He Economic Burden Of The Environment On Two Childhood .

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The Economic Burdenof the Environment onTwo Childhood Diseases:Asthma & Lead Poisoningin MinnesotaD e c e m b e r 2014

Economic Burden of the Environmenton Two Childhood Diseases in Minnesotaminnesota Department of HealtHminnesota environmental public HealtH trackingDecember 2014For more information, contact:Minnesota Department of HealthMinnesota Environmental Public Health TrackingPO Box 64882, St. Paul, MN 55164-0882Phone: 651-201-5900Toll Free: 1-800-205-4987Email: health.tracking@state.mn.us

Economic Burdenof theEnvironmentonChildhood DiseaseIntroductionChildhood diseases have substantial impacts on families andcommunities. Several reports published over the past decade haveestimated the costs to individuals and to society due to chronicdiseases and developmental disorders in children (U.S. EnvironmentalProtection Agency, 2013; World Health Organization, 2006).This report focuses on two important environmentally-related healthconditions in Minnesota’s children: asthma and blood lead poisoning.It documents the economic cost of both conditions in one year,2010, from current surveillance data and estimates the fraction thatis attributable to environmental causes. It focuses on environmentalfactors that are amenable to interventions.To estimate the economic value of preventive actions, this reportdemonstrates a method for using quality environmental public healthtracking (surveillance) data. Using this approach, policy decisions andresources can be directed towards actions that have a measurable impactboth in reducing childhood disease and saving money.The Minnesota Environmental Public Health Tracking Program (MNTracking) was established in 2007 by the Minnesota Legislature (MNStatutes, sections 144.995-998) and, in 2009, joined 23 other statesas part of the Centers for Disease Control and Prevention (CDC)National Tracking Network. For this report, MN Tracking collaboratedwith CDC and other states with tracking programs includingCalifornia, Connecticut, Florida, New Hampshire, Oregon andUtah. The Tracking Network is committed to making quality publichealth data more accessible and useful to the public for informing andevaluating environmental public health actions and policies.MN Tracking worked closely with the Minnesota Department ofHealth (MDH) Asthma Program and the MDH Lead and HealthyHomes Program on this report.Pag e 3inM i n n e s o t a 2014KEY FINDINGS The total economicburden of childhoodasthma in Minnesota in2010 attributable to theenvironment was 31.6million (in 2014 ) (range: 10.5 million – 36.9million) The total economic burdenof childhood lead poisoningin Minnesota on lifetimeearnings is 1.9 billion (in2014 ).KEY LIMITATIONSThe costs calculated in thisreport likely underestimatethe true cost to Minnesota’seconomy of asthma episodesand lead poisoning inchildren that are attributableto environmental riskfactors. The burden and costof environmentallyattributed disease inMinnesota’s children is notshared equally across allcommunities of the state. The EnvironmentallyAttributable Fraction (EAF)is an uncertain estimate.

