Number 381 + December 12, 2006 Revised as of December 29, 2006

The State of Childhood Asthma, United States,

1980–2005

By Lara J. Akinbami, M.D., Office of Analysis and Epidemiology

Introduction

Millions of children in the United

States are affected by asthma, a chronic

respiratory disease characterized by

attacks of difficulty breathing. An

asthma attack is a distressing and

potentially life-threatening experience.

Scientific advances have greatly

improved the understanding of the

mechanisms that cause asthma attacks

and have led to effective medical

interventions to prevent morbidity and

improve quality of life (1). Yet, the

burden in prevalence, health care use,

and mortality remains high. Asthma

remains a significant public health

problem in the United States.

Keywords: childhood asthma c

prevalence c health care use c mortality

Trend

+ Asthma prevalence rates among

children remain at historically high

levels following dramatic increases

MT 

WY 

ID 

WA 

OR 

NV 

UT 

CA 

AZ 

ND 

SD 

NE 

CO 

NM 

TX 

OK 

KS 

AR 

LA 

MO 

IA 

MN 

WI 

IL IN 

KY 

TN 

MS AL GA 

FL 

SC 

NC 

VA WV 

OH 

MI 

NY 

PA 

MD 

DE 

NJ 

CT RI 

MA 

ME 

VT 

NH 

AK 

HI 

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VA WV

OH

MI

NY

PA

MD

DE

NJ

CT RI

MA

ME

VT

NH

AK

HI

DC 

4.4 - 7.8 percent 

7.9 - 8.5 percent 

8.6 - 9.7 percent 

Over 9.8 percent 

Data not reliable 

NOTES: Ranges are based on approximate quartiles among states with available estimates. Differences portrayed in this 

map should be interpreted with caution. The 95 percent confidence intervals for many states overlap. Current asthma 

prevalence estimates are based on the questions “Has a doctor or other health professional ever told you that {child's 

name} had asthma?" and “Does {child’s name} still have asthma?” Estimates for Delaware, the District of Columbia, 

Mississippi, Nebraska, Nevada, and New Hampshire have a relative standard error greater than 30 percent and less than or 

equal to 50 percent and should be interpreted with caution as they do not meet the standard of reliability or precision. The 

estimates for Alaska, Idaho, Maine, Montana, North Dakota, South Dakota, Vermont, West Virginia, and Wyoming have a 

relative standard error greater than 50 percent and therefore are not represented in this figure. 

SOURCE: CDC/NCHS, National Health Interview Survey. 

from 1980 until the late 1990s.

+ Despite the plateau in asthma

prevalence, ambulatory care for

asthma use has continued to grow

since 2000.

+ Since 1992, when data first became

available, the rate of emergency

department visits for asthma has

remained relatively stable.

Figure 1. Current asthma prevalence among children 0–17 years of age, by state, annual

average for the period 2001–2005

Current asthma prevalence rates are generally higher in the Northeast region

(Figure 1). While it is tempting to attribute prevalence patterns to climate or air

quality, many factors affect prevalence and may also vary by region. Some

examples include the likelihood that symptomatic children are diagnosed accurately

with asthma (2), and population composition. For example, the Puerto Rican

population, in which asthma prevalence is highest, tends to be concentrated in the

Northeast region of the country (3).

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
2 Advance Data No. 381 + December 12, 2006

+ Hospitalization rates for asthma have

followed a trend similar to those in

asthma prevalence rates since 1980 and

also remain at historically high levels.

+ Asthma death rates appear to have

declined recently following a rising

trend from 1980 through the mid1990s.

Recent patterns by age and

race/ethnicity

+ Asthma prevalence increases with

age, but health care use is highest

among the youngest children. Boys

have higher prevalence and death

rates compared with girls throughout

childhood.

+ Non-Hispanic black and Puerto Rican

children have higher prevalence rates

compared to non-Hispanic white

children. Moreover, rates in adverse

outcomes such as emergency

department visits, hospitalizations,

and death are substantially higher for

black children. The disparity in

asthma mortality between black and

white children has increased in recent

years.

The national picture of

childhood asthma

A major frustration in fighting

asthma is the mystery of its

development. It remains unknown why

some people get the disease and others

do not. Research has identified several

factors associated with the development

of asthma, but none have proven to be

the causative agent. Asthma is

characterized by episodes or attacks of

inflammation and narrowing of small

airways. Symptoms can include

shortness of breath, cough, wheezing,

and chest pain or tightness, and are

triggered by a variety of things such as

allergens (e.g., pollen, dust mites,

animal dander, etc.), infections, exercise,

changes in the weather, and exposure to

airway irritants (e.g., tobacco smoke).

Some people have mild asthma; others

have severe and life-threatening attacks;

and some people may have attacks

ranging from mild to severe (4). People

develop asthma at different stages of

their lives, and many subsequently cease

to have any symptoms (5). Most likely,

the disease known as asthma is a

spectrum of conditions, and likewise,

the causes of asthma are a complex

interaction of different factors. A

constellation of causes is likely to

gradually emerge.

Asthma is a priority for the

research, medical, environmental, and

public health communities because:

+ Asthma is one of the leading chronic

childhood diseases in the United

States (6) and a major cause of

childhood disability (7).

+ Asthma places a huge burden on

affected children and their families:

asthma may limit a child’s ability to

play, learn, and sleep; necessitates

potentially complex and expensive

interventions (8); and results in both

direct medical costs and indirect costs

(e.g., missed school days and work

days).

+ Childhood asthma prevalence more

than doubled from 1980 to the

mid-1990s (9;10) and remains at

historically high levels. The factors

driving this pattern are still not fully

understood.

+ The causes of asthma remain unclear

and current research paints a complex

picture (5).

+ Although there are means to prevent

attacks or exacerbations among

children with asthma (1), the majority

of children with asthma still suffer

from attacks (11).

+ The burden of avoidable emergency

department visits and hospitalizations

for asthma is high and has remained

relatively resistant to intervention

efforts (9,11).

+ Evidence of the impact of the

environment on asthma incidence and

morbidity—especially allergens and

irritants such as cigarette smoke and

outdoor pollutants—has been

mounting (12).

This brief report presents overall trends

in childhood asthma over the past two

decades and examines the burden of

asthma through each stage of childhood

and among children of different race

and ethnic groups. While data for

prevalence, health care use, and

mortality are major indicators of the

impact of asthma on children, asthma

symptoms that are unrecognized or not

severe enough to warrant emergency

care or hospitalization can still lower

quality of life. Part of recent efforts to

address the burden of asthma involves

developing methods to track symptoms

and disease management. When

available, these new sources of data will

provide greater insight into the burden

of asthma and the impact of intervention

efforts.
Advance Data No. 381 + December 12, 2006 3

Asthma prevalence rates

among children remain at

historically high levels

following dramatic increases

from 1980 until the late 1990s

Currently, there are no national

measures of asthma incidence, or the

rate at which people develop asthma

over a period of time. Instead, we focus

on asthma prevalence, the percentage of

the population that has asthma at a

given point in time, and thus face the

risk of suffering symptoms and adverse

effects of the disease. Prevalence is

important as it identifies the population

in need of effective measures to control

asthma symptoms. Figure 2 shows the

trend in asthma prevalence since

1980. The major tracking system for

asthma prevalence is the National

Health Interview Survey (NHIS), which

is used to produce annual health

estimates based on self report of a

nationally representative sample. From

1980 to 1996, the NHIS measured

asthma period prevalence, that is, the

percentage of people with asthma in the

past 12 months. In 1997, the NHIS

questionnaire was redesigned. Starting

in 1997, asthma prevalence estimates are

based on receiving an asthma diagnosis,

currently having the disease at the time

of the interview, and experiencing an

attack in the past year. The new

measure that is most similar to the

previous measure of asthma period

prevalence is current asthma

prevalence—the percentage of children

with asthma at the time of the health

interview. An analysis of NHIS data

before and after the 1997 redesign

indicates that if the redesign had not

been undertaken, the period prevalence

measurements would show a plateau in

the late 1990s (13). That is, most of the

apparent jump between the 1996 asthma

period prevalence estimate from the old

NHIS and the 2001 current asthma

prevalence estimate is likely attributable

to the change in the NHIS questionnaire,

and not a substantial change in

prevalence.

Asthma period prevalence 

Lifetime asthma diagnosis 

Asthma attack prevalence 

Current asthma prevalence 

Survey redesign 

SOURCE: CDC/NCHS, National Health Interview Survey. 

0 

2 

4 

6 

8 

10 

12 

14 

1980 1985 1990 1995 2000 2005 

Percent 

Figure 2. Asthma prevalence among children 0–17 years of age for measures of asthma

prevalence available in each year, United States, 1980–2005

+ From 1980 to 1996, asthma period

prevalence among children 0–17

years of age more than doubled, from

3.6% in 1980 to 7.5% at the peak of

the trend in 1995.

