**How Communities can Collaborate with Schools to Implement a
Comprehensive Asthma Program**

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**Prepared by the Detroit Department of Health and Wellness Promotion -
Center for Asthma Education, Management and Policy under the Centers for
Disease Control and Prevention - Environmental Health Services Grant \#
US0/CC4524350-03**

**Detroit Department of Health and Wellness Promotion-Center for Asthma
Education Management and Policy**

**How Communities can Collaborate with Schools to Implement a
Comprehensive Asthma Program**

**Table of Contents**

I.  Introduction Pg. 3

II. Purpose Pg. 3

III. Goals Pg. 3

IV. School Intervention Components Pg. 4

V.  Establishing a Community Collaborative Pg. 4

VI. What Needs to be Addressed at the Initial Meeting of the
    Collaborative Pg. 5

VII. Expectations of Collaborative Partners Pg. 5

VIII. Collaborative Coordinator's Responsibilities Pg. 5

IX. After Receiving Approval from the School System Pg. 6

X.  Sustainability Strategies Pg. 7

XI. Communities' Expectation of School Pg. 9

XII. Roles and Responsibilities Pg. 10

     a.  Parents Pg. 10

     b.  School Administrators Pg. 12

     c.  Coaches and Physical Education Instructors Pg. 14

     d.  Counselors and Teachers Pg. 15

     e.  Building Engineers and Custodians Pg. 17

     f.  Food Service Worker Pg. 19

XIII. Success Story Pg. 20

XIV. Indoor Air Quality Pg. 21

XV. Outdoor Air Quality Pg. 23

XVI. Resource Websites Pg. 24

XVII. Smoking Cessation Pg. 26

**I. Introduction**

According to the National Center for Chronic Disease Prevention and
Health Promotion, asthma is a leading chronic illness among children and
youth in the United States. In 2003, 5 million school-aged children and
youth were reported to currently have asthma and 3.1 million had an
asthma episode or attack within the previous year.^1^ On average, in a
classroom of 30 children, about three are likely to have asthma.

In addition:

-   Asthma is one of the leading causes of school absenteeism. In 2002,
    14.7 million school days were missed due to asthma.^2^

-   Low-income populations, minorities, and children living in inner
    cities experience more emergency department visits,
    hospitalizations, and deaths due to asthma than the general
    population.^3^

-   Asthma can be controlled with proper diagnosis, appropriate asthma
    care, and management activities.

-   In 2003, 5.9% of school-aged children and youth experienced an
    asthma episode or attack within the previous year.^1^

-   The estimated cost of treating asthma in those under 18 is \$3.2
    billion per year.^4^

-   Asthma is the third-ranking cause of hospitalization among children
    under 15.^5^

-   Asthma attacks, also referred to as episodes, can be caused by
    tobacco smoke, dust mites, furred and feathered animals, certain
    molds, chemicals, and strong odors in the school environment.

Although asthma cannot be cured, it can be controlled. Schools can do
their part to control asthma by becoming more "asthma-friendly," i.e.,
adopting policies and procedures, and coordinating student services to
better serve students with asthma. For example, all students with
diagnosed asthma should have an asthma action plan on file that is
easily accessible at school.^2^ Schools can provide asthma education and
collaborate with organizations that focus on asthma. Chances for success
are better when the whole school community takes part---school
administrators, teachers, and staff, as well as students and parents.

The purpose for starting a community-based comprehensive asthma program
in schools is to decrease the number of school days missed because of
asthma. Also, to ensure that school administrators, principals,
teachers, counselors, coaches and physical education teachers,
custodians, other staff, and parents know how to recognize and respond
to an asthma emergency.

**II. Purpose**

The purpose of this document is to provide guidance on how to develop
and implement a community-based comprehensive asthma program for
schools. This document can be used by anyone interested in addressing
asthma in school setting including but not limited to parent lead
organizations such PTA's, school nurses, community members, and asthma
advocates.

**III. Goals**

-   Provide asthma management education in schools and the community
    with an emphasis on identifying and avoiding and reducing exposure
    to asthma triggers

-   Provide safe and healthy school environment and reduce exposures to
    asthma triggers

-   To ensure that physical education activity opportunities are safe
    and enjoyable for students with asthma

-   Have student able to participate in Normal activities, including
    play, sports, exercise, or other school activities

-   Coordinate with school, family and the community to better manage
    asthma symptoms and reduce school absences among students with
    asthma

-   Reduce acute episodes of asthma that require visits to a doctor, the
    emergency room, or urgent care

-   Reduce missed school days

**IV. School Intervention Components**

-   Implement asthma programs for all schools and all grades, including
    preschool/daycare. Provide programs such as *Open Airways* (American
    Lung Association) in elementary schools, *Power Breathing™* (Asthma
    and Allergy Foundation of America) in middle schools, and *Puff City
    model* (Henry Ford Health System) in high schools.

-   Implement evidence-based interventions whenever possible.

-   Conduct an assessment - Asthma programs that are currently in the
    schools should be identified and evaluated to determine if the
    program needs to be enhanced.

-   Provide asthma education and management workshops for students,
    teachers, food service workers, counselors, sports /physical
    education staff, school administrators.

-   Identify and establish a database for students with asthma

-   Ensure that all students have a completed health appraisal form in
    schools

-   Identify age appropriate asthma education resources

-   Have asthma action plans and peak flow meters for all students with
    asthma.

-   Provide awareness on state inhaler law, if not available the State
    of Michigan Inhaler Law can be used as a model for legislation in
    your state

-   Have signs explaining how to recognize an asthma emergency and how
    to respond to an asthma emergency placed in strategic locations in
    all schools

-   Conduct asthma workshops for bus drivers

-   Educate school administrators, and staff about the impact of indoor
    air quality on the health of students and personnel.

