# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 24 {#section-1 .Chapter-#}

# Respiratory Diseases

Co-Lead Agencies: Centers for Disease Control and Prevention\
National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 24-3](#goal)

[Overview Page 24-3](#overview)

[Asthma Page 24-3](#asthma)

[Chronic Obstructive Pulmonary Disease Page
24-8](#chronic-obstructive-pulmonary-disease)

[Obstructive Sleep Apnea Page 24-10](#obstructive-sleep-apnea)

[Interim Progress Toward Year 2000 Objectives Page
24-11](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
24-12](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
24-13](#healthy-people-2010-objectives)

[Asthma Page 24-13](#asthma-1)

[Chronic Obstructive Pulmonary Disease Page
24-20](#chronic-obstructive-pulmonary-disease-1)

[Obstructive Sleep Apnea Page 24-22](#obstructive-sleep-apnea-1)

[Related Objectives From Other Focus Areas Page
24-23](#related-objectives-from-other-focus-areas)

[Terminology Page 24-24](#terminology)

[References Page 24-25](#references)

##  {#section-2 .unnumbered}

##   {#section-3 .unnumbered}

## Goal

Promote respiratory health through better prevention,\
detection, treatment, and education efforts.

## Overview

Asthma, chronic obstructive pulmonary disease (COPD), and obstructive
sleep apnea (OSA) are a significant public health burden to the United
States.[^1] Specific methods of detection, intervention, and treatment
exist that may reduce this burden. Several behaviors and diseases that
affect the respiratory system, such as tuberculosis, lung cancer,
acquired immunodeficiency syndrome (AIDS), pneumonia, occupational lung
disease, and smoking, are covered in other chapters. (See Focus Area 3.
Cancer, Focus Area 13. HIV, Focus Area 14. Immunization and Infectious
Diseases, Focus Area 20. Occupational Safety and Health, Focus Area 25.
Sexually Transmitted Diseases, and Focus Area 27. Tobacco Use.) Certain
other important respiratory diseases, such as respiratory distress
syndromes, sarcoidosis, and chronic sinusitis, which are difficult to
define, detect, prevent, or treat, are not discussed in this chapter.
Their omission, however, is not a reflection on the magnitude of the
health problems associated with them.

Asthma and COPD are among the 10 leading chronic conditions causing
restricted activity. After chronic sinusitis, asthma is the most common
cause of chronic illness in children.[^2] Methods are available to treat
these respiratory diseases and promote respiratory health.

### Asthma 

#### Issues and Trends

Asthma is a serious and growing health problem. An estimated 14.9
million persons in the United States have asthma.[^3] The number of
people with asthma increased by 102 percent between 1979--80 and
1993--94.[^4]

Asthma is responsible for about 500,000 hospitalizations,Error:
Reference source not found 5,000 deaths,Error: Reference source not
found and 134 million daysError: Reference source not found of
restricted activity a year. Yet most of the problems caused by asthma
could be averted if persons with asthma and their health care providers
managed the disease according to established guidelines. Effective
management of asthma comprises four major components: controlling
exposure to factors that trigger asthma episodes, adequately managing
asthma with medicine, monitoring the disease by using objective measures
of lung function, and educating asthma patients to become partners in
their own care.Error: Reference source not found**^,^** [^5] Such
prevention efforts are essential to interrupt the progression from
disease to functional limitation and disability and to improve the
quality of life for persons with asthma.

In 1996, asthma was the 10th most common principal diagnosis in
emergency department (ED) visits.Error: Reference source not found Among
diseases commonly seen in outpatient\
departments, asthma was the ninth most frequent diagnosis in 1996.[^6]
In 1995, some 9 million physician office visits were made for
asthma.Error: Reference source not found From 1990 to 1992, persons with
asthma spent an estimated 64 million days in bed because of asthma,
ranking asthma as the fourth highest chronic health condition.Error:
Reference source not found The proportion of people with asthma who are
limited in activity increased slightly from 19.4 percent in 1986--88 to
19.6 percent in
1994--96.[^7]![](media/image2.wmf){width="4.603472222222222in"
height="5.113888888888889in"}

Direct medical expenditures for asthma amounted to \$3.64 billion in
1990, and indirect economic losses accounted for an additional \$2.6
billion.[^8] Of direct medical care costs, approximately 57 percent was
spent on hospitalizations (\$1.6 billion), outpatient hospital visits
(\$190 million), and ED visits (\$295 million). Physician-related
services accounted for 14 percent of the total expenditures, including
\$347 million for outpatient services. Prescription medications
represented 30 percent of direct medical costs. Such facts highlight the
significant cost of hospital care for asthma, compared to the more
frequently used and less costly outpatient and pharmaceutical services.

Indirect costs---nonmedical economic losses such as days missed from
work or school, caregiver costs, travel and waiting time, early
retirement due to disability, and premature death---account for slightly
less than 50 percent of the total costs of asthma. Data suggest that the
uneven distribution of costs of asthma relates to nonscheduled acute or
emergency care, indicating poor asthma management and suboptimal
outcomes.[^9]**^,^** [^10]

Environmental and occupational factors contribute to illness and
disability from asthma. Decreases in lung function and a worsening of
asthma have been associated with exposure to allergens, indoor
pollutants (for example, tobacco smoke), and ambient air pollutants (for
example, ozone, sulfur dioxide, nitrogen dioxide, acid aerosols, and
particulate matter).[^11]**^,^** [^12] Approximately 25 percent of
children in the United States live in areas that exceed the Federal
Government's standard for ozone.[^13] Occupational factors cause or
trigger asthma episodes in 5 to 30 percent of adults with the
disease.[^14] Environmental factors are associated with upper
respiratory infections that contribute to illness and disability in
children and adults.[^15] (See Focus Area 8. Environmental Health.)

#### Disparities

Within the U.S. population, the health, economic, and social burdens of
asthma vary. Disproportionate rates of death, hospitalization, ED use,
and disability from asthma occur in certain age, gender, racial, and
ethnic groups.