+ Although not strictly comparable, the

most similar post-1997 measure is

current asthma prevalence that has

been measured since 2001 and has

remained relatively stable since

then. Because current asthma

prevalence estimates are higher than

pre-1997 asthma period prevalence

estimates, it may be tempting to

conclude that asthma prevalence

continued to increase after

1996. However, the difference

between asthma period prevalence

estimates and current asthma

prevalence estimates is likely due to

NHIS questionnaire changes (13).

Nonetheless, prevalence remains at

historically high levels. In 2005, 8.9%

of children currently had asthma (6.5

million children).

+ Asthma attack prevalence measures

the percentage of children who had at

least one attack over the past 12

months. It is a crude estimate of the

percentage of symptomatic children

who may have poorly controlled

asthma, and thus are at risk of

adverse outcomes such as emergency

department visits or hospitalization.

In 2005, 5.2% of children had at least

one asthma attack in the previous

year (3.8 million children). Nearly

two of every three children who

currently have asthma had at least

one attack in the past 12 months.

+ Lifetime asthma diagnosis measures

the percentage of children who have

ever received a diagnosis of asthma.

It is a more general measure of the

impact of asthma among children.

Many of these children do not

currently have asthma. In 2005,

12.7% of children had been

diagnosed with asthma at some point

in their lifetime (9 million children),

of whom 70% were reported to

currently have asthma (6.5 million).

+ Measures of asthma morbidity and

control are available periodically

from the NHIS. In 2003:

– Children with at least one asthma

attack (4 million) in the previous

year missed an estimated 12.8 million

school days due to asthma.

– Among children with asthma, 39%

reported receiving an asthma

management plan from their health

care provider, 57% reported being

taught how to monitor peak flow, and

52% reported being advised to

change things at home or in school to

improve asthma management.
4 Advance Data No. 381 + December 12, 2006

Despite the plateau in asthma

prevalence, ambulatory care

use has continued to grow

since 2000

Increasing rates of visits to

physician offices and hospital outpatient

departments for asthma may indicate

increasing prevalence or severity, or

reflect progress in addressing the burden

of asthma. Clinical practice guidelines

from the National Asthma Education

and Prevention Program (1) recommend

that asthma symptoms be treated early

and aggressively. These guidelines also

recommend that patients be evaluated

for asthma severity, initial treatment be

tailored to severity level, and close

monitoring of symptoms and adjustment

of therapy be continued over time. Poor

asthma outcomes such as

hospitalizations and deaths are at least

partially sensitive to the quality of

ambulatory health care (14). An

appropriate frequency of outpatient

visits is one component of quality

ambulatory care. Managing asthma

involves close monitoring by health care

professionals both when asthma

symptoms flare and when the disease is

quiescent. Thus, trends in visits for

asthma in outpatient settings reflect a

spectrum of reasons for making visits to

the doctor for asthma (Figure 3).

Visits to physician offices are

measured by the National Ambulatory

Medical Care Survey (NAMCS),

administered in 1980–1981, 1985, and

continuously since 1989. In 1992, the

National Hospital Ambulatory Medical

Care Survey (NHAMCS) began to

provide data on visits to hospital

outpatient departments. Information is

obtained on visit events rather than the

number of people who went to see

physicians.

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey. 

0 

20 

40 

60 

80 

100 

1980 1985 1990 1995 2000

Visits per 1,000 

Physician office Hospital outpatient Total 

Figure 3. Number of ambulatory visits for asthma per 1,000 children 0–17 years of age, by

site, United States, 1980–2004

+ The periodic data available from

1980 to 1990 show a relatively stable

rate of visits for asthma to physician

offices. Since the early 1990s, there

has been an increase in visit rates.

The temporary increase in 1998

appears to be due to random

variation.

+ The majority of nonurgent ambulatory

visits for asthma occur in physician

offices. In 2004, there were 89 visits

to physician offices per 1,000

children (6.5 million visits) and 6 per

1,000 children (0.5 million visits) to

hospital outpatient departments, a

total of 95 visits per 1,000 children,

or 7 million ambulatory visits for

asthma. Just over 2.5% of all

ambulatory visits among children

0–17 years of age made in 2004 were

for asthma.

+ Ambulatory care use has continued to

increase after 2000 despite a plateau

in prevalence trends. Factors driving

this upward trend may include

increasing disease severity, and

increased health care use to improve

asthma control due to increased

public and provider awareness.

Increased ambulatory care use for

asthma has continued during an era

when overall rate of ambulatory care

use for children did not increase (15).
Advance Data No. 381 + December 12, 2006 5

Since 1992, when data first

became available, the rate of 140 

emergency department visits 120 

for asthma has remained

relatively stable 100 

Asthma attacks or exacerbations are

frequently managed in emergency

departments (EDs). Having an asthma

attack that warrants a visit to the ED

may be a sign of severe asthma or

Visits per 10,000 

80 

60 

40 

uncontrolled disease, inadequate access

to specialist health care, or inappropriate

use of emergency services (16,17).

Recurrent ED visits and hospitalizations

are risk factors for fatal asthma attacks

(18). In theory, asthma symptoms and

poor outcomes are avoidable with

implementation of environmental control

measures to minimize exposure to

allergens and irritants, appropriate

medication use, and patient and health

care provider education (1). However,

recognizing the early signs and

symptoms of the disease, avoiding

asthma triggers, arranging appropriate

health care, and managing the schedule

of medication administration can be

complex for children and their families.

Indeed, evidence shows that children

who visit the ED for asthma continue to

suffer from symptoms and activity

limitations despite having the health

encounter in the ED (19). Trends in ED

visits (Figure 4) are a crude indicator of

the burden of severe and uncontrolled

disease on families and the health care

system, the impact of public health

interventions, the degree of uptake of

asthma guidelines in disease

management, and the successful

translation of research into medical

practice.

Data on ED visits are collected by

the National Hospital Ambulatory

Medical Care Survey (NHAMCS),

administered since 1992. Information is

available for visit events rather than the

number of people who visited EDs.

20 

0 

1992 1994 1996 1998 2000 2002 2004 

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey. 

Figure 4. Number of visits to emergency departments for asthma per 10,000 children 0–17

years of age, United States, 1992–2004

+ From 1992 to 2004, there is no + In 2004, there were 103 visits per

consistent trend in the rate of ED 10,000 children, for a total of

visits for children. There appears to 750,000 visits to EDs for asthma.

be an increase in rates until the late Asthma ED visits represented about

1990s followed by a plateau after 2.8% of all ED visits among children

1999. 0–17 years of age in 2004.
6 Advance Data No. 381 + December 12, 2006

Hospitalization rates for 40 asthma have followed a trend

similar to those in asthma

prevalence rates since 1980

30

Hospitalizations per 10,000

and also remain at historically

high levels

An asthma hospitalization represents

a severe exacerbation that requires an

increased level of monitoring and care.

It also represents significant costs to the

health care system and to affected

families. Risks for hospitalization for

asthma include previous asthma

20 

10 

admissions, previous intubation for

asthma, and severe symptoms (20). In

theory, hospitalizations for asthma

should be largely preventable if patients

and their families are adequately

educated about the disease and have

access to high quality health care (14).

Although some hospitalizations may not

be avoidable, especially in very young

children suffering from respiratory

infections, trends in hospitalization over

time (Figure 5) can help determine if

intervention and management strategies

are having an impact on the burden of

disease.

The National Hospital Discharge

Survey (NHDS) collects information on

hospitalizations. The NHDS counts

events (hospitalizations) rather than the

number of people who are admitted to

hospitals. Although some of the

hospitalizations for asthma may be

re-admissions, research suggests that

re-admissions are not driving the overall

pattern for asthma (21).

0 

1980 1985 1990 1995 2000 

SOURCE: CDC/NCHS, National Hospital Discharge Survey. 

Figure 5. Number of hospitalizations for asthma per 10,000 children 0–17 years of age,

United States, 1980–2004

+ From 1980 through the mid-1990s,

asthma hospitalization rates increased

for children 0–17 years of age. This

pattern follows that for prevalence,

although there is evidence that

improved diagnosis of asthma also

contributed to the increase in

hospitalizations attributed to asthma

(9). Since the late 1990s, it appears

that the asthma hospitalization rate

among children plateaued at

historically high levels.

+ In 2004, there were 27

hospitalizations for asthma per 10,000

children for a total of 198,000

hospitalizations. Asthma

hospitalizations represented about 3%

of all hospitalizations among children.

+ Many factors drive hospitalization

rates among children. Overall

hospitalization use among children

has decreased over the time period

when asthma hospitalization rates

remained level (22). The threshold of

attack severity for a hospital

admission has likely increased. That

is, asthma hospitalizations in recent

years may represent more severe

exacerbations compared with earlier

years.
Advance Data No. 381 + December 12, 2006 7

Asthma death rates appear to

have declined recently 5 

following a rising trend from

1980 through the mid-1990s 4 

Asthma deaths among children are

Deaths per 1,000,000

rare but potentially avoidable. Children

most at risk of dying from asthma are

those with severe, uncontrolled disease,

a near-fatal attack of asthma, a history

of recurrent hospitalization or intubation

3 

2 

ICD Revision 19991 

for asthma (18). Trends in asthma 1 

deaths (Figure 6) are a stark indicator of

how well the disease is diagnosed and

controlled.

