Children's Perspectives on Food Allergy in Schools: A Qualitative Study.

Approximately 7% of children live with food allergy, a condition that requires dietary avoidance to prevent an allergic reaction. In this qualitative study, we aimed to understand food allergy-related experiences, beliefs and learning preferences among children with and without food allergies, to inform a school-based, food allergy education program. Data were analysed thematically. We virtually interviewed children in Kindergarten-Grade 8 in Manitoba, Canada, with (n = 7) and without (n = 9) parent-reported, physician-diagnosed food allergies. We identified three themes: Naive reliance on peers and school staff to assist with food allergy management; Limited food allergy knowledge; and, Recommended food allergy curricula: complementary perspective. Our findings will help inform the development of a school-based, food allergy education program, with a long-term goal of minimizing food allergy-related worries and optimizing safety for children with food allergy. Ongoing, school-based food allergy education is needed.

Estimating age-specific influenza-associated asthma morbidity in Ontario, Canada.

BACKGROUND: There is a need to quantify the potential benefits of influenza-focused interventions in reducing asthma morbidity at a population level. This study aims to estimate age-specific annual excess asthma morbidity attributable to influenza in Ontario, Canada. METHODS: Weekly counts of hospitalizations, emergency department (ED) visits and outpatient physician office visits for asthma were obtained from health administrative data in Ontario from 2010 to 2015, for ages 0-14, 15-59 and 60+. Asthma morbidity was modelled as a function of influenza A and B activity using linear regression, controlling for seasonal and long-term trend, mean temperature and respiratory syncytial virus. Excess asthma morbidity attributable to influenza was calculated as the difference between full model predictions and model predictions with influenza A and B variables set to 0. RESULTS: Annually, influenza was associated with the following rates of excess asthma morbidity, per 100,000 people with prevalent asthma: 12.5 hospitalizations for ages 15-59 (95% confidence interval (CI): 1.1-23.5); 35.7 hospitalizations for ages 60+ (95% CI: 3.3-67.1); 114.1 ED visits for ages 15-59 (95% CI: 46.9-181.6); 154.6 ED visits for ages 60+ (95% CI: 86.7-223.3); and 1025.7 outpatient physician office visits for ages 60+ (95% CI: 79.0-1877.3). CONCLUSIONS: Influenza was associated with excess asthma hospitalizations and ED visits for ages 15-59 and 60+ and outpatient physician office visits for ages 60+. Individuals with asthma aged 15-59 and 60+ might be important targets for influenza-focused interventions, to reduce asthma morbidity at the population level.

Patterns of health care use related to respiratory conditions in early life: A birth cohort study with linked administrative data.

OBJECTIVES: To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles. METHODS: This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars). RESULTS: The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased). CONCLUSIONS: One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation.

Montelukast and Neuropsychiatric Events in Children with Asthma: A Nested Case-Control Study.

OBJECTIVE: To examine the association between montelukast prescription and neuropsychiatric events in children with asthma. STUDY DESIGN: A matched, nested case-control design was used to identify cases and controls from a cohort of children aged 5-18 years with physician-diagnosed asthma from 2004 to 2015, in Ontario, Canada, prescribed an asthma maintenance medication. Cases were children with a hospitalization or emergency department visit for a neuropsychiatric event. Cases were matched to up to 4 controls on birth year, year of asthma diagnosis, and sex. The exposures were dispensed prescriptions for montelukast (yes/no) and number of dispensed montelukast prescriptions in the year before the index date. Conditional logistic regression was used to measure the unadjusted OR and aOR and 95% CIs for montelukast prescription and neuropsychiatric events. Covariates in the adjusted model included sociodemographic factors and measures of asthma severity. RESULTS: In total, 898 cases with a neuropsychiatric event and 3497 matched controls were included. Children who experienced a new-onset neuropsychiatric event had nearly 2 times the odds of having been prescribed montelukast, compared with controls (OR 1.91, 95% CI 1.15-3.18; P = .01). Most cases presented for anxiety (48.6%) and/or sleep disturbance (26.1%). CONCLUSIONS: Children with asthma who experienced a new-onset neuropsychiatric event had nearly twice the odds of having been prescribed montelukast in the year before their event. Clinicians should be aware of the association between montelukast and neuropsychiatric events in children with asthma, to inform prescribing practices and clinical follow-up.

Asthma and Chronic Obstructive Pulmonary Disease Overlap in Women. Incidence and Risk Factors.