While the number of adults with asthma is greater than the number of
children with asthma, the asthma rate is rising more rapidly in
preschool-aged children than in any other group.Error: Reference source
not found In 1995, the rate of self-reported asthma among children and
adolescents under age 18 years was 7.5 percent, compared to 5.7 percent
among the general population. The rates were higher in boys under age 18
years than in girls in the same age group. The rates of self-reported
asthma were higher for women (6.7 percent) than men (5.2 percent) and
higher for African Americans (6.7 percent) than whites (5.6
percent).Error: Reference source not found Among adults, women of all
races have higher rates of illness and death from asthma than men.[^16]

Death from asthma is two to six times more likely to occur among African
Americans and Hispanics than among whites.Error: Reference source not
found Although the number of deaths annually from asthma is low compared
to other chronic diseases, the death rate for children aged 5 to 14
years and young adults aged 15 to 34 years doubled from 1979--80 to
1993--95 (from 1.5 to 3.7 deaths per million children aged 5 to 14 years
and 2.8 to 6.3 deaths per million persons aged 15 to 34 years).Error:
Reference source not found In 1993--95, death rates are slightly higher
overall in women than in men.**^1^**

Rates of hospitalization for asthma demonstrate similar variations.
Rates for African Americans are almost triple those for whites. Rates
are higher among women than among men.Error: Reference source not found
Asthma hospitalization rates have increased dramatically among children
under age 5 years. From 1980 to 1993, the rate increased from 36 to 65
children hospitalized per 10,000 children under age 1 year. Some of this
increase may be related to changes in diagnostic practices and changes
in coding and reimbursement, but a large portion represents a true
increase in illness and disability.

In the inner city, patients frequently use EDs for asthma care. In 1993
and 1994, African Americans were four times more likely than whites to
visit an ED because of asthma.Error: Reference source not found Asthma
patients in general and high-risk inner-city patients---in particular,
those with a history of severe asthma who were hospitalized or visited
the ED for asthma within the previous 2 years---need to be able to
recognize the signs and symptoms of uncontrolled asthma and know how to
respond appropriately.

The economic burden of asthma disproportionately affects patients with
severe disease. Socioeconomic status, particularly poverty, appears to
be an important contributing factor to asthma illness, disability, and
death. In the United States, the rate of asthma cases for nonwhites is
only slightly higher than for whites, yet the death, hospitalization,
and ED-visit rates for nonwhites are more than twice those for
whites.Error: Reference source not found Although reasons for these
differences are unclear, they likely result from multiple factors: high
levels of exposure to environmental tobacco smoke, pollutants, and
environmental allergens (for example, house dust mites, cockroach
particles, cat and dog dander, and possibly rodent dander and mold); a
lack of access to quality medical care; and a lack of financial
resources and social support to manage the disease effectively on a
long-term basis.[^17] Research into the role of socioeconomic factors is
needed to identify additional prevention opportunities.

#### Opportunities

Scientific research has led to greater asthma control than was available
in the early 1980s.Error: Reference source not found Effective
management of asthma includes four components: avoiding or controlling
the factors that may make asthma worse (for example, environmental and
occupational allergens and irritants), taking appropriate medications
tailored to the severity of the disease, objective monitoring of the
disease by the patient and the health care professional, and actively
involving the patient in managing the disease.Error: Reference source
not found Effective asthma management reduces the need for
hospitalizations and urgent care visits (in either an ED or physician's
office) and enables patients to enjoy normal activities.[^18]**^,^**
[^19]

Advances in human genetics related to asthma are expected to provide
better information about the contribution of genetic variation to the
development of disease when people are exposed to certain environmental
factors and variation in individual response to therapy. The use of this
genetic information will improve targeted disease prevention and health
management strategies for respiratory diseases.

Patient education is one of four components of effective asthma
management.Error: Reference source not found Patients who are taught
asthma self-management skills are able to manage and control their
disease better than patients who do not receive education.Error:
Reference source not found Patients need to learn to work with health
care providers to optimize asthma care. Thus, both patients and health
care providers need to be trained and educated on effective asthma
management. Health outcomes for asthma---illness, disability, quality of
life, and death---are related directly to the actions of health care
professionals and patients. The National Asthma Education and Prevention
Program (NAEPP) provides guidelines for diagnosis and management that
should be incorporated into the curricula of health professional
schools.Error: Reference source not found**^,^** [^20] Currently, there
are no national data systems for tracking the training of health care
providers in asthma management. Therefore, the issue is not covered in
this focus area's objectives. It represents an important research and
data collection agenda for the coming decade. In addition, research to
identify the primary causes of development of asthma is a high priority.
Such research can provide a scientific basis for efforts to prevent the
development of asthma.

To control asthma effectively, asthma patients, particularly those on
daily medication, need an asthma action plan developed under their
physician's guidance. The plan spells out when and how to take medicines
correctly, as well as what to do when asthma worsens. The treatment of
persistent asthma emphasizes daily long-term therapy aimed at the
underlying inflammation and preventing symptoms, rather than relying
solely on treating symptoms with short-acting inhaled medication, such
as a beta agonist medication. Use of more than one canister of the
short-acting inhaled beta agonist medication per month is an indication
of uncontrolled asthma and the need to start or increase long-term
preventive therapy. Patients also need to work with health care
providers during followup visits, particularly after being hospitalized,
to make sure they understand and are able to follow the long-term
management plan.

Working with local community groups to mobilize community resources for
a comprehensive, culturally and linguistically competent approach to
controlling asthma among high-risk populations is a priority. From a
community-based perspective, States need to track occupational and
environmental factors that cause or trigger asthma episodes. Such
surveillance efforts should include collecting State-based data on the
proportion of the population with asthma and monitoring occupational and
environmental exposures and their impact on illness and disability
related to asthma. Efforts directed to improving the environmental
management of asthma also include reducing exposure to allergens and
irritants, such as environmental tobacco smoke, and outdoor air
pollution from ozone, sulfur dioxide, and particulate diesel matter.
(See Focus Area 8. Environmental Health.)