Economic Burdenof theEnvironmentonChildhood DiseaseinM i n n e s o t a 2014Estimating costs per diseasecase, direct and indirectMethodologyOverviewThis report adopts methods established inpreviously published works (Landrigan, Schechter,Lipton, Fahs, & Schwartz, 2002; Trasande & Liu,2011) and updates these methods with current statedata and information.The formulaThe formula for estimating the economic burdenof environmentally-related disease relies on thecomponents described below:ECONOMIC BURDEN:DISEASE COUNTSXCOST PER CASEXENVIRONMENTALLY ATTRIBUTABLE FRACTION(EAF)Economic burden is estimated as the numberof cases of disease in a defined populationand specified time period, multiplied by theenvironmentally attributable fraction (EAF) andthe estimated cost per disease case. The time periodused in this report was the 2010 calendar year.Counts of disease casesThe estimated number of children treated forasthma came from the CDC Chronic Disease CostCalculator. MN Tracking staff worked closely withthe MDH Asthma Program to obtain data on childasthma deaths.MN Tracking staff worked closely with the MDHLead and Healthy Homes Program to determine theaverage blood lead level in Minnesota children bornin 2004 based on MN Blood Lead InformationSystem data.For asthma, cost estimates were derived from theCDC Chronic Disease Cost Calculator for directmedical care costs per case in 2010 including thecosts of clinic visits, hospitalizations, emergencydepartment visits, and medications. Indirect costs,including wages lost from a parent who cares fora child with asthma, were also derived from thecalculator, while the cost of a premature death wasderived from Max, Rice, Sung & Michel (2004).For childhood lead poisoning, cost estimates werecalculated using wages lost from the impact of alower IQ on lifetime earning capacity, derived frommarket productivity estimates in Grosse, Kreuger &Mvundura (2009).The environmentallyattributable fraction (EAF)The environmentally attributable fraction (EAF)is the estimated proportion of disease casesthat are thought to be causally associated withenvironmental risks. Environmental risks for thisreport include modifiable physical and chemicalfactors in our home, work and communityenvironments. The calculations in this reportexclude naturally occurring risks, such as radon,and behavioral risk factors such as smoking anddiet, and are limited to risk factors that could bequantified based on the available scientific evidence.EAF estimates the fraction of the disease that wouldbe avoided or eliminated if the environmentalrisk were removed or reduced to the lowest levelpossible. Published relative risk estimates from theepidemiological literature and the prevalence of theexposure in the population are used to calculatethe EAF. This report uses the EAF estimates firstpublished by Landrigan et al. (2002).Pag e 4

Economic Burdenof theEnvironmentonChildhood DiseaseinM i n n e s o t a 2014DISPARITIES OBSERVEDAsthma prevalence in Minnesota is currentlylower than the national average; however, thereare significant disparities in prevalence by race/ethnicity.The Costs ofChildhood AsthmaAccording to data from the 2013 MinnesotaStudent Survey,21% OF AMERICAN INDIAN AND 24% OF AFRICANAMERICAN YOUTH REPORT AN ASTHMA DIAGNOSISCOMPARED TO 16% OF WHITE AND HISPANICSTUDENTS, AND 13% OF ASIAN STUDENTS.Asthma burden and trendsin MinnesotaAccording to 2012 data from the Behavioral RiskFactor Surveillance System,About one in 14 Minnesota children (under 18)currently have asthma, or about 90,000 children.ASTHMA PREVALENCE AMONG ADULTS IS HIGHERAMONG BLACKS (14%) THAN WHITES (8%).Many indicators of the burden of asthma inMinnesota have been improving over time. Asthmahospitalization rates continue to decline in theseven-county Twin Cities metropolitan area,particularly among children. However, rates ofasthma-related emergency department (ED) visitshave remained relatively stable since 2005, and aftera dramatic decrease through 2006, statewide asthmamortality rates have been rising slowly.Disparities in asthma prevalence by race/ethnicityare also evident among enrollees in Minnesota’smedical assistance programs, with the highestprevalence among Blacks (Minnesota Departmentof Health, 2012).ASTHMA HOSPITALIZATIONS FOR MINNESOTA CHILDRENRate per 10,000 children2520151050200020012002200320042005Twin Cities MetroGreater MinnesotaSource: Minnesota Hospital Association; MDH AsthmaPage 5200620072008200920102011