-   Implement EPA's Tools for Schools

-   Ensure that school system adopts EPA's Clean School Bus USA which
    includes: anti-bus idling practices, retrofitting buses with modern
    emission control technology, using cleaner fuels, and replacing
    older buses

**V. Establishing a Community Collaborative**

Whoever takes the lead to initiate a community collaborative in schools
should do the following:

-   Research regional area for national, state and local organizations
    that can provide services and assist with implementation of goals
    and expected outcomes

-   Solicit organizations with members interested in working as a
    collaborative

-   Solicit organizations to find an in-kind meeting place

> Selecting a location is very important step in the process. The
> building and surrounding grounds should be accessible for all
> committee members. There should be ample room, store room, restrooms
> and office space if possible. Possible locations include: local and
> state health departments, schools, churches, community organizations,
> hospitals, healthcare management organizations and corporations.
> Request space be donated and also request phone and internet access if
> possible.

-   Schedule meeting with at least 2 weeks notice, more time if
    necessary

-   Set a meeting agenda that outlines purpose, goals and school
    intervention component

**VI. What Needs to be Addressed at the Initial Meeting of the
Collaborative**

-   Review purpose, goal and school intervention component

-   Poll attendees on level of expertise decide if other organizations
    and individuals need to be at the table

-   Brainstorm and find out what services organizations and can provide
    to implement strategies

-   Determine operation guidelines/procedures

**VII. Expectations of Collaborative Partners**

-   Provide resources to schools through donations, minimal cost or
    in-kind education for students k-5,grades 6-8, grades 9-12, parents
    and staff

-   Provide in-kind resources to collaborative and schools (i.e. peak
    flow meters, holding chambers, nebulizers, asthma action plans for
    all students, integrated pest management analysis, non-toxic
    cleaning supplies, etc.

-   Attend scheduled meetings and volunteer if possible for committees
    and special activities

-   Establish a Memorandum Of Understanding (MOU) with schools

-   Support other collaborative partners

-   Identify coordinator for the collaborative

**VIII. Collaborative Coordinator's Responsibilities**

-   Poll attendees to determine who has contacts with school board and
    superintendent or other members of the school system, obtain contact
    name and determine who will contact them

-   Research the protocol for working in the school i.e. (Do you need a
    Memorandum of Understanding?)

-   Review school intervention components

-   Draft a to do list

-   Decide which collaborative partner is responsible for specific tasks

-   Decide on meeting dates, locations, who will be responsible for
    chairing the meetings

-   Approach school and set a meeting with appropriate person whether it
    is the School Board or Superintendent or principals (It is important
    to note that approaching the school board or the superintendent
    would be the best approach. However, do not discount the
    relationships that your collaborative partners have with school
    staff member or parent groups. It is important to capitalize on all
    relationship to have success in the school.) Goal is to get the
    buy-in of upper management to implement program in schools.

> Note: Once the school system or school gives the collaborative
> permission to implement the comprehensive asthma program, organize a
> district wide team if a Coordinated School Health Council is not
> available

**IX. After Receiving Approval from the School System**

-   Select a coordinator from each school (should be the school nurse if
    available.)

-   Assign tasks to school coordinator and/or school volunteer

-   Conduct training for all school coordinators, staff, and volunteers
    to familiarize them with the comprehensive asthma program

> *Review school district's policy for volunteers*
>
> Minimum Requirements:

-   Completed application

-   Release and authorization for clearances: State Police Clearance,
    FBI Clearance, Child Abuse Clearance

-   Health Appraisal including TB test

-   Emergency Information sheet

-   Letters of reference

-   CPR and First Aid training

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-   Conduct school assessment

-   Conduct a school walk through with designated building maintenance
    or custodian

-   Work with school to prioritize interventions and implement school
    interventions

-   Ensure that all students have a completed health appraisal form in
    school file

-   Identify and establish a database for students with asthma

-   Identify age appropriate asthma education resources

-   Distribute asthma action plans, peak flow meter and holding chambers
    for each student with asthma

-   Schedule evidence based asthma education for students suggestions
    include: *Open Airways* (American Lung Association) in elementary
    schools, *Power Breathing™* (Asthma and Allergy Foundation of
    America) in middle schools, *Puff City model* (Henry Ford Health
    System) in high schools

-   Schedule training in school for parents with an emphasis on
    environmental asthma triggers, secondhand smoke, medication,
    advocacy, and smoking cessation

-   Post signs in school on how to recognize and respond to an asthma
    emergency

-   Develop a training module and provide training to each staff and
    school coordinator. Suggested curriculum should include the
    following:

> What is asthma?
>
> Asthma Symptoms
>
> State and Local Statistics
>
> Mortality Rates
>
> Risk Factors for Asthma
>
> Asthma Management
>
> Goals of Asthma Management
>
> Environmental Interventions
>
> Medical Interventions
>
> Behavioral Changes
>
> What are Asthma Triggers?
>
> Common Asthma Triggers: Allergens, Irritants, and other Triggers
>
> How to reduce exposure to asthma triggers?
>
> Asthma Medications
>
> Peak flow monitoring
>
> Asthma Management Plan
>
> How to recognize and respond to an asthma emergency
>
> Early Warning Signs
>
> Danger Signs

Note: Handouts should be culturally and literacy appropriate materials.

**X. Sustainability Strategies**

-   Create a sustainability plan

-   Create a train-the-trainer program for school coordinators and
    volunteer programs as a part of a sustainability strategy

-   Evaluate program's effectiveness; make program changes as
    appropriate to achieve desired goals

-   Implement an effective internal and external communication plan to
    keep staff, students, parents and community abreast of school
    improvements

-   Facilitate system changes in schools by establishing good school
    polices such as:

> Integrated Pest Management
>
> Indoor Air Quality
>
> Clean School Bus USA
>
> Continuing Education for Staff
>
> Medication Policy
>
> Inhaler Law
>
> Smoke Free School

A quality community program can be expensive. High quality, efficiency
and careful management will hold cost down, and donations of goods and
services- while still a part of the cost of running a program -- help
reduce the amount of money required to run a program. There are regional
variations in cost associated with running a program which reflect
differences in wages, available facilities and other resources.