Professional organizations, lay volunteer groups, Federal agencies, and
the private sector have worked together and with NAEPP to implement a
spectrum of asthma programs at national and local community levels. For
example, numerous publications, media campaigns, and conferences target
various audiences. Intensified efforts are planned to reach primary care
providers, patients, and school personnel.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** A high-level work
group convened by the U.S. Department of Health and Human Services in
1997 assessed the most urgent needs for tackling the growing problem of
asthma. The work group's departmentwide strategic plan, Action Against
Asthma, identified opportunities and presented a coordinated approach
for improving asthma prevention and
management.**^Error:\ Reference\ source\ not\ found^**

### Chronic Obstructive Pulmonary Disease

#### Issues and Trends

COPD includes chronic bronchitis and emphysema---both of which are
characterized by irreversible airflow obstruction and often exist
together. Similar to asthma, COPD may be accompanied by an airway
hyperresponsiveness. Most patients with COPD have a history of cigarette
smoking. COPD worsens over time with continued exposure to a causative
agent---usually tobacco smoke or sometimes a substance in the workplace
or environment.

COPD occurs most often in older people. As much as 10 percent of the
population aged 65 years and older is estimated to have COPD.Error:
Reference source not found COPD has a major impact on health care,
illness, disability, and death in the older population, and the
magnitude of the problem is growing. Since 1980, the prevalence and
age-adjusted death rate for COPD increased more than 30 percent.Error:
Reference source not found**^,^** [^21]**^,^** [^22] Most of the
increase occurred in people over age 65 years. Taking into account the
expected aging of the U.S. population over the next 10 to 30 years as
well as the improved management of other smoking-related diseases, any
decline in the proportion of persons with COPD is unlikely without
substantial changes in risk factors, mainly reductions in cigarette
smoking. This is important for both men and women, given the modest
decline in cigarette smoking rates from 1990 to 1995.Error: Reference
source not found

Between 80 and 90 percent of COPD is attributable to cigarette smoking.
However, not all smokers develop COPD, and not all patients with COPD
are smokers or have smoked in the past.[^23]**^,^** [^24] Individual
susceptibility to the adverse health effects of cigarette smoke on the
lung appears to vary within the general population. Some 10 to 15
percent of smokers show a rate of decline in lung function that will
result in COPD with severe disability. Smoking cessation is the only
treatment that slows the decline. Susceptible smokers who stop smoking
do not regain lost lung function,[^25] but the rate of loss will return
to what is normal for a nonsmoker.

How cigarette smoking causes COPD is an active area of research. The
development of COPD---in particular, emphysema---is thought to be due to
a chemical imbalance in the lungs caused by cigarette smoke.[^26] In
some individuals, emphysema occurs because of a genetic deficiency.
Emphysema due to genetic deficiency, called familial emphysema, occurs
even in nonsmokers, but smoking hastens its occurrence. Familial
emphysema probably accounts for less than 5 percent of all cases of
COPD.[^27]

Smoking and occupational exposures together cause respiratory diseases
and lung cancer.[^28]**^,^** [^29] Miners, firefighters, metal workers,
grain handlers, cotton workers, paper mill workers, agricultural
workers, construction workers who handle cement, and others employed in
occupations associated with prolonged exposure to dusts, fumes, or gases
develop significant airflow obstruction, coughing, phlegm, dyspnea,
wheezing, and reduced lung function.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^30]

Population studies have shown that chronic exposure to air pollution has
an independent adverse effect on lung function.[^31]**^,^** [^32] A
multiyear study of the respiratory effects of long-term exposure to
environmental tobacco smoke and air pollution reported that both
long-term ozone and childhood exposure to maternal tobacco smoke were
associated with diminished lung function in college students.[^33] Viral
infections also may contribute to susceptibility to COPD, and they are
considered to play a role in the onset of airflow obstruction.

The direct costs of health care services and indirect costs through loss
of productivity related to COPD amounted to \$26 billion in 1998.Error:
Reference source not found About 14 million persons in the United States
have COPD---about 12.5 million have chronic bronchitis and 1.9 million
have emphysema.Error: Reference source not found Emphysema has not
increased, but since 1980, cases of chronic bronchitis increased 75
percent.Error: Reference source not found

Because national data systems will not be available in the first half of
the decade for tracking progress, two subjects of interest concerning
respiratory diseases are not addressed in this focus area's objectives.
The first topic addresses increasing the proportion of primary care
providers who are trained to provide culturally competent health
services to racial and ethnic groups seeking care for chronic
obstructive pulmonary disease. The second involves increasing the
proportion of primary care providers who are trained to use appropriate
lung function tests to recognize the early signs of chronic obstructive
pulmonary disease before the disease becomes serious and disabling.

#### Disparities 

Reliable statistics are not as available for COPD total cases, illness,
disability, or death in African Americans, Hispanics, and other ethnic
groups as for whites.[^34]**^,^** [^35] From 1982 to 1984, the
proportion of adults with COPD was 6.2 percent among whites and 3.2
percent among African Americans. In 1982, the age-adjusted COPD death
rate for whites was 16.6 deaths per 1,000 population and 12.8 deaths per
1,000 for African Americans. Among the Hispanic groups studied, Puerto
Ricans demonstrated a higher proportion of chronic bronchitis (2.9
percent) than Mexican Americans (1.7 percent) or Cuban Americans (1.7
percent).Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

In 1995, the proportion of the population with COPD was 5 percent in men
aged 45 to 64 years and 11 percent in men aged 65 years and older. The
proportion was 10 percent in women aged 45 to 64 years and 9 percent in
women aged 65 to 74 years.

