Editor's note: This story is part of "Breathless," EHN's in-depth look at asthma in Pittsburgh and what can be done to help children breathe easier.
Smokestacks of US Steel's Clairton Coke Works are visible behind a row of homes in Clairton, PA. (Connor Mulvaney/EHN)<p>Manzi acknowledges that there's not yet enough research on that topic to officially designate asthma an autoimmune disorder. "But," she adds, "I think a lot of people would say that many autoimmune diseases have environmental triggers, and asthma would not be distinct from that."</p><p>While we know asthma rates in Allegheny County are higher than average, there's a lack of data available on the overall prevalence of autoimmune disease, (mostly due to to the sheer number of them) which makes it difficult to compare rates between regions. Manzi doesn't have statistics on which autoimmune diseases are most prevalent in Pittsburgh, but based on her observations, she says the institute most commonly treats patients with inflammatory bowel disease, Crohn's disease, celiac disease, ulcerative colitis, autoimmune thyroid disease, rheumatoid arthritis and multiple sclerosis.</p><p>We do know that Allegheny County has higher than average mortality rates for at least one autoimmune disorder: From the years 2000 through 2008, the age-adjusted death rate for multiple sclerosis in Allegheny County <a href="http://www.post-gazette.com/news/health/2010/12/16/Other-diseases-show-up-at-higher-rates/stories/201012160372" target="_blank">exceeded the state average by 40 percent</a>, according to state Department of Health mortality data.</p><p>"There have been a lot of studies looking at whether areas that have higher concentrations of small particle pollutants have higher risk of autoimmune disease, or at least higher risk of ones that are under poor control," Manzi says. "There's been some data to support that beyond asthma, which we know can be triggered by air pollution, a number of autoimmune diseases, like rheumatoid arthritis and lupus, have been linked to these particles in the air."</p><p>Scientists have <a href="https://www.sciencedirect.com/science/article/pii/S1568997211001509?via%3Dihub" target="_blank">documented numerous links</a> between autoimmune diseases and exposure to various forms of air pollution. In particular, research shows that exposure to particulate matter pollution—which Allegheny <a href="http://www.ehn.org/pittsburgh-air-quality-is-getting-worse-2561249417.html" target="_blank">ranks 10th worst in the nation for</a>—can worsen existing cases of autoimmune diseases like lupus, neuroinflammatory disease, and type 1 diabetes, and in some cases may even be a trigger for the onset of disease.</p><h3><em>Related: </em><a href="http://www.ehn.org/how-many-pittsburgh-kids-have-uncontrolled-asthma-2575403222.html" target="_blank"><em>60% of Pittsburgh kids with asthma don't have their disease under control</em></a></h3><p>As an example, Manzi pointed to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717131/" target="_blank">a 2009 study</a> that found people who lived near high-traffic roadways face greater risk of developing rheumatoid arthritis. Traffic-related pollution worsens ozone pollution levels. In addition to particulate matter pollution, ozone was one of the categories that Allegheny County received an "F" grade for in the American Lung Association's <a href="http://www.lung.org/our-initiatives/healthy-air/sota/city-rankings/states/pennsylvania/allegheny.html" target="_blank">2018 State of the Air report</a>.</p><p>Numerous studies have also shown that elevated levels of particulate matter pollution lead to spikes in ER visits for asthma and other acute heart and respiratory illnesses, as well an increase in deaths related to those diseases. A recent study in Allegheny County found that in the year after one of Pittsburgh's biggest polluters shut down, ER visits for asthma and chronic obstructive pulmonary disease (COPD) <a href="http://www.ehn.org/shenango-coke-works-closed-asthma-dropped-2566777141.html" target="_blank">dropped by 38 percent</a>.