Despite high cost, however, the hope for high quality does not have to
be abandoned by any community, rich or poor. Those who set out to
provide quality programs must count on dedicating a considerable amount
of time to fund-raising and solicitation of in-kind services.
Collaborative partnerships must create a fund development strategy which
considers multiple funding sources. Consider every major component of
the program operation. Decide how each component is to be provided in
the program setting or elsewhere; by using staff or outside help; by
hiring specialist or consultants on an hourly basis; on a long-term or
short-term contract, or on a per-job basis. In most communities, both a
carefully planned budget and successful pursuit of funds from one or
more sources will help in sustaining a comprehensive program. Below are
examples of funding sources:

**Public Funds**

Most public funds are available to school systems, public health
departments and municipal governments as well as community based
organizations. Some funding sources give priority to communities that
experience health disparities. Guidelines of public funding sources may
change so it is important for collaborative partners and schools to
review this information on a regular basis.

**Community Fund Raising Campaigns**

The collaborative or the school should apply to private philanthropic
agencies, such as The United Fund/Way or local Community foundations for
funding. To receive these funds, an organization is generally required
to be a nonprofit agency with a 501c3 designation. They may also require
an organization to be incorporated and to meet other standards. Funds
are usually granted only as a means to relieve a deficit between annual
operating expenses and income from all other sources, a may not be used
on one-time needs.

**Individual Fund Raising Campaigns**

Collaborative Partners can undertake their own campaigns to raise money.
The collaborative can sponsor bake sales, car washes, dramatic
performances or social occasions; or they may charge membership dues or
issue letters of appeal. These efforts can be successful but the funds
generated through these methods could be limited. Unless run by groups
with considerable experience, the project may actually produce expenses
higher than income. The most effective way to manage such activities is
to create a fundraising committee made up of Collaborative Partners.

**Grants**

Many foundations and organizations make grants to education, health and
child welfare entities that can provide a unique service for asthma
students. Applying for grants can be laborious, time consuming,
complicated process and usually involves submitting a detailed proposal
and a budget. Details differ widely and should be obtained from each
individual organization or foundation.

**In-kind Donations**

Gifts of goods or services are often available in the community,
especially if the program uses good advertisement and public relations
techniques that inform the community about the program. Local merchants
may donate various items.

> **XI. Communities' Expectation of Schools**

-   Implement EPA Indoor Air Quality Tools for Schools (IAQ TfS)

> IAQ TfS program is flexible, comprehensive resource for a school
> building's health. The district wide approach for implementing the IAQ
> TfS Kit has become the standard for schools that are looking to
> initiate proactive indoor air quality practices in there school
> system.

-   Implementation of EPA's Clean School Bus USA

> Twenty-Four Million of our nation's children are transported safely by
> school buses between home and classrooms. Children spend and average
> of more than one hour on the bus each day. Unfortunately, school buses
> particularly older ones lack emission control devices and therefore,
> emit tiny sooty particles and toxic gases in their exhaust that can
> pose a health hazard for children. When inhaled, pollutants in diesel
> exhaust may aggravate asthma and allergies or cause other serious
> health problems for our nation's children.

-   Use Integrated Pest Management

> Integrated Pest Management (IPM) is the coordinated use of pest and
> environmental information with available pest control methods to
> prevent unacceptable levels of pest damage by the most economical
> means and with the least possible hazard to people, property, and the
> environment. IPM uses mechanical trapping devices, natural predators
> (e.g., insects that eat other insects), insect growth regulators,
> mating disruption substances (pheromones), and if necessary, chemical
> pesticides.  The use of biological pesticides is an important
> component of IPM.
>
> Since children spend so much of their day at school, integrated pest
> management provides an opportunity to create a safer learning
> environment - - to reduce children\'s exposure to pesticides as well
> as eliminate pests. EPA is encouraging school officials to adopt IPM
> practices to reduce children\'s exposure to pesticides.
> [www.chej.org](http://www.chej.org/)

-   Establish a resource library for all school personnel and students
    to obtain additional information about asthma, including: pamphlets,
    brochures, and other publications. 

-   Schedule any extensive building repairs or cleaning during long
    vacations or summer months in order to avoid exposing students to
    fumes, dust, and other irritants.

-   Support and encourage communication with parents to improve school
    health services.

-   Reinforce twenty-four/seven tobacco-free policies within all school
    buildings and at all school events held on school grounds. 

-   Require staff to wear non-latex gloves when preparing foods or
    treating students medically.

-   Follow state medication policy for schools, if available

-   Make sure that the ingredients in all foods served by the cafeteria
    are posted/published and/or have a complete ingredient list
    available for students with food allergies

**XII. Roles and Responsibilities**

**(a.) Parents**

> In order to keep your child's asthma under control at school, parents
> need to prepare themselves, their child and school staff. Here's what
> MUST de done before school starts:

1.  Have the student's written [Asthma Action
    Plan](http://www.getasthmahelp.org/actionplan_components.asp)
    prepared by child's doctor and give a copy to your child's school.

2.  Make sure the school has emergency numbers to reach the parent or
    guardian.

3.  Schedule a conference with your child's teacher to talk about your
    child's asthma.

> Working with [school
> staff](http://www.getasthmahelp.org/intro_schools.asp) year round will
> help your child have a healthy school year. Below is a checklist of
> important items to remember:
>
>  **During the summer:**

-   Visit the student's doctor or health care professional, and complete
    a new as[thma action
    plan](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=16).
    Give a copy to each of the child's teachers, school nurse, and
    school secretary and after school activity staff.

-   While at school, be sure to talk about your child's:

    -   technique with [peak flow
        meter](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=56),
        inhaler and spacer

    -   asthma
        [triggers](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=69),
        especially those that the child might have at school, such as
        exercise, animals, and food allergies

    -   medications

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-   Complete all medication/health forms from the school - don't forget
    the ones for sports or other physical activities

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-   Request copy of school Indoor Air Quality (IAQ) report. The IAQ
    repot should include information on:

    -   cockroaches

    -   dust mite sources (often found in humid places and in pillows,
        carpets, upholstery and stuffed toys)

    -   mold

    -   other airborne asthma triggers (i.e. particulate matter and
        Volatile Organic Compounds (VOCs)

> Request the smoke free policy (if applicable). Review the policy and
> find out how well it is enforced. If no smoke free policy exists, work
> with school to establish one. Example of a smoke free policy can be
> found at
> [http://schoolasthmaallergy.com](http://schoolasthmaallergy.com/)
>
> If you are concerned about any of the above, talk to the school staff
> about correcting the problems prior to school starting.
>
>  **Before school starts:**

-   Complete all school, activity, medication and health forms

-   Check to see if all inhalers are full and in working order

-   If your child uses a
    [nebulizer](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=51),
    make sure all of its parts are clean.

