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Rutgers Health Forms Corps To Clear The Air About Asthma

An initiative headed by the Ernest Mario School of Pharmacy aims to use education to end pediatric asthma deaths in Newark and beyond

When two children died from asthma-related complications at the same Newark, N.J., school in 2016 and 2019, caregivers wanted answers. When the asthma deaths didn't stop, doctors and health advocates demanded action.

"No child should die from an asthma attack," said Denise Rodgers, vice chancellor for interprofessional programs at Rutgers Health.

To address this health crisis, Rodgers and colleagues launched Asthma Corps, a partnership between the Ernest Mario School of Pharmacy and the Rutgers Health Service Corps (RHSC), a community health service and training organization for students, faculty and staff.

"By working with the departments of pediatrics at University Hospital and Newark Beth Israel Medical Center, and in collaboration with other Rutgers Health departments, we've created a community health education program involving students to decrease incidences of these preventable deaths," Rodgers said.

By working with the departments of pediatrics at University Hospital and Newark Beth Israel Medical Center, and in collaboration with other Rutgers Health departments, we've created a community health education program involving students to decrease incidences of these preventable deaths.

Denise Rodgers

Vice Chancellor for Interprofessional Programs, Rutgers Health

A critical goal of the program is to help parents and caregivers understand the importance of getting emergency care if routine treatments don't control their child's asthma attack, Rodgers said. Another is to help parents and caregivers – and children themselves – better manage pediatric asthma.

Working with the Greater Newark Health Care Coalition (GNHCC), a nonprofit organization, Asthma Corps volunteers conduct online and in-person training in community centers. Pharmacy doctoral students share personal experiences with asthma and teach asthma basics – from identifying what causes an attack to using proper medication. 

"Asthma Corps' students are teaching community members how to identify triggers, what resources are available for long-term care and how to create asthma action plans, such as what to do in an acute attack," said Ebonie Steele, program manager for child and adolescent health at GNHCC. "With Rutgers, we recognize that we have something great here."

Throughout the United States, pediatric asthma is a persistent problem, particularly in cities, where air pollution poses a constant irritant to young lungs. In Newark, it is estimated that 1 in 4 children has asthma, far outpacing the national average of 1 in 11. Rates of asthma are only expected to climb further as higher temperatures linked to climate change are fueling conditions that can spark asthma attacks.

In New Jersey, children die every year from asthma-related complications. The risks are greater for children of color. The New Jersey State Health Assessment estimates that the mortality rate among Black and Hispanic children is a combined 4.9 per 100,000 people. For white children, it's less than 1 per 100,000.

Far more common are adverse consequences of poorly managed asthma, such as school absenteeism, lower academic performance and reduced physical activity.

Through outreach and education, the Asthma Corps – officially known as Clearing the AIR about Asthma: Awareness, Information and Resources – is empowering children and caregivers to bring asthma under control. Training topics include identifying asthma symptoms, exercising with asthma and avoiding over-the-counter medications that are ineffective in treating an asthma attack.

About 100 Newark-area parents and caregivers have received the training since the program launched in May, and hundreds more are in the pipeline.

John "Jack" Hemphill, a program manager in the Rutgers Office of Population Health and co-convenor of Asthma Corps, said the idea for the program began in the "trenches of COVID." A vaccine program run out of the pharmacy school had achieved high marks for vaccination rates and its ability to connect experts across Rutgers schools.

"We did all this amazing interprofessional work during the pandemic, and we wanted to bottle that up, cultivate that and move beyond the vaccination initiative," Hemphill said.

The VAX Corps, as it was known, eventually evolved into RHSC, which Hemphill co-leads. After the second child asthma death in Newark in 2019, the service corps and pharmacy faculty teamed up with Rodgers and the Rutgers Office of Interprofessional Programs to create the Asthma Corps, bringing together public health experts, pharmacy students and faculty. The initiative is supported with funding from RHSC and private donations.

Among the facilitators are Rupal Mansukhani, a clinical professor at the pharmacy school, who produced much of the training material; Lucio Volino, a professor of pharmacy, and Nina Raps, a curriculum field manager, who helped develop and deliver programs; and Donna Feudo, associate dean for experiential education at the School of Pharmacy.

As Asthma Corps matures, we're bringing in students from other programs, like the School of Nursing. The interprofessional nature is what makes this program so special for our students.

Donna Feudo

Associate Dean for Experiential Education, Rutgers Ernest Mario School of Pharmacy

"As Asthma Corps matures, we're bringing in students from other programs, like the School of Nursing," Feudo said. "The interprofessional nature is what makes this program so special for our students."