Death from COPD is more common in men than in women, and the death rate
increases steeply with age.Error: Reference source not found**^,^**
[^36] Men and women have similar COPD death rates before age 55 years,
but the rate for men rises thereafter. At age 70 years, the rate for men
is more than double that for women, and at age 85 years and older, the
COPD death rate for men is 3.5 times that for women.[^37] The proportion
was 8 percent for whites aged 45 to 64 years and 10 percent for whites
aged 65 years and older. The proportion of African Americans with COPD
was 6 percent for those aged 45 to 64 years and 8 percent for those aged
65 years and older.Error: Reference source not found COPD death rates
were lower in the Hispanic groups than in non-Hispanic whites; however,
these rates have been increasing for Hispanics.Error: Reference source
not found

Women might be more susceptible than men to developing COPD when exposed
to risk factors such as tobacco smoke.[^38] The beneficial effects of
stopping smoking on the rate of lung function decline may be greater for
women than men.[^39]

#### Opportunities

Primary care physicians are in a key position to provide optimal care to
patients with COPD and to provide counseling during clinical or health
center visits to patients who smoke. Effective tests are available to
screen patients for COPD, and primary care physicians need to be trained
in the latest methods to detect and treat the disease.

### Obstructive Sleep Apnea

#### Issues and Trends

Some 18 million persons in the United States were estimated to have OSA
in 1993.[^40] OSA affects all races, ages, and socioeconomic and ethnic
groups.[^41] Because OSA causes serious disturbances in normal sleep
patterns, patients experience excessive daytime sleepiness and impaired
performance. Common consequences of OSA range from personality changes
and sexual dysfunction to falling asleep at work or while driving.Error:
Reference source not found**^,\ Error:\ Reference\ source\ not\ found^**

OSA symptoms include many repeated involuntary breathing pauses during
sleep. The breathing pauses often are accompanied by choking sensations
that may wake the patient. Other symptoms include intermittent snoring,
awakening from sleep (poor sleep), early morning headaches, and
excessive daytime sleepiness.

OSA can increase the seriousness of other lung diseases that decrease
airflow, such as asthma and COPD. Cardiovascular deaths alone due to OSA
have been estimated at 38,000 a year.**^40^** Individuals with OSA often
do not recognize reductions in alertness, diminished productivity, and
discord in interpersonal relationships as part of the syndrome. Persons
affected by OSA, for example, are seven times more likely to be involved
in multiple vehicular crashes.[^42] In children, OSA can disrupt sleep.
OSA also may cause daytime behavioral problems that affect workplace
performance and affect their learning ability in school.

Infants with siblings or parents who have OSA inherit an increased risk
of sudden infant death syndrome (SIDS).[^43] This tragic sleep-related
breathing disorder takes the lives of more infants than all other causes
combined.

#### Disparities

OSA is prevalent particularly in men over age 50 years and in
postmenopausal women, when hormonal changes appear to increase risk. The
risk of OSA also is increased in certain racial and ethnic groups. Among
young African Americans, the likelihood of experiencing OSA symptoms is
twice that of young whites.[^44] Nearly 50 percent of OSA patients have
high blood pressure.[^45]**^,^** [^46]**^,^** [^47]

#### Opportunities

A major factor in the pervasiveness of OSA's effects on health and
society has been the failure to educate people---and especially health
care practitioners---about the disorder. A wide range of behavioral,
mechanical, and surgical treatments can be used to manage OSA symptoms.
Providing persons at risk with culturally and linguistically appropriate
information about OSA could enable them to prevent or lessen the effects
of OSA. Improved awareness of OSA symptoms represents a major public
health challenge.

Primary care providers are an important barometer of OSA awareness
because they are a first stop for patients who are seeking appropriate
diagnosis and treatment. However, only 79 cases of sleep disorder were
diagnosed in a sample of 10 million patient records from 1989 and
1990.Error: Reference source not found In 1990 about a third of the
medical schools in the United States offered no training in sleep
medicine, and another third provided less than 2 hours on average for
all sleep topics.[^48] Data systems to track the training of health care
providers in OSA over the decade are not currently available, and
therefore the issue is not addressed in this focus area's objectives.
However, it represents an important research and data collection agenda.
In the absence of strong educational models for physicians, the risk
remains high that OSA will be misdiagnosed and mismanaged.

The National Commission on Sleep Disorders ResearchError: Reference
source not found was established by the U.S. Congress in 1988 to assess
the societal and economic impact of sleep disorders and the resources
available to promote the prevention, diagnosis, and treatment of such
disorders. In a 1994 report to Congress, the Commission concluded that
even though the science of sleep disorders is not fully developed, such
disorders can be prevented. The commission recommends that research on
the natural history of sleep disorders be made an urgent national
concern. Epidemiologic studies must be conducted to evaluate risk
factors that lead to sleep disorders and to determine which sleep
disorders lead to other serious health problems.

## Interim Progress Toward Year 2000 Objectives

For the three objectives specific to asthma in Healthy People 2000,
available data indicate movement away from the targets as the rate of
hospitalizations and activity limitation increase and movement toward
the target for increasing the proportion of persons with asthma who
receive patient education. There were no objectives in Healthy People
2000 for COPD and OSA.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Respiratory Diseases {#respiratory-diseases-1 .Heading-Special-Sub}

**Goal:** Promote respiratory health through better prevention,
detection, treatment, and education efforts.

  --------------- -------------------------------------------------------------
  **Number**      **Objective Short Title**

  **Asthma**      

  24-1            Deaths from asthma

  24-2            Hospitalizations for asthma

  24-3            Hospital emergency department visits for asthma

  24-4            Activity limitations

  24-5            School or work days lost

  24-6            Patient education

  24-7            Appropriate asthma care

  24-8            Surveillance systems

  **Chronic       
  Obstructive     
  Pulmonary       
  Disease         
  (COPD)**        

  24-9            Activity limitations due to chronic lung and breathing
                  problems

  24-10           Deaths from COPD

  **Obstructive   
  Sleep Apnea     
  (OSA)**         

  24-11           Medical evaluation and followup

  24-12           Vehicular crashes related to excessive sleepiness
  --------------- -------------------------------------------------------------

## Healthy People 2010 Objectives

### Asthma

24-1. Reduce asthma deaths.