RATIONALE: Women with asthma are at a high risk of developing chronic obstructive pulmonary disease (COPD) or asthma and COPD overlap syndrome (ACOS) as they age, which is a condition associated with a high mortality rate, low quality of life, and high healthcare costs. However, factors influencing the development of ACOS remain unclear. OBJECTIVES: To quantify the risk of developing COPD in women in Ontario with asthma and identify factors that are associated with increased risk. METHODS: Data for women in Ontario with asthma who participated in the Canadian National Breast Screening Study from 1980 to 1985 were linked to health administrative databases, and participants were followed from 1992 to 2015. A competing risks survival model was used to measure the associations between sociodemographic, lifestyle, and environmental risk factors and time to COPD incidence, accounting for death as a competing risk. RESULTS: A total of 4,051 women with asthma were included in the study, of whom 1,701 (42.0%) developed COPD. The mean age at the study end date was 79 years. Low education, high body mass index, rurality, and high levels of cigarette smoking were associated with ACOS incidence, whereas exposure to fine particulate matter, a major air pollutant, was not. CONCLUSIONS: Individual risk factors appear to play a more significant role in the development of ACOS in women than environmental factors, such as air pollution. Prevention strategies targeting health promotion and education may have the potential to reduce ACOS incidence in this population.

Asthma health services utilisation before, during and after pregnancy: a population-based cohort study.

During pregnancy, females with asthma may be at higher risk of exacerbation. The objective of this study was to determine whether females with asthma in Ontario, Canada have increased health services utilisation (HSU) during pregnancy.Rates of asthma-specific, asthma-related and non-pregnancy-related HSU were calculated in a population-based cohort of pregnant females with asthma. Poisson regression with repeated measures was used to determine adjusted rate ratios and 95% confidence intervals of HSU during and 1 year after pregnancy, compared to the year before pregnancy.The cohort consisted of 103 976 pregnant females with asthma. Compared to the year prior to pregnancy, hospitalisation rates per 100 person-months during pregnancy increased 30% for asthma (from 0.016 to 0.020), 24% for asthma-related conditions (from 0.012 to 0.015) and decreased 37% for non-pregnancy-related conditions (from 0.24 to 0.15). Emergency department visits for asthma and asthma-related conditions did not increase significantly during pregnancy. During pregnancy, physician office visits decreased 19% for asthma (from 2.20 to 1.79), 10% for asthma-related conditions (from 9.44 to 8.47) and increased 74% for non-pregnancy-related conditions (from 56.4 to 98.2).Hospitalisations for asthma and asthma-related conditions increased during pregnancy, demonstrating that the overall increase in non-pregnancy-related physician office visits may not meet the primary care needs of pregnant females with asthma.

Association Between Inhaled Corticosteroid Use and Bone Fracture in Children With Asthma.

Importance: Daily use of inhaled corticosteroids is a widely recommended treatment for mild persistent asthma in children. There is concern that, similar to systemic corticosteroids, inhaled corticosteroids may have adverse effects on bone health. Objective: To determine whether there is an increased risk of bone fracture associated with inhaled corticosteroid use in children with asthma. Design, Setting, and Participants: In this population-based nested case-control study, we used health administrative databases to identify a cohort of children aged 2 to 18 years with a physician diagnosis of asthma between April 1, 2003, and March 31, 2014, who were eligible for public drug coverage through the Ontario Drug Benefit Program (Ontario, Canada). We matched cases of first fracture after asthma diagnosis to fracture-free controls (ratio of 1 to 4) based on date of birth (within 1 year), sex, and age at asthma diagnosis (within 2 years). We used a 1-year lookback period to ascertain history of inhaled corticosteroid use. Multivariable conditional logistic regression was used to obtain an odds ratio (OR) with 95% confidence interval for fracture, comparing no inhaled corticosteroid use vs current, recent, and past use. Exposures: Inhaled corticosteroid use during the child's 1-year lookback period, measured as current user if the prescription was filled less than 90 days prior to the index date, recent user (91-180 days), past user (181-365 days), or no use. Main Outcomes and Measures: First emergency department visit for fracture after asthma diagnosis, identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes. Results: This study included 19 420 children (61.0% male; largest proportion of children, 31.5%, were aged 6-9 years at their index date). The multivariable regression results did not show a significant association between first fracture after asthma diagnosis and current use (OR, 1.07; 95% CI, 0.97-1.17), recent use (OR, 0.96; 95% CI, 0.86-1.07), or past use (OR, 1.00; 95% CI, 0.91-1.11) of inhaled corticosteroids, compared with no use, while adjusting for sociodemographic factors and other medication use. However, use of systemic corticosteroids in the 1-year lookback period resulted in greater odds of fracture (OR, 1.17; 95% CI, 1.04-1.33). Conclusions and Relevance: Systemic corticosteroids, but not inhaled corticosteroids, were significantly associated with increased odds of fracture in the pediatric asthma population.

Mental Health Services Claims and Adult Onset Asthma in Ontario, Canada.