-   Label all medications and asthma tools with child's name and
    classroom

-   Arrange a meeting with child's teacher and other school staff,
    include the child in the meeting if possible

-   Arrange a meeting with child's after school day care teachers, if
    needed

>  \
> **At the meeting with the school/daycare staff, discuss:**

-   Basics of asthma and allergies

-   [Warning
    signs](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=72)
    for your child's [asthma
    episodes](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=18)

-   Triggers, such as animals in the classroom, cold air at recess, and
    strong odors

-   Your child's Asthma Management/Action Plan

-   Your child's Emergency Plan, make sure staff knows what to do and
    how to do it

-   Medications and access to medications. Some states and/or schools
    have policies that allow students to carry their
    [inhalers](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=46)
    with them at all times.

-   Asthma tools, such as peak flow meters, spacers, and nebulizers

-   Emotional aspects of your child's asthma

-   Gym class and other times they play hard

-   Missing school and making up school work

-   A time for asthma education for the class -- ask the school nurse,
    doctor or [local asthma
    coalition](http://getasthmahelp.com/UserCoalitionList.asp) if you
    need help talking about this or arranging for someone else to do the
    talking.

-   Any other important items parents and people caring for your child
    can do to help the teacher/staff

>  **During the school year:**

-   Be sure to check often with teacher and other staff to make sure
    they are not having problems following the asthma management or
    action plan -- if the plan changes, be sure to give the school staff
    a new one, and review changes with them

-   Make sure there are enough medication supplies - use weekends and
    school vacations to clean or replace [valved-holding
    chambers](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=71)/spacers
    and peak flow meters, and check inhalers

-   Talk to your child about any difficulties or problems in controlling
    their asthma at school.

Note: It is equally important to make sure to reduce exposure to
allergens and irritants in the home. Parents should review the Indoor
Air Quality information and implement the steps at home.

**(b.) School Administrators/Principals**

Involve your staff in the school asthma management program. A school
asthma management program is a cooperative effort that involves the
student, parents, teachers, school staff, and physicians. Many members
of the school staff can play a role in maintaining your school's asthma
management program, although the principal or the school nurse may be
most instrumental in getting a program started. Take the steps listed
below to help set up an asthma management program at your school. 

Develop a clear policy on taking medication during school hours. Work
with parents, teachers, the school nurse (if available), and others to
provide the most supportive policy that your school system allows so
that the student can get the medication he or she needs. Be
knowledgeable about medication policy that allows students to carry
their
[quick-relief](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=62)
[inhalers](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=46)
with them at school, for use in preventing or treating [asthma
symptoms](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=21),
if permission is given by the doctor and parent.

-   Designate one person on the school staff to be responsible for
    maintaining every student's [Asthma Action
    Plan](http://www.getasthmahelp.org/actionplan_components.asp). If
    there is not a nurse at the school, assign this task to a staff
    member who has received appropriate asthma training. To find asthma
    training opportunities, contact your [local American Lung
    Association
    office](http://www.alam.org/Home_Page/Contact_Us/contact_us.asp).
    For helpful information about delegating school health services to
    unlicensed personnel visit
    [www.lungusa.org](http://www.lungusa.org/)\
     

-   Provide in-service opportunities for staff to learn about asthma and
    allergies. Assistance is available from the school nurse, a local
    hospital, or asthma coalition. Additional resources are available
    from: the [American Lung
    Association](http://www.lungusa.org/school/), [Asthma and Allergy
    Foundation of America](http://www.aafa.org/), [National Jewish
    Center for Immunology and Respiratory
    Medicine](http://nationaljewish.org/diseases/dt4.html), and the
    [Mothers of Asthmatics.](http://www.aanma.org/schoolhouse/)\
     

-   Asthma may be considered a disability for a student, depending on
    severity, under Section 504 of the Rehabilitation Act. Many students
    with asthma, especially those with
    [severe](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=64)
    asthma, may need a 504 Plan/Individual Education Plan (IEP) to
    ensure that they receive the services they need to learn in the
    school environment. IEP's, as appropriate, particularly for health
    services and physical activity modifications.

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-   Establish a resource library for all school personnel and students
    to obtain additional information about asthma, including: pamphlets,
    brochures, and other publications. This library of information will
    provide staff and school personnel an opportunity to obtain
    additional information about asthma. Many organizations offer
    educational materials for this purpose.\
     

-   Schedule any extensive building repairs or cleaning during long
    vacations or summer months in order to avoid exposing students to
    fumes, dust, and other irritants.

-   Support and encourage communication with parents to improve school
    health services.

-   Enforce any tobacco-free policies. Ideally, should be 24/7 within
    all school buildings and at all school events held on school
    grounds.

-   If such a policy does not exist, work with collaborative partners to
    have one established.

-   Require staff to wear non-latex gloves when preparing foods or
    treating students medically.

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```
-   Follow your state medication policy for schools, if there is not a
    policy available, the state of Michigan has a good medication policy
    for schools that may be helpful. 

-   Make sure that the ingredients in all foods served by the cafeteria
    are posted/published and/or have a complete ingredient list
    available for interested families

-   Control exposure to chemicals and volatile materials used in
    science, art and other classes (i.e. store in airtight containers
    and ensure proper ventilation.)

-   Avoid using pens, glue, and paints that emit irritating fumes. The
    fumes can be a trigger for asthma symptoms.

**(c.) Coaches and Physical Education Instructors**

-   Appreciate that exercise can cause acute episodes for many students
    with asthma. Exercise performed in cold dry air and activities that
    require extended running tend to exacerbate asthma more readily than
    other forms of exercise. Medicines can be taken before exertion to
    help avoid an episode. Discuss appropriate pre-medication before
    student begins any physical activity. Warm-up and cool-down
    activities appropriate for any exercise will also help the student
    with asthma. These preventive measures allow most students with
    asthma triggered by exercise to participate in any activity they
    choose.