Placing the program within the pharmacy school makes sense, said Vince Silenzio, a professor at Rutgers School of Public Health and another Asthma Corps co-convenor. As a first point of contact, pharmacists serve as a vital lifeline for young asthma sufferers.

"There's a whole set of reasons why caregivers might not seek asthma care for their kids, even if they have access to a clinician," Silenzio said. "Pharmacists can often be a more convenient touchpoint in many communities."

So, too, can future pharmacists.

"It's been working beautifully so far, having the students facilitate the workshops," Steele said of the Greater Newark Health Care Coalition. "We all have the same goal – to ensure that not another child dies from asthma."

Childhood Asthma Disparities By Race/Ethnicity Larger Early On, Taper With Age

Prevalence rates for early childhood asthma in the United States show marked racial/ethnic and socio-economic disparities that taper with age, according study findings published in the Annals of the American Thoracic Society.

Investigators assessed how disparities related to race/ethnicity and socioeconomic status (SES) are associated with the age trajectory of asthma burden in US children. Outcomes of interest were age at asthma diagnosis and cumulative asthma prevalence and asthma hospitalization rates.

The investigators conducted a cross-sectional study analyzing 3 datasets with US children up to 17 years of age: the 2018-2019 National Inpatient Sample (NIS) (n=23,713 children with asthma); the 2015-2017 Child Asthma Call-Back Survey (ACBS) (n=4289); and the 2016-2021 National Children's Health Survey (NCHS) (n=223,551). The NIS provided asthma hospitalization rates by age, race, and ethnicity. The ACBS provided data by race, ethnicity, and SES on mean age at asthma diagnosis, adjusted and unadjusted for confounders. The NCHS showed cumulative asthma prevalence by age, race, and ethnicity.

With respect to cumulative asthma prevalence, the researchers found that among White children, prevalence gradually increases through childhood from an early age, with rates of 1.0% before 1 year of age, 6.6% at 5 years of age, and 16.1% at 17 years of age. Black children showed greater asthma prevalence in early childhood, with rates of 2.8% before 1 year of age and 17.6% at 5 years of age, with rates plateauing at 22.8% after 9 years of age. The researchers further noted that Black-White relative disparities in asthma prevalence declined during adolescence (relative risk [RR], 2.6; 95% CI, 1.9-3.8). In Hispanic children, asthma rates went from 0.8% before 1 year of age, to 9.9% at 5 years of age, to 18.5% at 11 years of age, with rates becoming similar to those of White children at adolescence.

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Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention.

Asthma prevalence according to SES showed a similar trajectory, with children of lower SES showing higher early-age asthma prevalence rates, and differences in prevalence by SES narrowing as children grew older.

Another notable difference: White and high-income children are diagnosed at a later age than Black, Hispanic, and low-income children. The mean age at diagnosis was 5.0 years among White children; 4.7 years among children from high-income (ie, $50,000+) households; 3.9 years; among Black children; 4.1 years among Hispanic children; and 4.0 to 4.2 years among children from low-income households. Those from the lowest income households were diagnosed at 4.9 years.

Among all children, asthma hospitalization rates rise in the earliest years, although more rapidly among Black children, with the peak absolute Black/White gap reached at 4 years of age. Throughout childhood, the relative Black/White gap remains wide and peaks at 10 years of age. From a per-child perspective among those with asthma, relative disparities rise through 15 years of age in Black/White hospitalizations.

Study limitations include the cross-sectional design, as well as recall and diagnostic bias. Additionally, no distinction was made between differing Hispanic ethnicities; notably, previous research shows Puerto Rican children have a higher asthma prevalence than both Black and White children and that Mexican-American children have a lower asthma prevalence.

"Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention," the investigators concluded, adding, "Other factors, however, likely contribute to marked Black-White disparities in major asthma morbidity (measured by hospitalizations) throughout childhood and beyond."

Cancellation Of Kids' Asthma Medication Continues To Cause Turmoil For Mass. Families

"January 1, those formulary lists are going to change again, and we don't know what's on them," said Dr. Robyn Cohen, associate medical director of asthma initiatives at Boston Medical Center. "I'm worried we're going to be back to where we were last year."

The root of families' distress is a 2021 federal initiative intended to keep medications affordable by adding penalties when a drug's price increase outpaces inflation. The penalties went into effect at the beginning of this year. Most companies responded by cutting their drug's list prices. GSK instead subbed out Flovent for the generic, which is not subject to the same penalties. (GSK also said it had for some time intended to discontinue Flovent.)

Professors at Johns Hopkins estimated in a study in November that if GSK had simply reduced the price of Flovent to avoid the new federal penalties, it would have cost at least $30 less than the generic, around $150 compared to the authorized average sale price for the generic of almost $184. One reason is the generic doesn't come with the same level of discounts and rebates that insurers got for Flovent.