Information on deaths occurring in

the U.S. is collected by the Mortality

Component of the National Vital

Statistics System. The National Center

for Health Statistics compiles

information abstracted by each state

from death records.

The impact of asthma varies

through the stages of

childhood; prevalence

increases with age, but health

care use is highest among the

youngest children

The profile of asthma changes as

children get older, as shown in Table A.

In general, when asthma burden is

examined over the stages of childhood,

trends in levels of health care with age

are inversely related to trends in

prevalence rates. Understanding the

characteristics of asthma in each stage

of childhood helps to explain this

pattern.

Wheezing is common among infants

and toddlers because their small airways

are more susceptible to any mechanism

that impedes airflow, and they have a

high incidence of respiratory infections.

Definitively diagnosing asthma in

infants and toddlers can be difficult

given the many etiologies that cause

wheezing in very young children.

Furthermore, young children who

wheeze only during respiratory

infections are likely to have transient

symptoms (5,23–25). This pattern may

make clinicians reluctant to label

wheezing as a chronic disease among

young children. However, respiratory

distress in young children can rapidly

become life threatening and warrants

prompt attention. For this reason,

0 

1980 1985 1990 1995 2000 2004 

1 Beginning with data year 1999, cause-of-death statistics published by NCHS are classified according to 


the Tenth Revision of the International Classification of Diseases (ICD-10). 


SOURCE: CDC/NCHS, Mortality Component of the National Vital Statistics System.


Figure 6. Number of deaths due to asthma per 1,000,000 children 0–17 years of age,

United States, 1980–2004

+ From 1980 to 1998, death rates for deaths among children has apparently

asthma climbed steadily. In 1999, the declined.

change from the International + In 2004, the rate of asthma deaths

Classification of Diseases Ninth was 2.5 asthma deaths per 1 million

Revision (ICD-9) to the International children, a total of 186 asthma

Classification of Diseases Tenth deaths.

Revision (ICD-10) codes for cause of

death resulted in an overall 11

percent decline in deaths attributed to

asthma. The coding change therefore

accounts for much of the decrease in

rates from 1998 to 1999. From 1999

onward, however, the rate of asthma

Table A. Asthma prevalence, health care use, and mortality among children 0–17 years of

age, by age group and sex, United States, 2003–2005

Current asthma Emergency Hospital

prevalence,1 Ambulatory department discharges Deaths per

percent visits2 per 1,000 visits per per 10,000 1,000,000

Age and sex (2004–2005) (2003–2004) 10,000 (2003–2004) (2003–2004) (2003–2004)

0–4 years .......... 6.2 121.1 163.7 61.3 2.0

Male ............ 7.4 160.3 199.6 77.0 2.9

Female .......... 5.0 80.0 126.2 44.9 1.1

5–10 years.......... 9.3 80.2 82.6 23.6 2.3

Male ............ 11.1 86.5 91.8 31.3 2.9

Female .......... 7.4 73.7 72.8 15.6 1.6

11–17 years ......... 10.0 76.9 69.0 11.8 3.3

Male ............ 11.1 71.8 63.5 13.3 4.0

Female .......... 8.8 82.2 74.8 10.2 2.5

Total.............. 8.7 90.0 99.2 29.1 2.6

1

Current asthma prevalence estimates are based on the questions ‘‘Has a doctor or other health professional ever told you that

{child’s name} had asthma?’’ and ‘‘Does {child’s name} still have asthma?’’ 2

Includes visits to physician offices and hospital outpatient departments.

DATA SOURCES: CDC/NCHS: National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital

Ambulatory Medical Care Survey, National Hospital Discharge Survey, and the Mortality Component of the National Vital

Statistics System.
8 Advance Data No. 381 + December 12, 2006

utilization of emergency department

(ED) and hospital services for asthma is

high among this group.

Among school-age children,

allergies/atopic sensitization starts to

become a more prominent cause of

wheezing, and displaces respiratory

infections as a main trigger of attacks

(5,24). The emergence of more clearly

identifiable and predictable symptoms in

school-age children allows easier

identification and management of

asthma compared with younger children.

Families, health care professionals, and

schools who work well together can

successfully control symptoms.

However, families coping with other

factors that can interfere with good

asthma management may be less

successful.

Adolescents with asthma need to

learn to recognize and treat symptoms

independently. Issues with emerging

autonomy may accentuate good

management strategies, or exacerbate

problems with asthma control. The

relatively low level of health care use

for asthma among adolescents may

indicate a combination of patterns

among this group: changes in disease

severity, higher success in controlling a

chronic disease, or lack of medical

attention and poor use of medication to

relieve symptoms. Of particular concern

for adolescents is the higher rate of

asthma deaths in this group compared

with younger children.

The pattern over childhood differs

for boys and girls. Boys experience a

higher current asthma prevalence rate

throughout most of childhood. By ages

15–17 years, however, the current

prevalence rate in girls, 10.5%, has

surpassed that among boys, 10.1%.

Higher prevalence among females

persists among adults. Use of

ambulatory and hospital health care

services through age 10 years is higher

among boys. During adolescence,

however, ambulatory care use is greater

among 11–17 year old girls compared

with boys. Hospitalization rates among

adolescent boys, however, remain

slightly higher. Asthma death rates

among boys remain higher throughout

childhood. Death rates rise between

school-age and adolescent groups among

both genders.

11-17 years 

5-10 years 

0-4 years 

Deaths 2003-2004 

Hospitalizations 2003-2004 

Emergency department 

visits 2003-2004 

Current prevalence 2004-2005 

0% 100% 200% 

Proportional impact relative to all children ages 0-17 years 

SOURCES: CDC/NCHS, National Health Interview Survey, National Ambulatory Medical Care Survey, 


National Hospital Ambulatory Medical Care Survey, and the Mortality Component of the National Vital Statistic System.


Figure 7. The proportional impact of asthma prevalence, health care use, and mortality

among children 0–17 years of age, by age group, United States, 2003–2005

To better illustrate the impact of

asthma across age groups, the

prevalence, health care use, and death

rates for each group are compared with

the rates for all children in Figure 7 to

show all outcomes on the same scale.

The 100 percent level represents the

overall rate for children 0–17 years for

each measure, and is shown by the

vertical line. Each bar on the chart

represents the proportional impact of

each outcome for each age group

relative to the total for all children ages

0–17 years (e.g., the proportional impact

of current asthma prevalence rates

among children 0–4 years is 6.2% over

the total prevalence for all children,

8.7%, for a proportional impact of

71%). Children 0–4 years have the

lowest proportional impact of

prevalence. However, the proportional

impact of ED visit and hospitalization

rates for asthma among the youngest

children overshadows that among older

age groups. Unlike younger children,

the proportional impact of mortality

from asthma among adolescents is

higher than that for health care use.

Racial disparities in childhood

asthma are extensive; black

and Puerto Rican children have

high prevalence rates, and

black children have

dramatically higher mortality

rates compared with white

children

The higher rates of asthma

prevalence, ED visits, hospitalizations

and deaths among minority children

have been well documented (9,26–

28). Racial disparities remained evident

in asthma prevalence through 2005

(Table B). Children of American Indian

or Alaska Native decent have current

asthma prevalence rates 25% higher and

black children 60% higher than white

children. Asian children have the lowest

prevalence rates. When race and

ethnicity are considered, Puerto Rican

children have the highest prevalence of

all groups, 140% higher than nonHispanic white children, whereas

Mexican children have low reported

rates. In light of these differing

prevalence rates, the lower rate for

ambulatory care visits among black

children compared with white children

suggests that black children may be

underutilizing ambulatory care.

Considering the evidence that minority

children do not receive the same level

and quality of ambulatory health care
Advance Data No. 381 + December 12, 2006 9

Table B. Asthma prevalence, health care use, and mortality among children 0–17 years of age, by race and ethnicity, United States,

2003–2005

Emergency

Current Ambulatory department Hospital

prevalence1

, visits2 per visits per discharges Deaths per

percent 1,000 10,000 per 10,000 1,000,000

Race and ethnicity (2004–2005) (2003–2004) (2003–2004) (2003–2004) (2003–2004)

Race only

White .............................. 7.9 94.8 73.0 16.9 1.5

Black .............................. 12.8 76.4 263.7 59.2 9.0

American Indian or Alaska Native............. 9.9 * * * *

Asian .............................. 4.9 * * * *

Race/ethnicity

Hispanic ............................ 7.8 83.3 108.1 ** 1.8

Puerto Rican ......................... 19.2   **  *

Mexican ............................ 6.4 **   1.7

Non-Hispanic white ..................... 8.0 100.2 65.8 **  1.3

Non-Hispanic black ..................... 12.7 71.5 251.6 ** 9.2

Total............................... 8.7 90.0 99.2 29.1 2.6

* Estimates are considered unreliable. For ambulatory visit rates, emergency department visit rates and hospital discharge rates, the relative standard error of the estimate is greater than 30%. For

death rates, rates based on a number of deaths fewer than 20 are not shown.