-   Avoid outdoor exercise when pollen or pollution levels are high.\
     

-   Follow the student's treatment plan if it requires pre-medication
    before exercise.\
     

-   Know what to do if an [asthma
    episode](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=18)
    occurs during exercise. Have the child's [Asthma Action
    Plan](http://www.getasthmahelp.org/actionplan_components.asp) and
    medicine readily available.\
     

-   Encourage students with asthma to participate actively in sports,
    recognizing and respecting their limits. Know the [warning signs and
    symptoms](http://www.getasthmahelp.org/warning_signs.asp) for
    asthma. Permit less strenuous activities if a recent illness or
    asthma episode precludes full participation. When asthma is under
    good control, students are able to play most sports. Many Olympic
    and professional
    [athletes](http://www.getasthmahelp.org/kids_sports.asp#athletes)
    have asthma.\
     

-   Refer your questions about a student's ability to fully participate
    in physical education to the parents, school nurse and student's
    physician.

> **(d.) Counselors and Teachers**

-   Be a resource and point of contact to help all school personnel.
    Understand that asthma is not an emotional or psychological disease
    -- it is not "all in the child's head." Strong emotions such as
    laughing or crying can
    [trigger](http://www.getasthmahelp.org/asthma_triggers.asp) an acute
    episode because this irritates and constricts the sensitive airways
    of a person with asthma.\
      

-   Recognize that learning to cope with asthma, as with any
    [chronic](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=26)
    illness, can be difficult. Teachers may notice low self-esteem,
    withdrawal from activities, discouragement over the steps needed to
    control asthma, or difficulty making up schoolwork. Special
    counseling with the student and/or parents may help the student
    handle problems more effectively.\
     

-   Help the student feel more comfortable by acknowledging their
    feelings. Try to maintain confidentiality. Educate classmates about
    asthma so they will be more understanding and know when to get help
    from an adult. If you need help talking about asthma, contact your
    school nurse, local [asthma
    coalition](http://www.getasthmahelp.org/UserCoalitionList.asp) or
    regional [American Lung
    Association.](http://www.alam.org/Home_Page/Contact_Us/contact_us.asp)\
     

-   When counseling pregnant students that have asthma: convey the
    *extra* need at this time for good medical care and control of
    asthma.\
     

```{=html}
<!-- -->
```
-   Assist students with asthma to factor avoidance in curriculum:\
    \
    Vocational/technical track: many fumes, vapors, dusts may aggravate
    lung disease (*examples*: soldering, grain dusts, animal dander,
    detergent enzymes, wood dusts, chloride, diisocyantes, products of
    heated adhesives, second hand smoke)

-   Know which students have asthma.

-   Know the early [warning
    signs](http://www.getasthmahelp.org/warning_signs.asp) of an [asthma
    episode](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=18)
    or attack and how to respond. 

```{=html}
<!-- -->
```
-   Have a copy of the [Asthma Action
    Plan](http://www.getasthmahelp.org/actionplan_components.asp) in the
    classroom. Review it with the student, parents and appropriate
    school personnel. Understand that a student with asthma may feel:

    -   Drowsy or tired

    -   Different from the other kids

    -   Anxious about access to medications

    -   Embarrassed about the disruption to school activities that
        asthma symptoms can cause

```{=html}
<!-- -->
```
-   Know the possible side effects of asthma medications and how they
    may impact the student's performance in the classroom. Refer any
    problem to the school nurse or other appropriate school staff, and
    parent(s). Common side effects of medicine that warrant referral are
    nervousness, nausea, jitteriness, hyperactivity, and drowsiness.

```{=html}
<!-- -->
```
-   Reduce known allergens in the classroom to help students who have
    allergies and asthma. Common allergens found in classrooms include
    chalk dust, animals, and strong odors (perfumes, paints).

-   Encourage the student with asthma to participate in physical
    activities, but make sure they follow proper
    [precautions](http://www.getasthmahelp.org/asthma_exercise.asp).

-   Plants are sources of mold growth; reduce the quantity of plants in
    classroom. Do not cover up any vents in the classroom. This prevents
    fresh air from circulating into the room.

**(e.)** **Building Engineers and Custodians**

Preventive actions taken by the school maintenance staff can reduce
asthma
[triggers](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=69):

-   In some students, pollen can be an asthma trigger. Keep pollen
    levels down by limiting grass and plant trimming to after hours,
    closing windows when pollen or pollution levels are high and if
    possible, and installing air conditioning in all classrooms.\
     

-   Use cleaning solvents or fumigate when school is not in session.
    Maintenance supplies may give off air contaminants during use and
    storage. Products low in emissions, are preferable. However, a
    product that is low in emissions is not necessarily better if it is
    more hazardous. Learn about your maintenance supplies and identify
    precautions regarding effects on indoor air or ventilation rates and
    requirements. Examples of maintenance supplies that may contribute
    to indoor air quality (IAQ) problems include:

    -    Caulks

    -    Solvents

    -    Paints

    -    Adhesives

    -    Sealants

    -    Cleaning agents

```{=html}
<!-- -->
```
-   Cleaning classrooms on a regular basis helps to reduce the amount of
    dust and dirt in the school, including pollens and molds, which can
    cause allergic reactions. Whenever possible, use non-toxic and
    non-irritating cleaning substances.\
     

    -   Install barrier floor mats at each school entrance to reduce the
        amount of dirt and dust in the school. Mats should be cleaned
        daily.\
         

    -   Use High Efficiency Particulate Air (HEPA) vacuum bags that can
        retain dust and particles in the 3 micron size range or
        smaller.\
         

    -   Vacuum dust from heating, cooling, and ventilation air return
        grilles, air supply vents and ceiling and wall surfaces
        regularly to remove visible dust.