</p><p>Exposure to air pollution has also been shown to worsen disease activity in people who already have an autoimmune disease. A 2011 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018498/" target="_blank">Canadian study</a> linked high levels of particulate matter pollution with lupus flare-ups. The researchers monitored 237 patients over seven years, while simultaneously measuring the air quality in their surrounding environments. After adjusting for certain climate factors and for race, ethnicity and gender, they found a direct correlation between spikes in particulate matter pollution and spikes in disease activity, both in patients' reported symptoms and in their lab tests.</p><p>A <a href="https://www.sciencedaily.com/releases/2016/06/160609115429.htm" target="_blank">similar study out of Brazil in 2016</a> looked at the impact of air pollution on children with lupus. Those researchers also observed spikes in disease activity that coincided with spikes in particulate matter pollution, and noted a significant increase in inflammation of the children's airways when pollution levels were high.</p><p>"Our findings have shown that air pollution doesn't just increase the incidence and prevalence of chronic lung disease and acute respiratory infections, lung cancer, heart disease and strokes, it is also an important contributory factor in childhood rheumatic diseases, such as lupus," Dr. Maria Fernanda Goulart, a co-author of the study from the University of São Paulo, said in a press release at the time.</p><p>A more recent Canadian study, conducted in 2014, concluded that particulate matter pollution <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063847/" target="_blank">could both trigger and accelerate</a> the development of gastrointestinal autoimmune diseases like Crohn's, ulcerative colitis, and inflammatory bowel disease.</p><p>Dr. Sally Wenzel, director of the Asthma Institute at the University of Pittsburgh Medical Center, says Pittsburgh would be an ideal place for further study on the links between air pollution, asthma, and autoimmune disease.</p><p>"Autoimmune disorders are inflammatory diseases just like asthma," Wenzel tells EHN. "And yet the data on how environment and location relate to autoimmune disease is much more lacking than it is for asthma.</p><p>"There's a lot of evidence now that what you breathe may impact your lungs in many ways, and could actually start an autoimmune process. That's a link we haven't fully explored in this region yet."</p>
Editor's note: This story is part of "Breathless," EHN's in-depth look at asthma in Pittsburgh and efforts to help children breathe easier.
Damaged airways, emergency room visits, missed school and obesity<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk3ODQ0NC9vcmlnaW4uZ2lmIiwiZXhwaXJlc19hdCI6MTYyMzc1MDI1MH0.6iVotgq7T080qREi2I3t3vP_ksuUiaKuwW8e-ceqHCg/img.gif?width=980" id="e05c9" class="rm-shortcode" data-rm-shortcode-id="f03207ad9e0ffcd5a164f681d302d80f" data-rm-shortcode-name="rebelmouse-image" />
“Pittsburgh patients are far and away the sickest”<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk3ODg4OC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0NjA4NjExMn0.URRk1EL1iglLSfsp_DrvbW6rxxUK1yGOWHuQWSxMVtc/img.jpg?width=980" id="ec19c" class="rm-shortcode" data-rm-shortcode-id="2f76a4b2c43830e53135a05ca1cfaed6" data-rm-shortcode-name="rebelmouse-image" />
Students walk past a mural depicting air quality issues in the halls of Clairton Education Center in Clairton, PA. (Connor Mulvaney/EHN)<p> In a city that's branded its post-industrial comeback as being all about "eds and meds," why are so many children living with an unchecked, life-threatening disease? </p><p> "There may have been some reluctance in Pittsburgh and the Western Pennsylvania region to talk much about respiratory disease in a place where there's a legacy of industrial pollution, but those industries have also been an economic driver in the region," says Dr. Wenzel. "There's always this conflict between health and economics here that seems to make it easy not to work too hard on things that impact air quality." </p><p> Asthma can also go uncontrolled due to improper use of medications or lack of access to them. Gentile speculates that Pittsburgh's dearth of reliable public transit could be making it difficult for low-income families in areas with high levels of air pollution to get to their doctors and pharmacies regularly. </p><p> We could also be seeing higher rates of uncontrolled asthma in Pittsburgh because asthma tends to be not only more prevalent here, but also more severe, which requires more complex treatment to manage. </p><p> Wenzel is part of a nationwide clinical research network on asthma created by the National Heart Lung and Blood