** Data not available. 1

Current asthma prevalence estimates are based on the questions ‘‘Has a doctor or other health professional ever told you that {child’s name} had asthma?’’ and ‘‘Does {child’s name} still have

asthma?’’ 2

Includes visits to physician offices and hospital outpatient departments.

DATA SOURCES: CDC/NCHS: National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, National Hospital Discharge Survey,

and the Mortality Component of the National Vital Statistic System.

for asthma (29,30), the disparity in

ambulatory care use may contribute to

the disparities in ED use,

hospitalization, and death. The racial

disparities in these adverse asthma

outcomes are much greater than those in

asthma prevalence. Compared with

white children, black children have a

260% higher ED visit rate, a 250%

higher hospitalization rate, and a 500%

higher death rate from asthma.

Unfortunately, information about

race/ethnicity and income are not

consistently available across the health

care data systems used to measure the

impact of asthma.

Figure 8 illustrates the impact of

these disparities by comparing the rates

for asthma prevalence, health care use,

and death for each group to the total

rate to show all outcomes on the same

scale. The 100 percent level represents

the overall rate for children 0–17 years

for each measure and is shown by the

vertical line. Only those groups with

data available for all indicators are

shown. The proportional impact of

prevalence is highest among nonHispanic black children. However,

disparities in adverse asthma

outcomes—ED visits and deaths—are

0% 100% 200% 300% 

Hispanic 

Non-Hispanic white 

Non-Hispanic black 

Deaths 2003-2004 

Emergency department 

visits 2003-2004 

Current prevalence 2004-2005 

SOURCES: CDC/NCHS, National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital 

Ambulatory Medical Care Survey, and the Mortality Component of the National Vital Statistic System. 

Proportional impact relative to all children ages 0-17 years 

Figure 8. The proportional impact of asthma prevalence, health care use and mortality

among children 0–17 years of age, by race and ethnicity, United States, 2003–2005

much higher. The pattern for the

Hispanic group is similar to nonHispanic white children, although

grouping all Hispanic subgroups

together masks the possible varied

patterns for Puerto Rican and Mexican

children.
10 Advance Data No. 381 + December 12, 2006

12 8 

7 10 Black

6 

Deaths per 1,000,000

8 

Black/white ratio5 

4 

3 

6 

4 

Total 

2 

2 

White 1 

0 0

1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004 

SOURCE: CDC/NCHS, Mortality Component of the National Vital Statistics System. 

Figure 9a (left). Number of deaths due to asthma per 1,000,000 children 0–17 years of age

by race, United States, 1999–2004

Figure 9b (right). Ratio of black to white asthma death rates, children 0–17 years,

United States, 1999–2004

Figures 9a and 9b present recent

trends in asthma death rates for black

children and white children. Although

overall asthma death rates have declined

since 1999 (Figure 9a), this pattern is

not observed for black children among

whom death rates remained relatively

level. As a result, the black and white

disparity for asthma deaths has

increased since 1999 as measured by the

ratio of the black rate to the white rate

(Figure 9b). The lack of progress among

black children in lowering mortality

from asthma may reflect a number of

factors such as more severe disease,

greater environmental obstacles (e.g.,

residence in more polluted or high

poverty areas), lag in uptake of medical

advances to control asthma symptoms

among health care providers who treat

black children, and lack of asthma

education or difficulties in adopting

certain asthma control methods by black

families.

Summary

The large increases in the burden of

childhood asthma seen in the 1980s

until the late 1990s appear to have

abated in recent years. Yet, the burden

remains at the highest levels recorded

for all measures except mortality. The

decrease in asthma death rates among

children since 1999 is encouraging, and

may signal the accomplishments of the

many diverse groups working to lighten

the burden of asthma. However, asthma

deaths are theoretically preventable, and

black children have not experienced a

decrease in asthma mortality.

Furthermore, the measures presented in

this report reveal only part of the burden

of asthma for children and their

families, especially because the

measures used rely on a physician

accurately diagnosing asthma and either

relaying this information to the child’s

family (prevalence measures) or

documenting the condition in medical

records (health care use). The most

current data show that the challenges of

childhood asthma remain and that

asthma persists as a significant public

health problem.
Advance Data No. 381 + December 12, 2006 11

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12 Advance Data No. 381 + December 12, 2006

Technical Notes

Asthma prevalence data

Prevalence data were obtained from

the National Health Interview Survey

(NHIS), a cross-sectional household

interview survey of the U.S. civilian

noninstitutionalized population.

Excluded are patients in long-term care

facilities, Armed Forces active duty

personnel (although dependents are

included), and U.S. nationals living in

foreign countries. NHIS interviewing is

continuous throughout each year, and

follows a multistage area probability

design that permits the representative

sampling of households. From each

family in the NHIS, one sample adult

and, for families with children under 18

years of age, one sample child are

randomly selected to participate in the

detailed health survey. A responsible

adult, usually a parent, reports in proxy

for the sample child.

NHIS obtains information on

illnesses, injuries, activity limitation,

chronic conditions, health insurance

coverage, utilization of health care,

other health topics, demographic

information, and risk factor data. Special

modules and supplements focus on

different issues each year. Additional

questions about asthma were most

recently included in the 2002 and 2003

NHIS.

NHIS has been conducted annually

since 1957. In 1997, the questionnaire

was redesigned and some basic concepts

were changed and other concepts were

measured in different ways. Also in

1997, the collection methodology

changed from paper and pencil

questionnaires to computer-assisted

personal interviewing. Since 1997, the

annual sample has numbered about

100,000 persons with about 30,000

persons participating in the sample adult

and about 15,000 persons in the sample

child questionnaires. In recent years, the

total household response rate was about

90%.

National estimates from NHIS are

produced by using the sample weights.

Because the sample weights incorporate

U.S. Census estimates of the civilian

noninstitutionalized population, no

denominators are necessary to compute

percentages.

For More Information: See the

NHIS website at: http://www.cdc.gov/

nchs/nhis.htm.

Physician office visit data

Data on asthma visits to physician

offices are obtained from the National

Ambulatory Medical Care Survey

(NAMCS), a national survey designed to

provide information about the provision

and use of medical care services in

office-based physician practices in the

U.S. The survey covers patient

encounters in the offices of nonfederally

employed physicians classified by the

American Medical Association or

American Osteopathic Association as

‘‘office-based, patient care’’ physicians.

Excluded are visits to hospital-based

physicians, visits to specialists in

anesthesiology, pathology, and radiology,

and visits to physicians who are

principally engaged in teaching,

research, or administration. Telephone

contacts and nonoffice visits are also

excluded. A multistage probability

design is employed. The final stage

involves systematic random samples of

office visits during randomly assigned

7-day reporting periods. In 1985 the

survey excluded Alaska and Hawaii.

Data are collected from medical

records on type of providers seen;

reason for visit; diagnoses; drugs

ordered, provided, or continued; and

selected procedures and tests ordered or

performed during the visit. Patient data

include age, sex, race, and expected

source of payment.

The NAMCS, which began in 1973,

was conducted annually until 1981,

again in 1985, and resumed an annual

schedule in 1989. In 2004, 1,961

physicians were in scope and 1,372

participated for a response rate of 65%.

Data were provided for 25,286 visits.

National estimates of the number of

asthma visits were calculated using

survey weights. To obtain visit rates for

a group, national estimates of the

number of visits were divided by the

civilian noninstitutionalized population

for that group (see section on population

estimates). For More Information: See

the Ambulatory Health Care Data

website at: http://www.cdc.gov/nchs/

about/major/ahcd/ahcd1.htm.

Hospital outpatient and

emergency department visit

data

Visit data to hospital outpatient

departments (OPDs) and emergency

departments (EDs) were obtained from

the National Hospital Ambulatory

Medical Care Survey (NHAMCS) that

collects data on the utilization and

provision of medical care services

provided in hospital OPDs and

EDs. The survey is a representative

sample of visits to EDs and OPDs of

nonfederal, short-stay, or general

hospitals. Telephone contacts are

excluded. In the NHAMCS OPD

survey, a clinic is defined as an

administrative unit of the OPD in which

ambulatory medical care is provided

under the supervision of a physician. If

a hospital OPD has five or fewer

in-scope clinics, all are included in the

sample. For hospital OPDs with more

than five clinics, a systematic sample of

clinics proportional to size is included in

the survey. Visits to eligible EDs and

OPDs are systematically sampled over

the 4-week reporting period such that

about 100 ED encounters and about 200

OPD encounters are selected.

