult Vermonters with current asthma were … significantly more likely to report arthritis, obesity, and diabetes.”
What Triggers Asthma?
When considering Vermont’s high asthma rates, state public health officials zero in on the allergens and irritants that trigger asthma attacks.
“Asthma can be triggered by environmental factors you wouldn’t necessarily think about: pets, older homes, mold, pollens, dust mites, wood-burning stoves, second-hand smoke and smoking,” Wolforth says.
However, because state public health officials’ main focus is on asthma treatment and prevention of asthma exacerbations, she explains, they can only make educated guesses about the connections between these triggers and Vermont’s high asthma rate.
“Asthma rates are higher among those who use wood stoves or wood-burning furnaces, which many rural Vermonters have. About 30 percent of people with asthma use wood stoves for heating purposes. But we can’t say for sure that that is what is causing their asthma, only that it’s a trigger for their asthma symptoms,” Wolforth says. “The same goes for pets. Vermont has one of the highest pet ownership rates in the nation, and a high asthma prevalence, but we don’t have the research to prove any direct link.”
In fact, “the single most common environmental trigger among adults was having an indoor pet,” affecting 73 percent of the adults with asthma and 80 percent of children, according to The Burden of Asthma in Vermont. “Carpeting in one’s bedroom and allowing pets in the bedroom were also common with more than half of youth and adults with current asthma reporting each respective trigger.”
In general, state public health officials surmise that Vermont’s high asthma rates are connected to “the older housing stock; the fact that Vermont is such a rural state, so access to proper care might be a barrier; to increased smoking rates; and to lack of awareness around asthma symptoms and how to properly control its symptoms,” Wolforth explains.
For instance, Vermonters who have difficulty breathing, she says, might attribute their wheezing to an allergic reaction, to obesity or to other factors. They don’t seek treatment because they don’t even know they have asthma.
Education is Key
Statewide education campaigns, therefore, are key. Even among those who do know they have asthma, less than 10 percent have attended an asthma management course that would help them better control their asthma and avoid an emergency room visit or hospitalization, Wolforth says. And only about a quarter of Vermont adults and half of all children with asthma have received asthma action plans from their medical providers. Patients need the plans to understand how best manage their chronic condition.
When it comes to improving the overall asthma rates, Wolforth says, Vermont is “really focused on promoting asthma awareness, management, and prevention in the school, work and home environment. Our big focus is on asthma education so people can manage their condition. After all, asthma doesn’t go away; it’s for a lifetime.”
For starters, asthma patients should:
- Identify triggers in their environment – and change or avoid them if possible.
- Recognize symptoms and know when and how to use medications and seek medical attention.
- Follow a “zero exposure” policy for tobacco and secondhand smoke, including at home and in the car.
How Vermont Reduces Asthma Rates
By understanding who gets asthma, state public health officials can better target their education campaigns and make a real impact on reducing asthma rates and hospitalizations, Wolforth says.
According to The Burden of Asthma in Vermont, the state’s education and prevention campaigns particularly should focus on:
- Those with low levels of education.
- Those with a household income below 125 percent of the FPL.
- Those with co-occurring chronic conditions.
- Smokers and those exposed to secondhand smoke.
- Those with work-related asthma.
- Those living in the Springfield and Rutland hospital service areas.
The Vermont Asthma Program, which is funded by the CDC, tracks asthma rates among these and other affected populations; educates patients, health providers and caregivers about proper diagnosis and treatment; works to increase asthma awareness; and works with partnering organizations to effect policy change, such as curbing tobacco use and car idling, to improve indoor and outdoor air quality for all Vermonters.
For instance, the program has:
- Worked with Idle-Free Vermont to implement a statewide ban on smoking in cars where children are present and also to create a statewide idling law. The Asthma Program worked with local businesses in four rural counties to implement no-idling policies for their fleets.
- Partnered with Vermont’s smoking cessation program, 802 Quits. The programs especially focus on populations with higher smoking rates: rural Vermonters, those with lower incomes, those without medical insurance, and those with mental illness. In addition, smoking bans have been implemented in many large public areas and institutions, including the University of Vermont and the Church Street Marketplace in Burlington.
- Partnered with Support and Services at Home (SASH), part of Vermont’s prevention and health improvement plan, Blueprint for Health. SASH personnel provide in-home asthma education, link people with specialty asthma care and steer them to smoking cessation resources.
- Established Asthma in the Rutland Region (AIRR), an in-home asthma education and environmental assessment program, with the goal of reducing emergency room visits and hospitalizations due to asthma.
- Created the Asthma Learning Collaborative, in collaboration with the Blueprint for Health, to engage clinical practices in improving delivery of care to asthma patients.
- Worked to increase the number of adults with Asthma Action Plans from 30 to 36 percent and children, from 51 to 61 percent, by 2018.
Vermont’s Hospitalization Rates for Asthma
Healthy Vermonters 2020, the State Health Assessment Plan, includes goals to reduce asthma rates in the state. The plan notes one bright spot: a decline in hospitalization rates among both adults and children with asthma.
Unlike its rates of asthma prevalence, Vermont is actually doing better than the United States overall when it comes to hospitalizations for asthma. The report notes reduced hospitalizations for:
- Children under age 5: 19 hospitalizations per 10,000 people in Vermont versus 41.4 in the United States. The report seeks to reduce this further, to 14, by 2020.
- People ages 5 to 64: 4.9 hospitalizations per 10,000 people in Vermont versus 11.1 nationwide. The 2020 goal: 9.3.
- Seniors: 11.8 hospitalizations per 10,000 people in Vermont versus 25.3 nationwide. The 2020 goal: 9.3.
“Utilization of acute inpatient care for asthma is an indicator of the health of Vermonters who have asthma,” Healthy Vermonters notes. “Asthma hospitalizations have been declining over time with improved clinical care and patients following treatment guidelines, and may be due to efforts to mitigate environment triggers that can exacerbate asthma.”