    -   

    -   Use a dust wiping technique that ensures the dust stays on the
        cloth. Avoid using a flicking motion when you wipe.\
         

    -   Clean all flooring, including vinyl, wood, terrazzo, tile and
        carpet daily. Remove spots and stains as soon as possible, using
        the flooring manufacturer's recommended techniques. Use care to
        prevent excess moisture or cleaning residue accumulation, and
        ensure that cleaned areas will dry quickly.

```{=html}
<!-- -->
```
-   Mold and mildew can grow almost anywhere that offers a food source
    and a small amount of moisture, whether from leaks and spills or
    condensation. Mold and mildew spark many allergic and asthmatic
    symptoms.\
     

    -   Inspect the building for signs of moisture, leaks or spills.
        Check for moldy odors, discoloration on ceilings, floors or
        walls, and signs of water damage. Also, check cold surfaces,
        such as under windows or in corners formed by exterior walls,
        and areas where moisture is generated, such as locker rooms.\
         

    -   Respond promptly to problems. Clean and dry damp or wet building
        materials and furnishings. Work with manufacturers of
        furnishings and building materials to learn recommended cleaning
        procedures and/or identify competent contractors who can clean
        damp materials.\
         

    -   Prevent moisture condensation by adding insulation near cold
        surfaces (piping, exterior walls, etc.), raising the temperature
        of the air, improving air circulation in problem areas, and
        decreasing the amount of water vapor in the air.

    ```{=html}
    <!-- -->
    ```
    -   Do not rely on widespread use of pesticides to control pests.
        Monitor and use [Integrated Pest Management
        (IPM)](http://www.epa.gov/pesticides/ipm) methods to control for
        cockroaches, mice and other pests. Pests can cause [asthma
        symptoms](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=21)
        in sensitive individuals.\
          

    -   If pesticides are used outdoors, do not apply near outdoor air
        intakes for the ventilation system, doors or open windows. If
        pesticides must be used, shut down the affected ventilation
        system(s) and remove occupants until application has been
        completed and ventilation has been restored.

```{=html}
<!-- -->
```
-   Drain traps can cause IAQ problems when water in the drain trap
    evaporates due to infrequent use. If the building interior is under
    negative pressure, soil gas or sewer gas can be drawn indoors
    through a dry drain trap.\
     

    -   Make sure all drains have drain traps, and make sure that all of
        the drains only you have access to are filled (pour about a
        quart of water down once per week, run water in sinks once per
        week).

    -   Check water in seldom-used toilets once each week, if low,
        flush.

-   Plants are sources of mold growth; reduce the quantity of plants in
    classroom. Do not cover up any vents in the classroom. This prevents
    fresh air from circulating into the room.

**(f.) Food Service Worker**

-   Maintain general cleanliness. A clean kitchen with food stored in
    secure containers discourages insects, rodents, and other pests.
    Integrated Pest Management (IPM) practices minimized the need for
    pesticides and discourage pests by eliminating the food sources,
    pathways, and shelter they need. Adhere to the state food safety
    program policy.\
     

-   The kitchen is often the busiest part of the school for deliveries.
    Because fans are exhausting air from the kitchen, air and exhaust
    from a nearby loading dock may be drawn into the kitchen. These
    exhaust fumes can be very irritating to those in the school with
    asthma. Post a sign prohibiting vehicles from idling their engines
    in the receiving area, and ask drivers to turn off their engines if
    they don't follow the sign's directions. In addition, smoking should
    not be allowed near receiving areas.\
     

-   Make sure that the ingredients in all foods served by the cafeteria
    are posted/published and/or have a complete ingredient list
    available for with food allergies.\
     

-   Other links that may be useful:\
    The Food Allergy & Anaphylaxis Network -
    [[http://www.foodallergy.org/guidelines.html]{.underline}](http://www.foodallergy.org/guidelines.html)\
                                                                 
    [[http://www.foodallergy.org/school.html]{.underline}](http://www.foodallergy.org/school.html)

**XIII. Success Story**

The Detroit Department of Health and Wellness Promotion-Center for
Asthma Education, Management and Policy (DHWP-CAEMP) addressed the
asthma issue in the Detroit Public School (DPS) by collaborating with
DPS' Coordinated School Health Council (CHSC) and the Environmental
Service Division. CHSC includes school nurses, physical education
department, parent organization, school-based health clinics, parent
liaisons and students. The school intervention includes DHWP-CAEMP
asthma management education in the schools with emphasis on identifying
and avoiding or reducing exposures to environmental asthma triggers. The
implementation of Environmental Protection Agency's (EPA) Tools for
Schools, and Indoor Air Quality assessments in schools were conducted by
the DPS' Environmental Health Service Division. Through successful
communication with DPS' Chief Executive Officer, DHWP-CAEMP had the
opportunity to present a workshop to over 240 principals and offer
asthma management workshops to each individual school. The workshop
enabled DHWP-CAEMP to introduce the asthma school packets. The asthma
school packets are a set of four booklets customized for principals,
teachers, administrative assistants, and custodians. The packet was
produced by the Asthma Imitative of Michigan a state collaborative
partner. DHWP is a member of the Detroit Alliance for Asthma Awareness
(Alliance), the asthma coalition for the City of Detroit. The coalition
consists of 45 member organizations and community people addressed the
asthma burden in Detroit through working with the Alliance members.
Several Alliance partners worked together to provide asthma education
and resources in schools. American Lung Association of Michigan -- *Open
Airways* in elementary schools, Angel Group-asthma education for
elementary schools, parents and staff, Asthma and Allergy Foundation of
America - *Power Breathing*™ for middle schools and Henry Ford Health
Systems - *Puff City* for high schools. The DHWP-CAEMP and the Alliance
involvement with DPS was important because only 30 out of the 240
schools have nurses on staff. As a result of our collaborative efforts,
the number of asthma emergency calls overall in the schools declined by
over 50% and was not limited to the schools with nurses. This model
demonstrates the effectiveness of pooling limited resources to improve
health outcomes, in this case, better management of asthma.