Data are collected from medical

records on type of providers seen;

reason for visit; diagnoses; drugs

ordered, provided, or continued; and

selected procedures and tests performed

during the visit. Patient data include

age, sex, race, and expected source of

payment.

Annual data collection began in

1992. In any given year, the hospital

sample consists of approximately 500

hospitals, of which 80 percent have EDs

and about half have eligible OPDs.

Typically, about 1,000 clinics are

selected from participating hospital

OPDs. In 2004, the hospital response

rate was 89% for EDs and 75% for

OPDs.

Sample data are weighted to

produce national estimates. To obtain

visit rates for a group, national estimates

of number of visits were divided by the
Advance Data No. 381 + December 12, 2006 13

civilian population for that group (see

section on population estimates).

For More Information: See the

Ambulatory Health Care website at:

http://www.cdc.gov/nchs/about/major/

ahcd/ahcd1.htm.

Hospital discharge visit data

Data on asthma hospital discharges

were obtained from the National

Hospital Discharge Survey (NHDS) that

collects and produces national estimates

on characteristics of inpatient stays in

nonfederal short-stay hospitals in the

U.S. Included in the survey are

hospitals with an average length of stay

of less than 30 days for all inpatients,

general hospitals, and children’s general

hospitals. Excluded are federal, military,

and Department of Veterans Affairs

hospitals, as well as hospital units of

institutions (such as prison hospitals),

and hospitals with fewer than six beds

staffed for patient use. Two data

collection procedures are used in the

survey. One is a manual system of

sample selection and medical

transcription from the hospital records to

abstract forms. The second is an

automated system in which the National

Center for Health Statistics purchases

machine-readable medical record data

from commercial organizations, state

data systems, hospitals, or hospital

associations.

Patient information collected

includes demographics, length of stay,

diagnoses, and procedures. Hospital

characteristics collected include

geographic region of the country,

ownership, and bed size.

The NHDS has been conducted

annually since 1965. Hospitals are

selected using a modified three-stage

stratified design. For 2004, the sample

consisted of 501 hospitals, of which 439

responded. Data were collected for

approximately 371,000 discharges.

Sample data are weighted to

produce national estimates. To obtain

hospitalization rates for a group,

national estimates of hospitalizations

were divided by the civilian population

of that group (see section on population

estimates). For More Information: See

the National Health Care Survey website

at: http://www.cdc.gov/nchs.nhcs.htm.

Mortality data

Data on deaths are obtained from

the Mortality Component of the

National Vital Statistics System (NVSS)

that collects and publishes official

national statistics on births, deaths, and

fetal deaths based on U.S. Standard

Certificates. Vital events occurring in

the U.S. to non-U.S. residents and vital

events occurring abroad to U.S.

residents are excluded. By law, the

registration of deaths is the

responsibility of the funeral director.

The funeral director obtains

demographic data for the death

certificate from an informant.

The physician in attendance at the

death is required to certify the cause of

death. The mortality file includes

demographic information on age, sex,

race, Hispanic origin, state of residence,

and educational attainment, and medical

information on cause of death.

The International Classification of

Diseases (ICD), by which cause of

death is coded and classified, is revised

approximately every 10 to 15 years.

Beginning with data year 1999, the

cause-of-death statistics are classified

according to the Tenth Revision of the

ICD (ICD-10). Discontinuities between

the Ninth and Tenth Revisions for

selected causes of death are measured

using comparability ratios. For asthma,

the comparability ratio for the overall

population in 1999 was 0.89. That is,

the overall number of deaths attributed

to asthma was 11% lower using ICD-10

compared with ICD-9.

Data obtained from the mortality

file represent a complete count of

deaths. To obtain asthma death rates for

a group, the number of deaths was

divided by the residential population of

that group (see section on population

estimates).

For More Information: See the

Mortality Data website at: http://

www.cdc.gov/nchs/about/major/dvs/

mortdata.htm.

Population estimates

The census of population (decennial

census) has been held in the United

States every 10 years since 1790. Data

on sex, race, age, and marital status are

collected from 100% of the enumerated

population.

Postcensal population estimates are

estimates made for the years following a

census before the next census has been

taken, and are derived by updating

counts in the decennial census using a

‘‘components of population change’’

approach (accounting for births, deaths,

net international migration and net

movement of U.S Armed Forces and

U.S. civilians). Postcensal population

estimates were used to calculate

ambulatory visit rates, hospitalization

rates and death rates for the years

2001–2004.

With the completion of the

decennial census at the end of the

decade, intercensal estimates for the

preceding decade were prepared to

replace the less accurate postcensal

estimates. Intercensal population

estimates take into account the census of

population at the beginning and end of

the decade. Intercensal population

estimates were used to calculate

ambulatory visit rates, hospitalization

rates and death rates for the years

1980–1999.

A different data source was used to

provide denominators to calculate death

rates for Puerto Rican and Mexican

children for the period 2003–2004.

Population estimates for 0–17 year old

children by Hispanic subgroup are not

available. However, the Current

Population Survey (CPS) website at:

http://www.census.gov/population/www/

socdemo/hispanic.html collects

information on Hispanic subgroup, and

so CPS population estimates were used

to calculate death rates for Puerto Rican

and Mexican children. Because CPS

estimates are based on survey data, they

are subject to sampling error. In

addition, studies have shown that

persons self-reported as Hispanic on

census and survey records may

sometimes be reported as white or

non-Hispanic on the death certificate,

resulting in an underestimation of deaths

and death rates for Hispanic groups. The

overall impact of these errors on asthma

death rates for Puerto Rican and

Mexican children is unknown.
14 Advance Data No. 381 + December 12, 2006

Table I. Data for Figure 1: Percentage of current asthma prevalence among children 0–17 years of age, by state, annual average for the

period 2001–2005

95% 95%

Confidence Confidence

Current asthma interval interval

prevalence lower bound upper bound

Massachusetts ........................ 12.1 9.7 14.5

Hawaii ............................. 10.9 4.7 17.1

Oklahoma ........................... 10.8 7.7 14.0

Maryland ............................ 10.8 8.5 13.2

Rhode Island ......................... 10.5 4.7 16.2

Kentucky ............................ 10.4 7.4 13.5

District of Columbia ..................... *10.3 2.2 18.4

Ohio............................... 10.2 8.4 12.0

New York............................ 10.2 9.0 11.4

Pennsylvania ......................... 9.9 8.2 11.7

Connecticut .......................... 9.9 6.8 13.0

Michigan ............................ 9.4 7.5 11.2

Illinois.............................. 9.0 7.6 10.4

Florida ............................. 8.9 7.7 10.1

Kansas ............................. 8.8 5.2 12.5

Delaware............................ *8.8 2.9 14.7

New Jersey .......................... 8.8 7.1 10.5

Virginia ............................. 8.7 6.8 10.6

Nebraska............................ *8.7 3.1 14.3

Alabama ............................ 8.7 6.1 11.2

New Mexico .......................... 8.6 4.6 12.7

Wisconsin ........................... 8.6 6.1 11.2

Missouri ............................ 8.6 6.4 10.7

Arkansas............................ 8.5 4.5 12.6

Colorado ............................ 8.5 5.8 11.1

Mississippi ........................... *8.4 3.5 13.4

Indiana ............................. 8.4 6.1 10.7

Louisiana............................ 8.3 5.9 10.7

Oregon ............................. 8.1 4.8 11.5

North Carolina ........................ 8.1 6.3 9.8

South Carolina ........................ 8.1 4.9 11.2

Georgia............................. 7.9 6.1 9.8

Texas .............................. 7.9 6.9 8.8

Minnesota ........................... 7.8 5.7 10.0

Arizona ............................. 7.7 5.7 9.6

New Hampshire ....................... *7.5 1.9 13.1

Washington .......................... 7.4 5.4 9.4

Tennessee ........................... 7.3 5.0 9.6

California............................ 7.1 6.4 7.8

Iowa............................... 7.1 3.1 11.1

Utah............................... 4.4 2.0 6.8

Nevada............................. *4.4 1.4 7.4

Alaska ............................. * . . . . . .

Idaho .............................. * . . . . . .

Maine.............................. * . . . . . .

Montana ............................ * . . . . . .

North Dakota ......................... * . . . . . .

South Dakota ......................... * . . . . . .

Vermont ............................ * . . . . . .

West Virginia ......................... * . . . . . .

Wyoming............................ * . . . . . .

* Estimates are considered unreliable. Estimates preceded by an asterisk have a relative standard error greater than 30 percent and less than or equal to 50 percent and should be interpreted with

caution. Estimates not shown have a relative standard error greater than 50 percent.

...Category not applicable.

NOTE: Current asthma prevalence estimates are based on the questions ‘‘Has a doctor or other health professional ever told you that {child’s name} had asthma?’’ and ‘‘Does {child’s name} still

have asthma?’’