Economic Burdenof theEnvironmentonThere are striking geographic disparities in rates ofasthma-related ED visits and hospitalizations inMinnesota. Asthma hospitalization rates amongchildren living in the Twin Cities metropolitanarea are 54% higher than among children livingin Greater Minnesota. Rates of asthma-related EDvisits are nearly twice as high among children inthe Twin Cities metro area compared to children inGreater Minnesota.Childhood DiseaseinM i n n e s o t a 2014Air pollution, such as particulate matter (PM),is associated with increased hospitalizations forasthma (Barnes, Rodger, & Thomson, 1998, p.589-596; Trasande & Thurston, 2005).In the Eastern U.S., summer ozone pollution isassociated with more than 50,000 hospitalizationsper year for asthma and other respiratoryconditions. U.S. and Canadian studies haveshown warm season ozone-associated increasesin respiratory hospital admissions ranging from2-30% per 20 ppb (24 hours), 30 ppb (8-hours)or 40 ppb (1-hour) (U.S. EPA, 2006).RISK FACTORSMost asthma episodes (also referred to as asthmaexacerbations), including those resulting inhospitalizations, are preventable if asthma isproperly managed according to established medicalguidelines, which include reducing exposures toenvironmental triggers (National Asthma Educationand Prevention Program, 2007). A variety of factorscan trigger an asthma episode, including viralrespiratory infections; exposure to allergens (e.g.dust mites, dander (protein particles shed by catsand dogs), and pollen; exercise; tobacco smoke; airpollution; strong emotions; chemical irritants; anddrugs (e.g., aspirin and beta blockers).EAF for asthmaEstimate: 30% (ranges from 10% to 35%)A panel of experts (Landrigan, et al.,2002) determined 30% of asthma episodes(exacerbations of childhood asthma) can beattributed to outdoor air pollution (e.g., vehicleexhaust and power plant emissions). This estimatedoes not include exacerbations due to othertriggers such as mold, secondhand cigarette smoke,pollen, or respiratory infections.STUDIES HAVE SHOWN5-20% INCREASES IN RESPIRATORY-RELATEDHOSPITALIZATIONS PER 50mcg/M3 OF PM10 AND5-15% PER 25mcg/M3 OF PM2.5 OR PM10-2.5WITH THE LARGEST EFFECT ONASTHMA HOSPITALIZATIONS(U.S. EPA, 2004)Pag e 6

Economic Burdenof theEnvironmentonEconomic BurdenChildhood DiseaseinM i n n e s o t a 2014The following costs estimates are included in thisreport:The CDC Chronic Disease Cost Calculator(Centers for Disease Control and Prevention,2013) estimates the number of asthma cases andthen calculates the direct and indirect costs per caseaccrued over the course of one year for children ages0-17 years, adjusted to 2014 dollars. Direct medical and non-medical costs Indirect costs, such as lost parental earningsdue to school absenteeism Lost potential earnings due to premature deathThe total costs of childhood asthma in Minnesotain 2010 was 105 million (in 2014 ), includingdirect medical costs, indirect cost of missed schooldays, and deaths due to asthma. Applying the30% EAF to this annual cost, the total economicburden of childhood asthma in Minnesota in2010 attributable to the environment was 31.6million (in 2014 ) (range: 10.5 million – 36.9million).The number of childhood deaths in Minnesotadue to asthma is quite small and can vary fromyear to year. Therefore, a five year average wasused to calculate the annual average number ofpremature deaths; there were an average of 2 deathsdue to asthma from 2007 to 2011 in Minnesota.Mortality cost for the premature death of a childwas estimated using the present value of lifetimeearnings (Max, et al., 2004). Values were averagedfor both boys and girls for 0-17 years of age.TABLE 1: ANNUAL COSTS OF CHILDHOOD ASTHMA IN MINNESOTA IN 2010.Type of costDirect(medical)Indirect (missedschool)Indirect(mortality)Included in costInputsAnnual value (2014 )Physician visits, ED,hospitalizations,prescriptionmedication 940 average costx78,900 childrentreated 80,190,000Lost parental earningsdue to missed schooldays 156 (daily wage)x141,000 school daysmissed 23,840,000On average, therewere 2 prematuredeaths due toasthma (2007-2011combined) 700,000 perpremature deathx2 deaths (average) 1,400,000Estimated total cost:EAF:Environmentally attributable cost of childhood asthma:Range (10%-35%):Source: CDC Chronic Disease Cost Calculator; EAF environmentally attributable fractionPage 7 105,430,00030% 31.6 million( 10.5 - 36.9 million)