Target and baseline:

+----------+-------------------------+---------------+---------------+
| O        | Age Group               | 1998 Baseline | 2010 Target   |
| bjective |                         |               |               |
+----------+-------------------------+---------------+---------------+
|          |                         | ####### Rat   |               |
|          |                         | e per Million |               |
+----------+-------------------------+---------------+---------------+
| **       | Children under age 5    | 2.1           | 1.0           |
| 24-1a.** | years                   |               |               |
+----------+-------------------------+---------------+---------------+
| **       | Children aged 5 to 14   | 3.3           | 1.0           |
| 24-1b.** | years                   |               |               |
+----------+-------------------------+---------------+---------------+
| **       | Adolescents and adults  | 5.0           | 2.0           |
| 24-1c.** | aged 15 to 34 years     |               |               |
+----------+-------------------------+---------------+---------------+
| **       | Adults aged 35 to 64    | 17.8          | 9.0           |
| 24-1d.** | years                   |               |               |
+----------+-------------------------+---------------+---------------+
| **       | Adults aged 65 years    | 86.3          | 60.0          |
| 24-1e.** | and older               |               |               |
+----------+-------------------------+---------------+---------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------+---------+--------+-------+--------+--------+
| **Select Age Groups,   | *       |        |       |        |        |
| 1998**                 | *Asthma |        |       |        |        |
|                        | D       |        |       |        |        |
|                        | eaths** |        |       |        |        |
+========================+=========+========+=======+========+========+
|                        | **      | **2    | **24  | **2    | **2    |
|                        | 24-1a.\ | 4-1b.\ | -1c.\ | 4-1d.\ | 4-1e.\ |
|                        | C       | Ch     | Ad    | Adults | Adults |
|                        | hildren | ildren | oles- | Aged\  | Aged\  |
|                        | Under   | Aged\  | cents | 35 to  | 65     |
|                        | Age 5   | 5 to   | and   | 64     | Years  |
|                        | Years** | 14     | A     | Y      | and    |
|                        |         | Y      | dults | ears** | O      |
|                        |         | ears** | Aged\ |        | lder** |
|                        |         |        | 15 to |        |        |
|                        |         |        | 34    |        |        |
|                        |         |        | Ye    |        |        |
|                        |         |        | ars** |        |        |
+------------------------+---------+--------+-------+--------+--------+
|                        | Rate    |        |       |        |        |
|                        | per     |        |       |        |        |
|                        | Million |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > **TOTAL**            | 2.1     | 3.3    | 5.0   | 17.8   | 86.3   |
+------------------------+---------+--------+-------+--------+--------+
| **Race and ethnicity** |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > American Indian or   | DSU     | DSU    | DSU   | DSU    | DSU    |
| > Alaska Native        |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Asian or Pacific     | DSU     | DSU    | DSU   | 12.8   | 136.9  |
| > Islander             |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Asian                | DNC     | DNC    | DNC   | DNC    | DNC    |
+------------------------+---------+--------+-------+--------+--------+
| > Native Hawaiian and  | DNC     | DNC    | DNC   | DNC    | DNC    |
| > other Pacific        |         |        |       |        |        |
| > Islander             |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Black or African\    | 8.1     | 9.7    | 16.6  | 52.3   | 130.4  |
| > American             |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > White                | DSU     | 2.0    | 3.0   | 13.3   | 81.1   |
+------------------------+---------+--------+-------+--------+--------+
|                        |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Hispanic or Latino   | DSU     | DSU    | 3.7   | 16.4   | 84.5   |
+------------------------+---------+--------+-------+--------+--------+
| > Not Hispanic or      | 2.1     | 3.5    | 6.9   | 17.8   | 86.2   |
| > Latino               |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Black or African     | 8.3     | 10.3   | 21.9  | 54.0   | 133.5  |
| > American             |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > White                | DSU     | 2.0    | 3.9   | 12.8   | 80.6   |
+------------------------+---------+--------+-------+--------+--------+
| **Gender**             |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Female               | 1.4     | 2.7    | 4.3   | 22.3   | 99.1   |
+------------------------+---------+--------+-------+--------+--------+
| > Male                 | 2.8     | 4.0    | 5.7   | 13.0   | 68.1   |
+------------------------+---------+--------+-------+--------+--------+
| **Education** (aged 25 |         |        |       |        |        |
| to 64 years)           |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > Less than high       | NA      | NA     | 1     | 31.0   | NA     |
| > school               |         |        | 0.0\* |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > High school graduate | NA      | NA     | 1     | 22.9   | NA     |
|                        |         |        | 1.4\* |        |        |
+------------------------+---------+--------+-------+--------+--------+
| > At least some        | NA      | NA     | 3.9\* | 9.3    | NA     |
| > college              |         |        |       |        |        |
+------------------------+---------+--------+-------+--------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

\*Data are for persons aged 25 to 34 years.

Note: The table above may have continued from the previous page.

24-2. Reduce hospitalizations for asthma.

Target and baseline:

+--------+---------------------------------+-------------+-------------+
| Obj    | Age Group                       | 1998        | 2010 Target |
| ective |                                 | Baseline    |             |
+--------+---------------------------------+-------------+-------------+
|        |                                 | #           |             |
|        |                                 | ###### Rate |             |
|        |                                 |  per 10,000 |             |
+--------+---------------------------------+-------------+-------------+
| **24   | Children under age 5 years      | 45.6        | 25          |
| -2a.** |                                 |             |             |
+--------+---------------------------------+-------------+-------------+
| **24   | Children and adults aged 5 to   | 12.5        | 7.7         |
| -2b.** | 64 years\*                      |             |             |
+--------+---------------------------------+-------------+-------------+
| **24   | Adults aged 65 years and        | 17.7        | 11          |
| -2c.** | older\*                         |             |             |
+--------+---------------------------------+-------------+-------------+

\*Age adjusted to the year 2000 standard population.