DATA SOURCE: CDC/NCHS: National Health Interview Survey.
Advance Data No. 381 + December 12, 2006 15

Table II. Data for Figure 2: Percentage of children 0–17 years of age for measures of asthma prevalence by years of data availability,

United States, 1980–2005

Asthma Lifetime Current Asthma

period asthma asthma attack

prevalence1 diagnosis2 prevalence3 prevalence4

1980 .............................. 3.6 – – – – – – – – –

1981 .............................. 3.7 – – – – – – – – –

1982 .............................. 4.0 – – – – – – – – –

1983 .............................. 4.5 – – – – – – – – –

1984 .............................. 4.3 – – – – – – – – –

1985 .............................. 4.8 – – – – – – – – –

1986 .............................. 5.1 – – – – – – – – –

1987 .............................. 5.3 – – – – – – – – –

1988 .............................. 5.0 – – – – – – – – –

1989 .............................. 6.1 – – – – – – – – –

1990 .............................. 5.8 – – – – – – – – –

1991 .............................. 6.3 – – – – – – – – –

1992 .............................. 6.3 – – – – – – – – –

1993 .............................. 7.2 – – – – – – – – –

1994 .............................. 6.9 – – – – – – – – –

1995 .............................. 7.5 – – – – – – – – –

1996 .............................. 6.2 – – – – – – – – –

19975 .............................. – – – 11.4 – – – 5.5

1998 .............................. – – – 12.1 – – – 5.3

1999 .............................. – – – 10.8 – – – 5.3

2000 .............................. – – – 12.3 – – – 5.5

2001 .............................. – – – 12.7 8.7 5.7

2002 .............................. – – – 12.2 8.3 5.8

2003 .............................. – – – 12.5 8.5 5.5

2004 .............................. – – – 12.2 8.5 5.4

2005 .............................. – – – 12.7 8.9 5.2

–––Data not available. 1

Asthma period prevalence estimates are based on the question ‘‘During the past 12 months, did anyone in the family have asthma?’’ 2

Lifetime asthma diagnosis estimates are based on the question ‘‘Has a doctor or other health professional ever told you that {child’s name} had asthma?’’ 3

Current asthma prevalence estimates are based on the questions ‘‘Has a doctor or other health professional ever told you that {child’s name} had asthma?’’ and ‘‘Does {child’s name} still have

asthma?’’ 4

Asthma attack prevalence estimates are based on the questions ‘‘Has a doctor or other health professional ever told you that {child’s name} had asthma?’’ and ‘‘Has {child’s name} had an

episode or attack of asthma in the past 12 months?’’ 5

The National Health Interview Survey was redesigned in 1997. Estimates from 1997 onward are not directly comparable to pre-1997 estimates.

DATA SOURCE: CDC/NCHS: National Health Interview Survey.
16 Advance Data No. 381 + December 12, 2006

Table III. Data for Figure 3: Number of ambulatory visits for asthma per 1,000 children 0–17 years of age, by site, United States,

1980–2004

Physician Hospital Total

office outpatient ambulatory

visit rate visit rate visit rate

1980 ................................... 42.0 – – – – – –

1981 ................................... 36.3 – – – – – –

1982 ................................... – – – – – – – – –

1983 ................................... – – – – – – – – –

1984 ................................... – – – – – – – – –

1985 ................................... 36.1 – – – – – –

1986 ................................... – – – – – – – – –

1987 ................................... – – – – – – – – –

1988 ................................... – – – – – – – – –

1989 ................................... 29.2 – – – – – –

1990 ................................... 38.2 – – – – – –

1991 ................................... 45.1 – – – – – –

1992 ................................... 56.4 4.4 60.8

1993 ................................... 54.2 9.0 63.3

1994 ................................... 49.8 5.4 55.1

1995 ................................... 46.9 8.0 55.0

1996 ................................... 50.4 5.3 55.7

1997 ................................... 52.5 7.3 59.8

1998 ................................... 76.0 6.5 82.5

1999 ................................... 46.8 8.9 55.7

2000 ................................... 55.2 8.1 63.3

2001 ................................... 60.7 7.9 68.6

2002 ................................... 60.0 8.7 68.7

2003 ................................... 74.0 10.3 84.3

2004 ................................... 89.5 6.3 95.8

–––Data not available.

DATA SOURCES: CDC/NCHS: National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey.

Table IV. Data for Figure 4: Number of visits to emergency departments for asthma per 10,000 children 0–17 years of age, United States,

1992–2004

Emergency

department

visit rate

1992 ................................................................................ 96.8

1993 ................................................................................ 106.0

1994 ................................................................................ 103.7

1995 ................................................................................ 91.2

1996 ................................................................................ 112.3

1997 ................................................................................ 109.7

1998 ................................................................................ 121.4

1999 ................................................................................ 101.7

2000 ................................................................................ 100.7

2001 ................................................................................ 91.7

2002 ................................................................................ 99.9

2003 ................................................................................ 95.5

2004 ................................................................................ 102.9

DATA SOURCE: CDC/NCHS: National Hospital Ambulatory Medical Care Survey.
Advance Data No. 381 + December 12, 2006 17

Table V. Data for Figure 5: Number of hospitalizations for asthma per 10,000 children 0–17 years of age, United States, 1980–2004

Hospitalization

rate

1980 ................................................................................ 21.0

1981 ................................................................................ 22.2

1982 ................................................................................ 25.7

1983 ................................................................................ 23.7

1984 ................................................................................ 25.5

1985 ................................................................................ 25.4

1986 ................................................................................ 27.3

1987 ................................................................................ 25.9

1988 ................................................................................ 28.5

1989 ................................................................................ 27.9

1990 ................................................................................ 28.4

1991 ................................................................................ 30.6

1992 ................................................................................ 30.8

1993 ................................................................................ 25.4

1994 ................................................................................ 26.8

1995 ................................................................................ 32.7

1996 ................................................................................ 29.8

1997 ................................................................................ 32.4

1998 ................................................................................ 24.4

1999 ................................................................................ 28.1

2000 ................................................................................ 29.6

2001 ................................................................................ 26.2

2002 ................................................................................ 26.9

2003 ................................................................................ 31.2

2004 ................................................................................ 27.1

DATA SOURCE: CDC/NCHS: National Hospital Discharge Survey.

Table VI. Data for Figure 6: Number of deaths due to asthma per 1,000,000 children 0–17 years of age, United States, 1980–2004

Death rate, Death rate,

Year ICD-91 ICD-102

1980 ................................ 1.7 . . .

1981 ................................ 1.9 . . .

1982 ................................ 2.3 . . .

1983 ................................ 2.4 . . .

1984 ................................ 2.2 . . .

1985 ................................ 2.5 . . .

1986 ................................ 2.8 . . .

1987 ................................ 2.9 . . .

1988 ................................ 2.6 . . .

1989 ................................ 2.7 . . .

1990 ................................ 2.9 . . .

1991 ................................ 3.0 . . .

1992 ................................ 2.8 . . .

1993 ................................ 3.0 . . .

1994 ................................ 3.2 . . .

1995 ................................ 3.4 . . .

1996 ................................ 3.7 . . .

1997 ................................ 2.9 . . .

1998 ................................ 3.2 . . .

1999 ................................ . . . 3.0

2000 ................................ . . . 2.9

2001 ................................ . . . 2.6

2002 ................................ . . . 3.0

2003 ................................ . . . 2.7

2004 ................................ . . . 2.5

...Category not applicable. 1

International Classification of Diseases, Ninth Revision (ICD-9). 2

Beginning with data year 1999, the cause-of-death statistics published by NCHS are classified according to the International Classification of Diseases, Tenth Revision (ICD-10). Discontinuities

between the Ninth and Tenth Revisions of the ICD for selected causes of death are measured using comparability ratios. For asthma, the comparability ratio for the overall population was 0.89.

That is, the overall number of deaths attributed to asthma in 1999 was 11 percent lower using ICD-10 compared with ICD-9.

DATA SOURCE: CDC/NCHS: Mortality Component of the National Vital Statistics System.
18 Advance Data No. 381 + December 12, 2006

Table VII. Data for Figure 7: Proportional impact of asthma prevalence, health care use, and mortality among children 0–17 years of age,

by age group, United States, 2003–2005

Current Emergency Death

prevalence department visit Hospitalization rate

Age group 2004–2005 rate 2003–2004 rate 2003–2004 2003–2004

0–4 years ............................. 71% 165% 211% 77%

5–10 years............................. 107% 83% 81% 88%

11–17 years ............................ 115% 70% 40% 127%

NOTE: Proportional impact is calculated by dividing the outcome for each age group by the outcome for all children 0–17 years of age. For example, the proportional impact of current asthma

prevalence rates among children 0–4 years is 6.2 percent over the total prevalence, 8.7 percent, for a proportional impact of 71 percent.