Economic Burdenof theEnvironmentonChildhood DiseaseinM i n n e s o t a 2014THRESHOLD LOWEREDThe Costs ofChildhood BloodLead PoisoningDisease burdenin MinnesotaLead poisoning is a medical condition that occurswhen lead builds up in the body. Elevated bloodlead levels (EBLLs) in young children are associatedwith adverse health effects, including learningimpairment, behavioral problems, and even death atvery high levels.The proportion of children with lead poisoning hasdeclined over time in Minnesota, from about 2% ofchildren born in 2000 to less than 1% of childrenborn in 2009, among children tested before 3 yearsof age.There is no safe level of exposure to lead. Thethreshold for an “elevated blood lead level” inMinnesota was recently lowered from 10 to 5 µg/dL (Minnesota Department of Health, 2014a). TheCDC also recently lowered the threshold to 5 µg/dL, and future reductions are likely. This thresholdis used to trigger actions for investigation andremediation of sources of lead in the home.BLOOD LEAD LEVELS ARE DECLINING INMINNESOTATesting for lead poisoning is important as itoften occurs with no identifiable symptoms. Thepercentage of tested children with elevated bloodlead, levels previously defined by the state ofMinnesota as a level of 10 µg/dL or higher, has beendecreasing.Blood lead testing in Minnesota is targeted and notuniversal, meaning not every child is tested. Thatmeans this measure is not generalizable and cannotbe used to interpret the prevalence or incidence forall children living in Minnesota.CHILDREN WITH CONFIRMED ELEVATED BLOOD LEAD LEVELS (EBLLs) IN povertyin1.6400Minnesota is lower than the national average, there are still many children living in poverty in the dhoodleadpoisoning.About15%ofallchildren( 18years)andabout1.23001.117% of all children under age 5 in Minnesota live in poverty. The majority of counties in northern Minnesota1.00.9have a higher percentage of children living in poverty, compared to the state average of 15%, as do Hennepin2000.80.7and Ramsey Counties.0.60.51000.4RISK FACTORS FOR CHILDHOOD LEAD POISONING AND THE ENVIRONMENTAL Younger00.02001because20022003 absorb2004 lead more2005 easily20062007brains20082009children are 2000more at risktheir bodiesand theirare still developing.Percent with EBLLsNumber with EBLLs500DISPARITIESOBSERVED (INCOME AND REGION)BIRTH COHORTYEARLead-based paint is a common cause of lead poisoning.Peoplecan be exposed to lead by ingesting dust fromdeteriorated leadNumberpaint, consumingothermaterialscontaminatedwith lead, or breathing aerosolized lead paintof Birth Cohort with EBLLsPercentofBirthCohortwithEBLLsDisparities observed (income and region)µg/dL means micrograms for lead per deciliter of bloodPag e 8