The Massachusetts Department of Public Health issued an advisory in November that described GSK's decision to discontinue Flovent as an additional barrier to people already struggling to access health care.

Senator Elizabeth Warren accused GSK of "price gouging," arguing the company switched to a generic as a way to avoid federal price controls on medications. The switch has hammered Medicaid providers, Warren said. Without the rebates and discounts that accompanied Flovent, Medicaid administrators, including MassHealth, are now paying about four times more for essentially the same drug, according to a letter Warren sent Wednesday to GSK chief executive Emma Walmsley.

The Johns Hopkins study estimated switching from Flovent to the licensed generic could add more than half a billion dollars to Medicaid net spending this year.

"GSK's actions appear to be intended to circumvent new provisions passed by Congress to hold drug manufacturers accountable for years of historical price increases," Warren wrote.

The British company reported operating profit of more than $8 billion in 2023.

Flovent was manufactured by a second company, Prasco Laboratories, under a license from GSK. A spokesperson for GSK deferred comment to Prasco, which did not respond to a call.

Warren's letter also castigated the company for failing to respond to requests for detailed information about the profit sharing between GSK and the manufacturer.

"It's shameless of the company to point fingers and try to shift the blame while kids across the country are suffering at the hands of clear, indisputable corporate greed," Warren said in a statement Friday.

Flovent, a corticosteroid treatment now sold under its generic name fluticasone propionate, was one of the most commonly prescribed pediatric asthma treatments, in particular because the inhaler used to deliver the medication was designed for young children's small lungs. Alternate medications, such as Asmanex and Symbicort, are either in short supply or more difficult to get covered by insurers.

Other pharmaceutical companies have yet to follow GSK's example, said Jeromie Ballreich, an associate research professor at Johns Hopkins's Bloomberg School of Public Health and an author of the report on Flovent, probably due to the bad publicity the move attracted. It is an open question though, he said, whether such maneuvers could become more common under the incoming Trump administration. Some of Trump's nominees, including Robert F, Kennedy Jr., are critical of big pharma. Others are likely to be more pro-business and antiregulation.

"I don't know how that increasing regulation, increasing pressure against pharma versus less pressure against pharma, is going to play out," Ballreich said. "It's a very cloudy crystal ball."

Hamilton O'Rourke, of Acton, is one of many whose care has suffered since the switch. Until last year, the 10-year-old routinely received prescriptions for Flovent. Near the end of 2023, his mother, Sarah O'Rourke, got her insurance company to cover a prescription for Symbicort as a Flovent replacement. In 2024, though, that drug was no longer included in the insurer's formulary.

For months, she and her son's doctor, Ben Nelson of Massachusetts General Hospital, exchanged calls with her insurer, trying to get coverage for the boy's prescription. Her son attempted to use a powdered medication that didn't work before the insurer relented in November and covered Symbicort. Even then, she had to sign up with a mail delivery company to avoid being charged $425 at her local pharmacy and still ended up paying out-of-pocket for an air chamber to help direct the medication into Hamilton's lungs.

The scramble for alternative asthma treatments puts significant demands on his staff, Nelson, a pediatric pulmonologist, said.

"If I'm worried about a delay getting their medicine, then I have to prescribe a secondary medicine and also have prednisone on hand, give them a script [for prednisone] for them to avoid the ER or the hospital," he said.

An October review of hospital admissions data by a medical industry researcher points to a rise in pediatric asthma-related hospital cases following the withdrawal of Flovent. In the second quarter of this year, hospital admissions nationally for asthma-related complications among children prescribed some version of fluticasone propionate, including Flovent in earlier years, increased 24 percent compared to the same periods in 2022 and 2023, according to Epic Research, the public research branch of a medical software company. Intensive care unit admissions increased more than 21 percent in the same span.

"It's very frustrating," said Dr. Timothy Lax, a physician with Central Mass Allergy & Asthma Care in Worcester. "Especially during the winter when there are a lot of environmental components that can contribute to their conditions, it's really important for them to have their inhalers."

Three times this year, Hamilton had asthma flare-ups, dry coughing severe enough to make him vomit. When he was on Flovent, attacks that serious typically happened just once a year.

"They think they're saving money, but what they're making people do is making people go to the emergency room because their kids can't breathe," Sarah O'Rourke said.

O'Rourke now has enough Symbicort to get her son through March or April, she said. She is hoping for the best after that.

"I don't know if we're going to have to go through this again next year," she said. "I'm guessing we will."

Jason Laughlin can be reached at jason.Laughlin@globe.Com. Follow him @jasmlaughlin.

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