DATA SOURCES: CDC/NCHS: National Health Interview Survey, National Hospital Ambulatory Medical Care Survey, National Hospital Discharge Survey, and the Mortality Component of the

National Vital Statistic System.

Table VIII. Data for Figure 8: The proportional impact of asthma prevalence, health care use and mortality among children 0–17 years of

age, by race and ethnicity, United States, 2003–2005

Current Emergency Death

prevalence department visit rate

Race/ethnicity 2004–2005 rate 2003–2004 2003–2004

Hispanic .............................. 90% 109% 69%

Non-Hispanic white ....................... 92% 66% 50%

Non-Hispanic black ....................... 146% 254% 354%

NOTE: Proportional impact is calculated by dividing the outcome among each race/ethnicity by the outcome for all children 0–17 years of age. For example, the proportional impact of current

asthma prevalence rates among non-Hispanic black children is 12.7 percent over the total prevalence, 8.7 percent, for a proportional impact of 146 percent.

DATA SOURCES: CDC/NCHS: National Health Interview Survey, National Hospital Ambulatory Medical Care Survey, and the Mortality Component of the National Vital Statistic System.

Table IX. Data for Figure 9a: Number of asthma deaths per 1,000,000 children 0–17 years of age, by race, 1999–2004

White Black Total

1999 ................................ 2.0 9.4 3.0

2000 ................................ 1.8 9.5 2.9

2001 ................................ 1.5 8.6 2.6

2002 ................................ 1.6 10.6 3.0

2003 ................................ 1.5 9.3 2.7

2004 ................................ 1.4 8.7 2.5

DATA SOURCE: CDC/NCHS: Mortality Component of the National Vital Statistics System.

Table X. Data for Figure 9b: Ratio of black to white asthma death rates, children 0–17 years, 1999–2004

Ratio

1999 ................................................................................ 4.7

2000 ................................................................................ 5.4

2001 ................................................................................ 5.6

2002 ................................................................................ 6.8

2003 ................................................................................ 6.1

2004 ................................................................................ 6.3

DATA SOURCE: CDC/NCHS: Mortality Component of the National Vital Statistics System.
19 Advance Data No. 381 + December 12, 2006

ma content

Purpose/Scope Design/Sample/Geographic coverage Selected asthma content

on:

The main objective of the NHIS is to monitor the

health of the U.S. population through the collectionand analysis of data on a broad range of health

topics. A major strength of this survey lies in the

ability to display these health characteristics by many

demographic and socioeconomic characteristics.

c Continuous survey; annual data releasec Household face-to-face interview

c Nationally representativec Multistage probability sample of the civilian

noninstitutionalized population

c Geography: National, 4 regions (Northeast, South,

Midwest,

West), some states

Administered by National Center for Health

Statistics, CDC

Asthma prevalence:c Lifetime asthma diagnosisc Current asthma prevalencec Asthma attack prevalence

Periodic supplements on asthma symptoms,

medication use, health care use, and diseasecontrol measures (1999, 2002, 2003)

The BRFSS is a state-based system of health

surveys that collects information on health risk

behaviors, preventive health practices, and healthcare access primarily related to chronic disease andinjury. For many states, the BRFSS is the only

available source of timely, accurate data on healthrelated behaviors about issues such as asthma,

diabetes, health care access, alcohol use,hypertension, obesity, cancer screening, nutrition and

physical activity, tobacco use, and more. Federal,

state, and local health officials and researchers use

this information to track health risks, identify

emerging problems, prevent disease, and improve

treatment.

c Continuous survey; annual data releasec Telephone interviewc Nationally representativec Stratified probability sample, households with

telephones among the adult civilian

noninstitutionalized population

c Geography: National, 50 states, District of

Columbia, U.S. Territories. Data available for large

metropolitan areas (see Selected Metropolitan/Micropolitan Area Risk Trends:

http://apps.nccd.cdc.gov/brfss-smart/

SelMMSAPrevData.asp)

Administered by National Center for Chronic Disease

Prevention and Health Promotion, CDC, conductedby States

Asthma prevalence, adults 18 years of age and

over:c Lifetime asthma diagnosisc Current asthma prevalencePeriodic supplements on asthma symptoms,medication use, health care use, severity and

controlSupplement on childhood asthma (2001)

k

3:

This survey examines the health, socioeconomic,

behavioral, and environmental predictors that relateto better control of asthma. This survey also exploresthe content of care and health care experiences ofpersons with asthma. Data for the initial survey,

which included a national sample and 4 states, were

collected in 2003 and released in the fall of 2005.

The survey is now conducted as a call-back interview

subsequent to identifying respondents with asthma

during the BRFSS interview (above).

c Periodic data collection

c Telephone interview

c Initial survey (2003–2004) nationally representativec Geography:

Initial survey 2003–2004: National and 4 pilot

states (AL, CA, IL, TX)Call-back survey: 2005: 3 states, 2006: 25 states,

and 2007: 35 states

Sponsored by the National Center for Environmental

Health, CDC

Asthma experiences:c Time since diagnosis

c Medication usec Health care usec Symptomsc Risk factorsc Disease management

rvey

The NHANES combines interviews and physicalexaminations to assess the health and nutritional

status of adults and children in the U.S. The

interview includes demographic, socioeconomic,

dietary, and health-related questions. The

examination component consists of medical anddental examinations, physiological measurements,and laboratory tests. Data from this survey are used

in epidemiological studies and health sciences

research, which help develop sound public healthpolicy, direct and design health programs andservices, and expand health knowledge.

c Continuous since 1999 with data release every 2

years; periodic from 1971–1994

c Household face-to-face interview, physical exam in

mobile examination center

c Nationally representativec Multistage probability sample of the civilian

noninstitutionalized population

c Geography: NationalAdministered by National Center for Health Statistics,

CDC

Asthma prevalence:c Lifetime asthma diagnosisc Current asthma prevalencec Asthma attack prevalence

Spirometry/pulmonary function testing, 1988–

1994Household dust analysis and allergensensitization data, 2005–2006

Environmental toxin exposure

Planned future relevant content:c Spirometry 2007

The NSCH examines the physical and emotional

health of children ages 0–17 years. Specialemphasis is placed on factors that may relate towell-being of children, including medical homes,

family interactions, parental health, school andafter-school experiences, and safe neighborhoods.

c Periodic data collection (2003–2004 data released)

c Telephone interview

c Nationally representativec Stratified probability sample, households with

telephones among the civilian noninstitutionalized

population (ages 0–17 years)

c Geography: National and state estimatesSponsored by Health Resources and Services

Administration (HRSA)

Seven asthma questions (ages 0–17 years):

c Lifetime asthma diagnosisc Current asthma prevalencec Asthma attack prevalencec Asthma severityc Family burdenc Time since medication taken

c Hospitalization in past 12 months
20 Advance Data No. 381 + December 12, 2006 

ma content—Con. 

Purpose/Scope Design/Sample/Geographic coverage Selected asthma content

m

The YRBS was developed in 1990 to monitor priority

health risk behaviors that contribute to the leading

causes of death, disability, and social problems

among youth and adults in the United States. Six

categories of priority health-risk behaviors aremonitored.

c Conducted every 2 yearsc Self-administered questionnaire in school settingc National, state, and local school-based surveys of

representative samples of 9th through 12th gradestudents

c Geography: National and state estimatesAdministered by the National Center for Chronic

Disease Prevention and Health Promotion, CDC

Asthma prevalence questions added in 2005 (not

directly comparable to NHIS, BRFSS above):

c Lifetime asthma diagnosisc Current asthma prevalence

c Asthma attack prevalence

79)

The NLSY79 is a nationally representative sample of12,686 young men and young women who where 14

to 22 years of age when they were first surveyed in

1979. Annual data collections provide a uniqueopportunity to study in detail the life course

experiences of this sample. In 1986, a separate

survey of all children born to NLSY79 female

respondents began, greatly expanding the breadth ofchild-specific information collected. In addition to allof the mother’s information from the NLSY79, the

child survey includes assessments of each child as

well as additional demographic and developmentinformation collected from either the mother or child.

c Longitudinal survey; annual interviewsc Face-to-face interviewc Nationally representative longitudinal samplec Geography: National estimates

Administered by the Bureau of Labor Statistics, U.S.

Department of Labor

Asthma questions were added for data collection

in 2004.2002 data file contains question on special health

care needs and limitations from chronicconditions, including asthma, for the children of

NLSY79 female respondents.