Economic Burdenof theEnvironmentonChildhood DiseaseDISPARITIES OBSERVEDChildren in poverty are at greater risk for leadpoisoning. About 15% of all children ( 18 years)and about 17% of all children under age 5 inMinnesota live in poverty. The majority of countiesin northern Minnesota have a higher percentageof children living in poverty, compared to thestate average of 15%, as do Hennepin and RamseyCounties.RISK FACTORSChildren less than 6 years old living in homes builtbefore 1978 are most at risk for lead poisoning.Younger children are more at risk because theirbodies absorb lead more easily and their brains arestill developing. Lead-based paint is a commoncause of lead poisoning. People can be exposed tolead by ingesting dust from deteriorated lead paint,consuming other materials contaminated with lead,or breathing aerosolized lead paint dust. Youngchildren frequently put their hands or other objects,which may be contaminated with lead, into theirmouths. The U.S. EPA estimates that more than80% of all homes built in the U.S. before 1978contain lead-based paint.inM i n n e s o t a 2014EAF for childhoodlead poisoningEAF: 100% (no range)A panel of experts (Landrigan et al., 2002)determined that all cases of lead poisoning areassumed to be of environmental origin. Therefore,the EAF is 100%, and no range was calculated.Economic BurdenAbout 54,000 Minnesota children born in 2004were tested before the age of 6, or about 76% ofthe 2004 birth cohort. The average peak bloodlead level (BLL) was 2.5 micrograms of lead perdeciliter of blood (µg/dL) – among children bornin 2004 and tested up to age 6. This BLL wasconverted into lost IQ points, then into lost lifetimeearnings for boys and girls, separately. The totaleconomic burden of childhood lead poisoning inMinnesota on lifetime earnings is 1.9 billion (in2014 ).TABLE 2: CALCULATION OF PERCENT LIFETIME EARNINGS LOST DUE TO CHILDHOOD LEADPOISONING AMONG THE 2004 BIRTH COHORT IN MINNESOTA.Mean peak BLLIQ points lostdue to leadpoisoningTotal IQ pointslost due to leadpoisoningLifetime earningslost due to IQ pointslostTotal lifetimeearnings lost2.5 µg/dL0.47 IQpoints per 1µg/dL1.19 IQ points2.39%per IQ point lost2.85%TABLE 3: COST OF CHILDHOOD LEAD POISONING ATTRIBUTABLE TO THE ENVIRONMENT FOR THE2004 BIRTH COHORT IN MINNESOTA.Lifetimeearnings lostdue to leadpoisoning2.85%Lifetimeearnings perchild (2007 )BoysGirls 1,055,542 622,653Lifetimeearningslost perchild 30,117 17,765Page 9NumberofchildrenLifetime earningslost35,98834,626 1,083,833,838 615,145,548Finaleconomicburden(2014 ) 1.9 billion

Economic Burdenof theEnvironmentonChildhood DiseaseinM i n n e s o t a 2014Strategies to reduceenvironmentalrisks and improvechildren’s healthDespite the limitations of the data (see page14), this report points to important actionsthat Minnesotans can take to reduce exposureto environmental risks and lower the economicburden.Actions Addressing AirPollution and AsthmaAccording to a recent report, air quality inMinnesota has been steadily improving over thepast 10 years (Minnesota Pollution Control Agency,2013). Both ozone and particulate matter levels,which are known asthma triggers, are decliningfor most Minnesotans. Local initiatives, whichinclude the Minnesota Emissions Reduction Project(reduced particle pollution from three metro areapower plants), Project Green Fleet (reduced dieselemissions from school buses and other vehicles),and school bus anti-idling laws are examples ofrecent actions that are making a difference.Soon, more stringent air quality standards willbe adopted, and new initiatives will be needed,such as those proposed by Clean Air Minnesota(Environmental Initiative, 2014) for reducingwood smoke, retiring older, polluting vehicles,and incentives for alternative fuels. In 2014, theMinnesota Pollution Control Agency and MDHare working on developing new tools for urbancommunities for monitoring and addressing localsources of air pollution that exacerbate asthma.The MDH Asthma Program educates health careproviders, people with asthma, their caregivers,and others about ways to improve asthma care andreduce exposure to asthma triggers (MinnesotaDepartment of Health, 2014b). Since 2005,the program has received funding for projectsto conduct low-cost home environmentalinterventions. These projects have led to decreasedasthma symptoms, fewer missed school days andhealth care visits following the intervention; theoriginal project was included in CDC’s CommunityGuide Asthma Control: Home-based Multitrigger Multicomponent EnvironmentalInterventions tml).Actions AddressingChildhood Lead PoisoningThe MDH Lead and Healthy Homes Program isa leader for childhood lead poisoning preventionefforts statewide, working toward the eliminationof childhood lead poisoning as a public healthproblem through lead education, by identifyingat-risk homes and children, and supporting peopleexposed to lead (Minnesota Department of He

Childhood Asthma. Asthma burden and trends in Minnesota . About one in 14 Minnesota children (under 18) currently have asthma, or about 90,000 children. Many indicators of the burden of asthma in Minnesota have been improving over time. Asthma hospitalization rates continue to decline i

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