**Target setting method:** Better than the best.

**Data source:** National Hospital Discharge Survey (NHDS), CDC, NCHS.

+---------------------------------+------------+-----------+-----------+
| **Select Age Groups, 1998**     | **Asthma   |           |           |
|                                 | Hospital   |           |           |
|                                 | izations** |           |           |
+=================================+============+===========+===========+
|                                 | **24-2a.\  | **24-2b.\ | **24-2c.\ |
|                                 | Children   | Children  | Adults    |
|                                 | Under Age  | and       | Aged 65   |
|                                 | 5 Years**  | Adults    | Years and |
|                                 |            | Aged 5 to | Older\*** |
|                                 |            | 64        |           |
|                                 |            | Years\*** |           |
+---------------------------------+------------+-----------+-----------+
|                                 | Rate per   |           |           |
|                                 | 10,000     |           |           |
+---------------------------------+------------+-----------+-----------+
| > **TOTAL**                     | 45.6       | 12.5      | 17.7      |
+---------------------------------+------------+-----------+-----------+
| **Race and ethnicity**          |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > American Indian or Alaska     | DSU        | DSU       | DSU       |
| > Native                        |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Asian or Pacific Islander     | DSU        | DSU       | DSU       |
+---------------------------------+------------+-----------+-----------+
| > Asian                         | DNC        | DNC       | DNC       |
+---------------------------------+------------+-----------+-----------+
| > Native Hawaiian and other     | DNC        | DNC       | DNC       |
| > Pacific Islander              |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Black or African American     | 82.4       | 28.4      | 27.3      |
+---------------------------------+------------+-----------+-----------+
| > White                         | 29.5       | 7.8       | 12.4      |
+---------------------------------+------------+-----------+-----------+
|                                 |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Hispanic or Latino            | DSU        | DSU       | DSU       |
+---------------------------------+------------+-----------+-----------+
| > Not Hispanic or Latino        | DSU        | DSU       | DSU       |
+---------------------------------+------------+-----------+-----------+
| > Black or African American     | DSU        | DSU       | DSU       |
+---------------------------------+------------+-----------+-----------+
| > White                         | DSU        | DSU       | DSU       |
+---------------------------------+------------+-----------+-----------+
| **Gender**                      |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Female                        | 33.1       | 15.9      | 24.6      |
+---------------------------------+------------+-----------+-----------+
| > Male                          | 57.6       | 9.0       | 8.5       |
+---------------------------------+------------+-----------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Age adjusted to the year 2000 standard population.

24-3. Reduce hospital emergency department visits for asthma.

Target and baseline:

+----------+----------------------+-----------------+-----------------+
| O        | Age Group            | 1995--97        | 2010 Target     |
| bjective |                      | Baseline        |                 |
+----------+----------------------+-----------------+-----------------+
|          |                      | #######         |                 |
|          |                      | Rate per 10,000 |                 |
+----------+----------------------+-----------------+-----------------+
| **       | Children under age 5 | 150.0           | 80              |
| 24-3a.** | years                |                 |                 |
+----------+----------------------+-----------------+-----------------+
| **       | Children and adults  | 71.1            | 50              |
| 24-3b.** | aged 5 to 64 years   |                 |                 |
+----------+----------------------+-----------------+-----------------+
| **       | Adults aged 65 years | 29.5            | 15              |
| 24-3c.** | and older            |                 |                 |
+----------+----------------------+-----------------+-----------------+

**Target setting method:** Better than the best.

**Data source:** National Hospital Ambulatory Medical Care Survey
(NHAMCS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------+-------------+------------+------------+
| **Select Age Groups,         | **Hospital  |            |            |
| 1995--97**                   | Emergency   |            |            |
|                              | Department\ |            |            |
|                              | Visits for  |            |            |
|                              | Asthma**    |            |            |
+==============================+=============+============+============+
|                              | **24-3a.\   | **24-3b.\  | **24-3c.\  |
|                              | Children\   | Children   | Adults     |
|                              | Under Age 5 | and Adults | Aged 65    |
|                              | Years**     | Aged 5 to  | Years and  |
|                              |             | 64 Years** | Older**    |
+------------------------------+-------------+------------+------------+
|                              | Rate per    |            |            |
|                              | 10,000      |            |            |
+------------------------------+-------------+------------+------------+
| > **TOTAL**                  | 150.0       | 71.1       | 29.5       |
+------------------------------+-------------+------------+------------+
| **Race and ethnicity**       |             |            |            |
+------------------------------+-------------+------------+------------+
| > American Indian or Alaska  | DSU         | DSU        | DSU        |
| > Native                     |             |            |            |
+------------------------------+-------------+------------+------------+
| > Asian or Pacific Islander  | DSU         | DSU        | DSU        |
+------------------------------+-------------+------------+------------+
| > Asian                      | DNC         | DNC        | DNC        |
+------------------------------+-------------+------------+------------+
| > Native Hawaiian and other  | DNC         | DNC        | DNC        |
| > Pacific Islander           |             |            |            |
+------------------------------+-------------+------------+------------+
| > Black or African American  | 407.2       | 191.7      | 90.8       |
+------------------------------+-------------+------------+------------+
| > White                      | 101.7       | 53.4       | 23.1       |
+------------------------------+-------------+------------+------------+
|                              |             |            |            |
+------------------------------+-------------+------------+------------+
| > Hispanic or Latino         | DSU         | DSU        | DSU        |
+------------------------------+-------------+------------+------------+
| > Not Hispanic or Latino     | DSU         | DSU        | DSU        |
+------------------------------+-------------+------------+------------+
| > Black or African American  | DSU         | DSU        | DSU        |
+------------------------------+-------------+------------+------------+
| > White                      | DSU         | DSU        | DSU        |
+------------------------------+-------------+------------+------------+
| ###### Gender                |             |            |            |
+------------------------------+-------------+------------+------------+
| > Female                     | 103.0       | 83.6       | 37.8       |
+------------------------------+-------------+------------+------------+
| > Male                       | 195.5       | 57.9       | 17.9       |
+------------------------------+-------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

24-4. Reduce activity limitations among persons with asthma.