_

h

tats/

The MEPS is a set of large-scale surveys of familiesand individuals, their medical providers, and

employers across the United States. MEPS is the

most complete source of data on the cost and use ofhealth care and health insurance coverage.

c Continuous survey; annual data releasec Household face-to-face interview

c Nationally representativec Overlapping panel design sample of the civilian

noninstitutionalized populationc Geography: NationalAdministered by AHRQ

Health care use, medication and device use, andexpenditures for asthma.

jor/

r/

The NHCS embraces a family of health care providersurveys, obtaining data about the facilities that

supply health care, services rendered, and patient

characteristics. Data offer the most accurate and

detailed data on diagnosis and treatment, as well as

on the characteristics of the institutions. These dataare used by policymakers, planners, researchers,

and others in the health community to monitorchanges in the use of health care resources, tomonitor specific diseases, and to examine the impact

of new medical technologies.

c Annual data releasec Multistage sampling design of health care facilities/

providers/patient records; medical record

abstraction

c Geography: National, 4 regions

1. National Ambulatory Medical Care Survey

(NAMCS): physician offices

2. National Hospital Ambulatory Medical Care

Survey (NHAMCS): hospital emergencydepartments and outpatient departments

3. National Hospital Discharge Survey (NHDS):

nonfederal short-stay hospitals

Administered by the National Center for Health

Statistics, CDC

Ambulatory, emergency department, and hospitalinpatient asthma visits and stays.
21 Advance Data No. 381 + December 12, 2006

ma content—Con.

Purpose/Scope Design/Sample/Geographic coverage Selected asthma content

P),

.jsp

c HCUP: a family of health care databases and

software tools developed through a Federal-stateIndustry partnership and sponsored by AHRQ.

c HCUPnet: a free, on-line query system based on

data from HCUP. It provides access to health

statistics and information on hospital stays at thenational, regional, and state level.

c The Kids’ Inpatient Database (KID): a powerfuldatabase of hospital inpatient stays for children.Researchers and policymakers can identify, track,

and analyze national trends in health care use,access, charges, quality, and outcomes.

c Annual data releasec Medical record abstractionc Geography: National and State1. State Inpatient Databases:

universe of inpatient discharge data from >35

states; >90% of US community hospital

discharges.

2. State Ambulatory Surgery Databases: data from

ambulatory care encounters in >20 states.

3. State Emergency Department Databases:

emergency dept. abstract data for >15 states

4. Nationwide Inpatient sample: 20% stratified

sample of U.S. community hospitals.

5. KID: all-payer inpatient care for children.

Administered by AHRQ

Ambulatory, emergency department, and hospitalinpatient asthma visits and stays.

s/s/

The vital statistics general mortality data are a

fundamental source of demographic, geographic, andcause-of-death information. This is one of the few

sources of comparable health-related data for smallgeographic areas and a long time period in the U.S.The data are also used to present the characteristicsof those dying in the U.S. to determine lifeexpectancy and to compare mortality trends with

other countries.

c Annual data releasec Compilation of data from death certificates from 50

states and D.C.

c Residential population (includes all deaths within

the U.S.)

c Geography: National and stateAdministered by the National Center for Health

Statistics, CDC

Deaths with asthma as the underlying or

contributing cause of death.
22 Advance Data No. 381 + December 12, 2006 

retabulated statistics, interactive data resources, and publications 

Site content Asthma-specific content 

Interactive statistical tool (query system) Statistical tables online Interactive statistical tool: Prevalence data by geographic location (national/state/territory) and sex, age, race/ethnicity, income, or education: http://apps.nccd.cdc.gov/brfss/

c Adults who have been told they currently have asthma

c Adults who have ever been told they have asthma

Online asthma prevalence tables by geographic location (state/territory) and sex, age, race/ethnicity, education, or education:

http://www.cdc.gov/asthma/brfss/default.htm

Interactive statistical tool(query system)ChartbooksPublications & Presentations

User can produce data tables for asthma by geographic location (National and state)c Percentage of children with asthma-related health issues in past 12 monthsc Percentage of children with current asthma but no symptoms in past 12 monthsc The extent to which a child’s asthma affects the family

c Percentage of children hospitalized for asthma in past 12 months

Interactive statistical tool(query system)

View by health topic—user can choose ‘‘other’’ topics to view asthma results by geographic location (National and state), year, age,

sex, and grade:

c Percentage of students who had ever been told by a doctor or nurse that they had asthmac Percentage of students who have ever been told by a doctor or nurse that they had asthma and who have asthma but had not had

an episode of asthma or an asthma attack during the past 12 months, or who had an episode of asthma or an asthma attack

during the past 12 months (i.e., current asthma)

c Among students with current asthma, the percentage who had an episode of asthma or an asthma attack during the past 12

months

Interactive statistical tool(query system)PublicationsStatistical tables online

Interactive statistical tool:c MEPSnet http://www.meps.ahrq.gov/mepsweb/data_stats/MEPSnetHC.jsp

Step 1: Data Source Selection - Select a data year; Step 2: Variable Selection - Choose variables to use; Step 3: (Optional)

Variable Recoding - Regroup variables your way; Step 4: (Optional) Record Selection - Select the records you want; Step 5:

Descriptive Statistics - Select Show Statistics to generate the statistics.

Statistical tables online:c Expenditures by medical condition by service site (customizable by age)

http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component= 1&subcomponent=0&tableSeries=2&year=­

1&SearchMethod=1&Action=Search

Publications:c Statistical brief ‘‘Demographic and Clinical Variations in Health Status’’

http://www.meps.ahrq.gov/mepsweb/data_stats/Pub_ProdResults_Details.jsp?pt=Methodology%20Report&opt=2&id=674

c Persons diagnosed with diabetes, asthma, or hypertension had worse physical health status overall than those who did not have

these conditions (adults only)

c Use of different medications and devices in children and adults with asthma (forthcoming)

Interactive statistical toolsPublications

Interactive statistical toolsc Health Data for All Ages: http://www.cdc.gov/nchs/health_data_for_all_ages.htm, and Trends in Health and Aging: http://

www.cdc.gov/nchs/agingact.htm. Enter ‘‘asthma’’ into the search box to access interactive tables on asthma prevalence, health care

use and mortality. Users can customize tables with any or all of the following characteristics: age, gender, race/ethnicity, and

geographic location (national/state depending on data source).

c Healthy People Data 2010: http://wonder.cdc.gov/DATA2010focus.htm. Users can view asthma data (national/state depending on

data source) on Healthy People Objectives by selecting focus area 24 (respiratory diseases).

Publications/Fact sheetsc Health E Stat: ‘‘Asthma Prevalence, Health Care Use and Mortality, United States’’ http://www.cdc.gov/nchs/products/pubs/pubd/

hestats/asthma/asthma.htm

c FASTSTATS asthma page: http://www.cdc.gov/nchs/fastats/asthma.htm

c Health, United States: http://www.cdc.gov/nchs/hus.htm (search for ‘‘asthma’)
23 Advance Data No. 381 + December 12, 2006

retabulated statistics, interactive data resources, and publications—Con.

Site content Asthma-specific content

PublicationsResources

List of Morbidity and Mortality Weekly Reports (MMWR) on asthma: http://www.cdc.gov/asthma/asthmadata.htm#mmwr. Updated

MMWR Asthma Surveillance Summary to be released in 2007.

Asthma Surveillance Data summary:

http://www.cdc.gov/asthma/asthmadata.htm#data. Includes overview of asthma surveillance questions on CDC surveys, and links to

asthma tables, maps, charts, and slides.Statistical tables online:c Asthma prevalence tables from the National Health Interview Survey (NHIS) for the U.S. by age, sex, race/ethnicity, geographic

region, and income: http://www.cdc.gov/asthma/nhis/default.htm.

c Asthma prevalence tables from the Behavioral Risk Factor Surveillance Survey (BRFSS) by geographic location (state/territory) and

sex, age, race/ethnicity, education, or education: http://www.cdc.gov/asthma/brfss/default.htm

CDC asthma resources: http://www.cdc.gov/health/asthma.htm

Research synthesesResearch findingsOngoing researchQuality improvementresources

Research syntheses:c Chronic Care for Low-Income Children with Asthma: Strategies for Improvement Research in Action, Issue 18

http://www.ahrq.gov/research/chasthria/chasthria.htm

c Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies—Volume 5: Asthma (forthcoming–check http://

www.ahrq.gov/clinic/epcix.htm)

Research Findings:c Child Health Research Findings: http://www.ahrq.gov/research/childfind/ (update in progress).

Research in progress:

c Grants on Line Database http://www.gold.ahrq.gov/ (Type ‘‘pediatric asthma’’ into keyword search box.)

Quality Improvement Resources:

c Asthma Care Quality Improvement Workbook and Resource Guide for States http://www.ahrq.gov/qual/asthmaqual.htm
24 Advance Data No. 381 + December 12, 2006

Suggested citation

Akinbami LJ. The State of childhood asthma,

United States, 1980–2005. Advance data from

vital and health statistics; no 381, Hyattsville,

MD: National Center for Health Statistics.

2006.

Copyright information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

Director

Edward J. Sondik, Ph.D.

Acting Co-Deputy Directors

Jennifer H. Madans, Ph.D.

Michael H. Sadagursky

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

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Hyattsville, MD 20782

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07-0017 (12/06)

CS107789

T27014

DHHS Publication No. (PHS) 2007-1250