BACKGROUND: Living with asthma is associated with a decrease in quality of life due to reductions in activities of daily living and increased psychological stress, both of which are associated with poor mental health outcomes. OBJECTIVE: The objective of this study was to quantify the burden of mental disorders on the adult asthma population and compare the risk of mental health services claims (MHSCs) in the 1 year before and 1 year after asthma diagnosis. METHODS: Ontario residents aged 25 to 65 years with incident physician-diagnosed asthma between April 1, 2005, and March 31, 2012, were included. MHSCs, which consisted of hospitalizations, emergency department (ED), and outpatient physician visits, were identified from universal health administrative data. Poisson regression models with repeated measures were used to estimate the relative risk (RR) of MHSCs for 2 time periods: 1 year after asthma diagnosis compared with the 1 year before and 2 years after compared with 2 years before. RESULTS: A total of 145,881 adults had incident asthma. In the 1 year after asthma diagnosis, 27% had an MHSC. The risk of ED visits for any mental disorders increased by 13% in the 1 year after asthma diagnosis compared with the 1 year before (adjusted RR [aRR], 1.13; 95% confidence interval [CI], 1.06-1.21). This increased risk of ED visits was not found when comparing 2 years after asthma diagnosis with 2 years before. The risk for outpatient physician visits for substance-related disorders increased by 21% at 1 year (aRR, 1.21; 95% CI, 1.14-1.28) and 37% at 2 years (aRR, 1.37; 95% CI, 1.28-1.46). CONCLUSIONS: The significant comorbid burden of mental disorders in adults with newly diagnosed asthma highlights the need for primary care physicians to assess mental health needs and provide appropriate care.

The Annual September Peak in Asthma Exacerbation Rates. Still a Reality?

RATIONALE: Recent research suggests that the asthma epidemic observed in the 1980s and 1990s has stabilized. Changing trends in asthma may have an impact on the well-reported global phenomenon of the "asthma September peak." The 38th week of the year has been identified as the peak time for asthma exacerbations among children. OBJECTIVES: The purposes of this study were to examine the longitudinal trend of the September peak and to see if it changed over time, differed by age groups, or varied across different geographical regions. METHODS: Monthly rates of asthma emergency department (ED) and physician outpatient visits were calculated using data provided by the Ontario Asthma Surveillance Information System from 2003 to 2013 for patients of all ages. The Ontario Asthma Surveillance Information System is a population-based surveillance system with over 2 million individuals with asthma. Age-specific rates were calculated using the prevalent asthma population-asthma individuals with at least one health service claim for asthma in the respective year-as the denominator. Rates were stratified by age group and region of residence. Spatial relationships within the province were tested to examine if the September peak was more prominent in certain regions of Ontario. MEASUREMENTS AND MAIN RESULTS: The highest September peak in ED visits was observed in 2005 for children aged 0-4 years and 5-9 years (18.35 and 8.11 per 1,000 asthma prevalence, respectively). The rate of asthma ED visits of all children was consistently highest in September; however, the spike became marginally less pronounced over time. Since 2005, there has been a 51.7% decrease in the September asthma ED visit rate for all age groups. Monthly physician visits for all age groups usually peaked in October, roughly 4 weeks following the peak in ED visits. Analysis by residence showed that rates throughout Ontario were higher in September than in other months, suggesting that the spike was widespread rather than localized. CONCLUSIONS: While the magnitude of the September peak has decreased over time, the asthma ED visit rate remains significantly higher in September than in other months. Physician visits are also highest in the fall. These findings stress the importance of empowering children and families to maintain good asthma control throughout the year, including hand washing, to minimize respiratory viral infections in September.

Estimating Toronto's health services use for the 2015 Pan American and Parapan American Games.

AIMS: Ambient air temperature may exacerbate the burden of chronic diseases on Ontario's healthcare system during mass gathering events. This study aimed to estimate the impact of increasing temperature in July and August on health services use for chronic conditions in Ontario's Golden Horseshoe region during the 2015 Pan American and Parapan American Games, using environmental and health administrative data from previous years. METHOD: Negative binomial regression was used to calculate incidence risk ratios for same-day health services use (hospitalisations, emergency department visits, physician office visits) for all causes, asthma, asthma-related conditions, diabetes and hypertension associated with unit increases in daily maximum temperature from 1 May to 31 August in 2008-2010. Sensitivity analysis was performed to estimate the added burden of an increased population size, in order to model an influx of visitors during the Games. RESULTS: In July and August, on days with daily maximum temperatures of 35 °C compared to 25 °C, we estimated seeing 7,827 more physician office visits for all causes in Ontario's Golden Horseshoe region. The estimated relative increase in physician office visits for diabetes due to temperature alone was 8.4%. With an estimated 10% increase in population, the increase in physician office visits for all causes tripled to an estimated 23,590. CONCLUSION: Temperature was identified as a potential contributor to greater health services use during the Games, particularly for those living with diabetes. These results highlight the importance of strategic delivery of health services during mass gathering events, and suggest a role for educating at-risk individuals on prevention behaviours, particularly on very hot days.