**Target:** 10 percent.

**Baseline:** 20 percent of persons with asthma experienced activity
limitations in activity in 1994--96 (age adjusted to the year 2000
standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons With Asthma, 1994--96**              | **Experienced\      |
|                                                | Activity\           |
|                                                | Limitations**       |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 20                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 26                  |
+------------------------------------------------+---------------------+
| > White                                        | 18                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 22                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 19                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 26                  |
+------------------------------------------------+---------------------+
| > White                                        | 18                  |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 21                  |
+------------------------------------------------+---------------------+
| > Male                                         | 17                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 28                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 20                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 16                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

24-5. (Developmental) Reduce the number of school or work days missed by
persons with asthma due to asthma.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

24-6. Increase the proportion of persons with asthma who\
receive formal patient education, including information about community
and self-help resources, as an essential part of the management of their
condition.

**Target:** 30 percent.

**Baseline:** 8.4 percent of persons with asthma received formal patient
education in 1998 (age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons With Asthma, 1998**                  | **Received Patient  |
|                                                | Education**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 8.4                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 11.2                |
+------------------------------------------------+---------------------+
| > White                                        | 7.8                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 7.8                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 8.4                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 11.3                |
+------------------------------------------------+---------------------+
| > White                                        | 7.9                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 9.1                 |
+------------------------------------------------+---------------------+
| > Male                                         | 7.1                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 7.2                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 10.3                |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 8.4                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

24-7. (Developmental) Increase the proportion of persons with asthma who
receive appropriate asthma care according\
to the NAEPP Guidelines.

**24-7a.** Persons with asthma who receive written asthma management
plans from their health care provider.

**24-7b.** Persons with asthma with prescribed inhalers who receive
instruction on how to use them properly.

**24-7c.** Persons with asthma who receive education about recognizing
early signs and symptoms of asthma episodes and how to respond
appropriately, including instruction on peak flow monitoring for those
who use daily therapy.

**24-7d.** Persons with asthma who receive medication regimens that
prevent the need for more than one canister of short-acting inhaled beta
agonists per month for relief of symptoms.

**24-7e.** Persons with asthma who receive followup medical care for
long-term management of asthma after any hospitalization due to asthma.

**24-7f.** Persons with asthma who receive assistance with assessing and
reducing exposure to environmental risk factors in their home, school,
and work environments.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS**.**

24-8. (Developmental) Establish in at least 25 States a surveillance
system for tracking asthma death, illness, disability, impact of
occupational and environmental factors on asthma, access to medical
care, and asthma management.

**Potential data sources:** Periodic surveys, Council of State and
Territorial\
Epidemiologists and Public Health Foundation; Association of Schools of
Public Health.

### Chronic Obstructive Pulmonary Disease

24-9. Reduce the proportion of adults whose activity is limited due to
chronic lung and breathing problems.

**Target:** 1.5 percent.

**Baseline:** 2.2 percent of adults aged 45 years and older experienced
activity limitations due to chronic lung and breathing problems in 1997
(age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 45 Years and Older, 1997**       | **Experienced\      |
|                                                | Activity\           |
|                                                | Limitations Due to  |
|                                                | Chronic Lung and    |
|                                                | Breathing\          |
|                                                | Problems**          |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 2.2                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 2.3                 |
+------------------------------------------------+---------------------+
| > White                                        | 2.3                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 1.7                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 2.3                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 2.2                 |
+------------------------------------------------+---------------------+
| > White                                        | 2.3                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 2.1                 |
+------------------------------------------------+---------------------+
| > Aged 45 to 64 years                          | 1.6                 |
+------------------------------------------------+---------------------+
| > Aged 65 years and older                      | 3.0                 |
+------------------------------------------------+---------------------+
| > Male                                         | 2.5                 |
+------------------------------------------------+---------------------+
| > Aged 45 to 64 years                          | 1.6                 |
+------------------------------------------------+---------------------+
| > Aged 65 years and older                      | 4.1                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 5.2                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 4.0                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 1.8                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

24-10. Reduce deaths from chronic obstructive pulmonary\
disease (COPD) among adults.

**Target:** 60 deaths per 100,000 adults.

**Baseline:** 119.4 deaths from COPD per 100,000 persons aged 45 years
and older occurred in 1998 (age adjusted to the year 2000 standard
population).

**Target setting method:** 50 percent improvement.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS*.*

+------------------------------------------------+---------------------+
| **Adults Aged 45 Years and Older, 1998**       | **Chronic\          |
|                                                | Obstructive\        |
|                                                | Pulmonary\          |
|                                                | Disease Deaths**    |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 119.4               |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 79.6                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 48.6                |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 85.3                |
+------------------------------------------------+---------------------+
| > White                                        | 124.3               |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 52.5                |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 122.8               |
+------------------------------------------------+---------------------+
| > Black or African American                    | 87.2                |
+------------------------------------------------+---------------------+
| > White                                        | 127.9               |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 98.8                |
+------------------------------------------------+---------------------+
| > Male                                         | 153.7               |
+------------------------------------------------+---------------------+
| **Education** (aged 25 to 64 years)            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 19.7                |
+------------------------------------------------+---------------------+
| > High school graduate                         | 12.5                |
+------------------------------------------------+---------------------+
| > At least some college                        | 4.4                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

### Obstructive Sleep Apnea

24-11. (Developmental) Increase the proportion of persons with symptoms
of obstructive sleep apnea whose condition is medically managed.