**XIV. Indoor Air Quality**

People with asthma have airways that are very twitchy or sensitive.
These airways may react to things that can (or cause) [asthma
symptoms](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=21).
When a person with asthma breathes in an asthma trigger, their airways
may swell up, tighten up, and produce too much
[mucus](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=49).
The person may then start to
[wheeze](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=73)
or cough, and may develop
[congestion](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=28),
itchy eyes, or a runny nose. Because of this, it is important for people
with asthma to find out what their asthma triggers are and learn ways to
control them.

Many different items in the indoor environment can be asthma triggers
and can affect people with asthma. It has been recognized that because
Americans spend so much time indoors - over 90% of the day is spent at
home, school, and/or work -- it is important that people with asthma
maintain healthy indoor environments and reduce exposures to indoor
asthma triggers. Not only can poor indoor air quality make the symptoms
of someone who already has asthma worse, but it may also play a role in
the development of asthma in more susceptible people, like small
children. In addition, some people with asthma may be more sensitive to
certain indoor air triggers than other people with asthma. To help you
find out what these asthma triggers are, people with asthma often keep a
written record of their activities. Writing down what they were doing,
and where, whenever there are symptoms will help to find out if being
near certain things causes the asthma symptoms. For example, if asthma
symptoms are worse when making the bed or vacuuming, dust mites may be a
trigger.

Indoor air triggers can be classified as either irritants or allergens.
*Irritants* include gases such as volatile organic compounds (voc) that
can aggravate the airways and cause inflammation. Irritants also include
small particles that can reach the lower regions of the respiratory
tract and cause inflammation. Examples of irritants include the
following:

-   Tobacco smoke, a well-documented respiratory tract irritant, can
    wheezing or an [asthma
    attack](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=17)
    in people with asthma. Smoke particles remain in the air long after
    the cigarette has been put out.  

-   Nitrogen dioxide (NO~2~) is a gas given off by indoor combustion
    appliances such as gas stoves and gas or kerosene space heaters. The
    presence of NO~2~ indoors may increase the risk of respiratory
    infections that can make asthma worse. 

-   Household dust includes a range of particles from smoke to pet
    [dander](http://www.getasthmahelp.org/UserGlossaryRecord.asp?gloID=30).
    Smaller particles remain airborne for longer periods, and therefore
    are more readily inhaled than larger particles that settle out more
    quickly onto floors, beds, countertops, and other surfaces. However,
    if particles are not routinely cleaned from heavy traffic areas or
    locations where air disturbances or currents occur, settled
    particles could become airborne again.

-   Chemical odors are given off from a wide variety of materials:
    paint, solvents, pesticides, adhesives, particleboard, vinyl
    flooring and tiles, dry-cleaned clothes, toner from photocopiers,
    and cleaning agents used in the home. These odors can an asthma
    attack in people with asthma.  

-   People with asthma may be quite sensitive to certain fragrances such
    as perfumes, scented detergents and soaps, personal deodorants, and
    room deodorizers.  

-   There are known causes of work-related asthma.

*Allergens* are materials that cause an immune-type reaction in people
who are sensitized to these materials. Allergens found in indoor air are
primarily biological material such as pet dander, cockroach and other
insect pest particles, pollen, bacteria, and mold. All of these
materials are small particles, can become airborne, and thus, are easily
inhaled. Allergens that are inhaled by sensitized people with asthma can
cause asthma attacks. For example, if you think about a group of people
with asthma, the presence of cat allergen could bring on an asthma
attack in people with cat allergies, but not in those people who do not
have cat allergies.

 Tobacco Smoke

Environmental tobacco smoke (ETS) or secondhand smoke is an irritant to
the eyes, nose, and throat, and can cause permanent damage to the lungs.
It may cause asthma attacks and respiratory infections to happen more
often, and may cause the development of asthma in children. Infants and
children are most vulnerable to ETS because their lungs are still
developing.

Mold  

Molds are fungi that appear as cottony tufts. Molds reproduce by making
and releasing spores, which range in size from 2 to 100 micrometers.
Spores become airborne when released by the mold or when disturbed
through physical contact. Certain molds may also contain substances
called mycotoxins that act as irritants in both allergic and
non-allergic people. Spores, mycotoxins, and other components can
trigger respiratory irritation. High humidity and dampness in the home
permit the growth of these microorganisms in heating, ventilating and
air conditioning systems (HVAC), dehumidifiers, condensate pans, damp
insulation, plaster/sheetrock, and carpets.

Cockroaches and Other Insect Pests

Waste products and rotting bodies from insect pests including
cockroaches are the source of many allergens. Cockroach allergens are
found in household dust and can become airborne. Studies have shown the
higher the concentration of cockroach allergen, the more asthma symptoms
children experience.

Pets

All warm-blooded pets, including dogs, cats, birds, and rodents, can
make asthma worse. Allergens from pet urine, dander, and saliva can
cause asthma symptoms and worsen lung function.

Dust Mites

Dust mites are tiny, microscopic spiders usually found in household
dust, bed linens, pillows, mattresses, and carpets and can trigger
asthma attacks. Dust mites grow well under humid conditions and several
thousand mites can be found in a pinch of dust.

Note: Resource websites are provided at the end of this document. For
people without access to the Internet, call the USEPA at 1-800-438-4318
to speak to an indoor air quality (IAQ) information specialist.

**XV. Outdoor Environmental Triggers**

Diesel exhaust from school buses, ozone, grass/trees on playgrounds,
pollen, mold, spores, and particulate matter are outdoor environmental
triggers that can be hazardous to health. Asthma attacks, respiratory
disease, heart attacks and premature death are all link to exposure to
pollution. The built environment (location of factories, incinerators,
living near freeways and other facilities) plays a major role in the
disproportionate impact of environmental pollution on human health and
contribute to asthma. To learn more about environmental pollution and
asthma visit [www.nbejn.org](http://www.nbejn.org/)

Montana State University, the United States Department of Agriculture
(USDA), and the United States Environmental Protection Agency (USEPA)
created a Microsoft PowerPoint presentation on asthma and outdoor asthma
triggers that can be seen on the following website:
[www.montana.edu/wwwcxair/](http://www.montana.edu/wwwcxair/).