**24-11a.** Persons with excessive daytime sleepiness, loud snoring, and
other signs associated with obstructive sleep apnea who seek medical
evaluation.

**24-11b.** Persons with excessive daytime sleepiness, loud snoring, and
other signs associated with obstructive sleep apnea who receive followup
medical care for long-term management of their condition.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

24-12. (Developmental) Reduce the proportion of vehicular crashes caused
by persons with excessive sleepiness.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS. Fatality Analysis Reporting System (FARS), U.S. Department of
Transportation, National Highway Traffic Safety Administration.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-10. Delay or difficulty in getting emergency care

7\. Educational and Community-Based Programs

7-8. Satisfaction with patient education

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

8\. Environmental Health

8-1. Harmful air pollutants

8-2. Alternative modes of transportation

8-3. Cleaner alternative fuels

8-4. Airborne toxins

8-14. Toxic pollutants

8-16. Indoor allergens

8-17. Office building air quality

8-20. School policies to protect against environmental hazards

8-23. Substandard housing

8-26. Information systems used for environmental health

8-27. Monitoring environmentally related diseases

8-28. Local agencies using surveillance data for vector control

11\. Health Communication

11-6. Satisfaction with health care providers' communication skills

15\. Injury and Violence Prevention

15-15. Deaths from motor vehicle crashes

15-17. Nonfatal motor vehicle injuries

20\. Occupational Safety and Health

20-1. Work-related injury deaths

20-2. Work-related injuries

20-4. Pneumoconiosis deaths

22\. Physical Activity and Fitness

22-6. Moderate physical activity in adolescents

22-7. Vigorous physical activity in adolescents

23\. Public Health Infrastructure

23-2. Public access to information and surveillance data

23-4. Data for all population groups

23-6. National tracking of Healthy People 2010 objectives

23-7. Timely release of data on objectives

23-10. Continuing education and training by public health agencies

23-16. Data on public health expenditures

23-17. Population-based prevention research

27\. Tobacco Use

27-1. Adult tobacco use

27-2. Adolescent tobacco use

27-3. Initiation of tobacco use

27-4. Age at first tobacco use

27-5. Smoking cessation by adults

27-6. Smoking cessation during pregnancy

27-7. Smoking cessation by adolescents

27-8. Insurance coverage of cessation treatment

27-9. Exposure to tobacco smoke at home among children

27-10. Exposure to environmental tobacco smoke

27-11. Smoke-free and tobacco-free schools

27-12. Worksite smoking policies

27-13. Smoke-free indoor air laws

27-14. Enforcement of illegal tobacco sales to minors laws

27-15. Retail license suspension for sales to minors

27-16. Tobacco advertising and promotion targeting adolescents and young
adults

27-17. Adolescent disapproval of smoking

27-18. Tobacco control programs

27-19. Preemptive tobacco control laws

27-20. Tobacco product regulation

27-21. Tobacco tax

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Ambulatory care:** Medical care provided at hospital emergency and
outpatient departments.

**Asthma:** A lung disease characterized by airway constriction, mucus
secretion, and chronic inflammation, resulting in reduced airflow and
wheezing, coughing, chest tightness, and difficulty breathing.

**Chronic bronchitis:** A lung disease characterized by the presence of
chronic productive cough most days for 3 months in each of 2 successive
years.

**Chronic obstructive pulmonary disease (COPD):** A lung disease
characterized by airflow obstruction due to chronic bronchitis and
emphysema, two diseases that often occur together. COPD is one of the
most common respiratory conditions among adults worldwide and is the
fourth leading cause of death in the United States.

**Dyspnea:** Shortness of breath.

**Emphysema:** Abnormal permanent enlargement of the airspaces in the
lungs accompanied by coughing and difficulty breathing.

**Epidemiologic studies:** Studies of disease occurrence.

**Obstructive sleep apnea (OSA):** An illness characterized by snoring,
partial or complete cessation of breathing during sleep, reductions in
blood oxygen levels, severe sleep disruptions, and excessive daytime
sleepiness. OSA is a chronic breathing problem with serious effects on
individual health and productivity, including an inheritable risk of
sudden infant deaths, behavior and learning disturbances, injury from
accidents, and reduced quality of life.

**Rate:** The basic measure of disease occurrence that most clearly
expresses the probability of risk of disease in a defined population
over a specified period of time. A rate is defined as:

> [Number of events]{.underline}
>
> Population at risk

## References

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[^2]: Benson, V., and Marano, M.A. Current estimates from the National
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[^3]: National Heart, Lung, and Blood Institute (NHLBI). *Data Fact
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[^4]: National Center for Health Statistics (NCHS). Current estimates
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[^5]: National Asthma Education and Prevention Program. *Expert Panel
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[^6]: NCHS. Ambulatory care visits to physicians' offices, hospital
    outpatient departments, and emergency departments: United States,
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[^7]: NCHS. *Healthy People 2000 Review, 1998--99.* Hyattsville, MD:
    PHS, 1999.

[^8]: Weiss, K.B.; Gergen, P.J.; and Hodgson, T.A. An economic
    evaluation of asthma in the United States. *New England Journal of
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[^9]: Sullivan, S.; Elixhauser, S.; Buist, A.S.; et al. National Asthma
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[^10]: Glaxco Canada. *The Costs of Asthma in Canada.* Princeton, NJ:
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[^11]: Koren, H.S. Environmental risk factors in atopic asthma.
    *International Archives of Allergy and Immunology* 113:65-68, 1997.

[^12]: Becklake, M.R., and Ernst, P. Environmental factors. *Lancet*
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[^13]: Office of Air Quality Planning and Standards, U.S. Environmental
    Protection Agency (EPA). *National Air Quality and Emissions
    Report*, *1997*. CPA Pub. No. EPA 454/R-98-016. Research Triangle
    Park, NC: EPA, 1998.

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