**XVI.** **Resource Websites**

+-----------------------------------------------------------------------+
| American Academy of Pediatrics                                        |
|                                                                       |
| [www.aap.org](http://www.aap.org/)                                    |
|                                                                       |
| -   Advocacy                                                          |
|                                                                       |
| -   Publications                                                      |
|                                                                       |
| -   Services                                                          |
+-----------------------------------------------------------------------+
| ASMANET- Asthma on the net                                            |
|                                                                       |
| [www.asmanet.com](http://www.asmanet.com/)                            |
|                                                                       |
| AIM Public Awareness Tool Kit\                                        |
| [www.getasthmahelp.com](http://www.getasthmahelp.com/)                |
|                                                                       |
| 1-866-ezlungs(395-8647)                                               |
|                                                                       |
| Allergy & Asthma Network- Mother of Asthmatics\                       |
| 800-878-4403                                                          |
|                                                                       |
| -   Patient education                                                 |
|                                                                       |
| -   Patient support                                                   |
|                                                                       |
| -   News                                                              |
|                                                                       |
| American Academy for Allergy and Immunology                           |
|                                                                       |
| [www.aaaai.org](http://www.aaaai.org/)                                |
|                                                                       |
| 1-800-822-2762                                                        |
|                                                                       |
| -   Diagnosis                                                         |
|                                                                       |
| -   Treatment                                                         |
|                                                                       |
| -   Support organizations                                             |
|                                                                       |
| -   Resources                                                         |
|                                                                       |
| -   Section for kids                                                  |
|                                                                       |
| American College of Allergy, Asthma & Immunology\                     |
| Phone: 1-800-842-7777                                                 |
|                                                                       |
| [http://allergy.mcg.edu](http://allergy.mcg.edu/)                     |
|                                                                       |
| -   Toll free number for referral to an allergist                     |
|                                                                       |
| -   Booklets and other materials on allergies and asthma.             |
+-----------------------------------------------------------------------+
| American Lung Association                                             |
|                                                                       |
| [www.lungusa.org](http://www.lungusa.org/)                            |
|                                                                       |
| -   Pamphlets                                                         |
|                                                                       |
| -   Educational programs                                              |
|                                                                       |
| -   Fact sheets                                                       |
|                                                                       |
| -   Patient information                                               |
+-----------------------------------------------------------------------+
| Asthma and Allergy Foundation of America                              |
|                                                                       |
| [www.aaafa.org](http://www.aaafa.org/)                                |
|                                                                       |
| 1-800-727-8462                                                        |
|                                                                       |
| -   Education                                                         |
|                                                                       |
| -   Advocacy                                                          |
|                                                                       |
| -   Support groups                                                    |
|                                                                       |
| -   Resources                                                         |
+-----------------------------------------------------------------------+
| e-Asthma                                                              |
|                                                                       |
| [http://www.e-asthma.com](http://www.e-asthma.com/)                   |
|                                                                       |
| -   Improve quality of life                                           |
|                                                                       |
| -   Goals of asthma management                                        |
|                                                                       |
| -   Self education                                                    |
|                                                                       |
| -   Partnership with clinician                                        |
|                                                                       |
| The Foundation for Better Health Care -- Asthma Care Profile          |
|                                                                       |
| <http://fbhc.org/modules/asthma.cfm>                                  |
|                                                                       |
| -   Comprehensive overview of asthma for patients                     |
|                                                                       |
| -   Additional links                                                  |
|                                                                       |
| The National Asthma Education and Prevention Program (NAEPP) of       |
| National Heart, Lung, and Blood Institute (NHLBI)                     |
|                                                                       |
| [www.nhibi.nih.gov/health/pu                                          |
| blic/lung/asthma](http://www.nhibi.nih.gov/health/public/lung/asthma) |
|                                                                       |
| -   How asthma friendly is your school?                               |
|                                                                       |
| -   How asthma friendly is your childcare setting?                    |
|                                                                       |
| -   Asthma action plan                                                |
|                                                                       |
| -   Emergency protocol                                                |
|                                                                       |
| -   School Health Index -- A self assessment and planning guide       |
|                                                                       |
| School Asthma Allergy.com                                             |
|                                                                       |
| [http://schoolasthmaallergy.com](http://schoolasthmaallergy.com/)     |
|                                                                       |
| -   State specific information                                        |
|                                                                       |
| -   Respiratory guideline and programs                                |
|                                                                       |
| -   Teaching Tool Kit                                                 |
|                                                                       |
| -   Medications                                                       |
|                                                                       |
| -   Information for teachers, coaches, parents and kids               |
|                                                                       |
| -   Allergy information                                               |
|                                                                       |
| -   Smoking prevention                                                |
+-----------------------------------------------------------------------+

**XVII. Smoking Cessation Web Sites**

American Lung Association (Freedom from Smoking):
[www.lungusa.org](http://www.lungusa.org/)

Dr. Koop Online: [http://www.drkoop.com](http://www.drkoop.com/)
Massachusetts Department of Health:
[www.trytostop.org](http://www.trytostop.org/)

Mayo Clinic: <http://www.mayoclinic.org/nicotine-rst>

Smoke free Families (Pregnancy):
[www.smokefreefamilies.org](http://www.smokefreefamilies.org/)

**[Other Important Tobacco Links]{.underline}**  

Smoke Free Environments Law Project 
[[www.tcsg.org/sfelp/home.htm]{.underline}](http://www.tcsg.org/sfelp/home.htm)

American Lung Association 
[[www.lungusa.org/tobacco/]{.underline}](http://www.lungusa.org/tobacco/)

Environmental Protection Agency
[[www.epa.gov/smokefree/]{.underline}](http://www.epa.gov/smokefree/)

American Cancer Society
[[www.cancer.org/docroot/PED/ped_10_1.asp?sitearea=PED]{.underline}](http://www.cancer.org/docroot/PED/ped_10_1.asp?sitearea=PED)

Center for Disease Control and Prevention
[[www.cdc.gov/tobacco/]{.underline}](http://www.cdc.gov/tobacco/) Bus
Drivers

Campaign for Tobacco-Free Kids:
[www.tobaccofreekids.org](http://www.tobaccofreekids.org/)

[www.getasthmahelp.org](http://www.getasthmahelp.org/)