Institute, which has been collecting data on asthma since 2009. For the last three years, she's been working on a project related to severe asthma that includes patient data from Madison, Wisconsin; Wake Forest, Arizona; St. Louis; Boston; San Francisco; Cleveland; and Pittsburgh. </p><p> "Over three years, Pittsburgh patients have consistently been far and away the sickest among the seven sites," Wenzel says. "Pittsburgh asthma patients have twice the rates of exacerbation, lower lung function, worse symptoms and more use of corticosteroids." </p><h3><em>Related: </em><a href="http://www.ehn.org/asthma-near-clairton-coke-plant-2539978896.html" target="_blank"><em>Coke plant pollution linked to "asthma epidemic" in Pittsburgh-area elementary school</em></a></h3><p> She notes that this may in part be due to referral bias, since she's known as an expert on severe asthma. </p><p> "But the difference is so striking," she adds, "that anytime we do a network-wide study we actually have to pull out the Pittsburgh group and control for that data." </p><p> She adds that more study is needed, and that she'd like to go back through the data to see whether there are clusters of patients with severe asthma in particular Pittsburgh neighborhoods. </p><p> "But," she says, "my impression is that they're fairly distributed throughout the region." </p><p> For kids with severe asthma, getting the disease under control can be life-changing. For some parents, that means moving them to places with cleaner air. </p><p> "We had a patient enrolled here with a child who had very, very severe asthma, and their family literally lived across the street from the coke works. They were fortunate enough to be able to move out," Gentile says. She reiterates that although asthma has many triggers, removing major, known triggers can only be helpful. Prior to leaving, she says, "this child was basically in the emergency room every week, very sick with his disease." </p><p> Collette is considering trying to do the same for Savaughn. "When my daughter graduates high school next year, I'm thinking about moving him out of state," she says. </p><p> "The coke plant is a big part of that. I figure if I move out of the area and give him fresher, normal air, maybe he'd be able play like other kids."</p>
Asthma plagues children in Allegheny County—and air pollution is making it worse.
Day 1<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk4MDU2Ni9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYwNTExNTA0OH0.pPwj150uYMCJPBWoT0_O6-aiQvaOQF5vZETM9ZWxwCE/img.jpg?width=980" id="5f7b7" class="rm-shortcode" data-rm-shortcode-id="62a585c19533d6a8b8c0910bd035516e" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="http://www.ehn.org/how-many-pittsburgh-kids-have-uncontrolled-asthma-2575403222.html" target="_blank">60% of Pittsburgh kids with asthma don't have their disease under control.</a></h3><p>Recent research revealed that asthma was uncontrolled in nearly 60 percent of Pittsburgh-area children with the disease. Nationally, the rate of uncontrolled asthma in kids is 38 percent. State-wide it's 27 percent. Uncontrolled asthma is often the result of a lack of diagnosis and subsequent lack of treatment. </p><p>"I've actually met kids that are only breathing at about a third of the capacity they should be."</p>
Day 2<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk4MDU3OC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYyMTU0MjE5NX0.x6bMBw-zvKkmmSjnPo6R8dfQW96YxYrBc7oSB0-2xDI/img.jpg?width=980" id="554f9" class="rm-shortcode" data-rm-shortcode-id="1ea8655baf4abecbddd329717b4fe5b7" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="http://www.ehn.org/is-there-a-connection-between-pittsburghs-high-rates-of-asthma-and-autoimmune-disorders-2575697497.html" target="_blank">Is there a connection between Pittsburgh's high rates of asthma and autoimmune disorders?</a> </h3><p>Although asthma has many triggers, some research suggests that the disease is also the result of a malfunctioning immune system, which results in inflammation of the airways. A number of researchers have called for further exploration of the links between the two. </p>
Day 3<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk4MDYyMi9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTQ0MTU2Mn0.kxKs-2o2c4kuQg5bOaVaaLi3fZcZruw628aM_sYnUqU/img.jpg?width=980" id="94abf" class="rm-shortcode" data-rm-shortcode-id="672040c4d6ece7d02a3caa2c3583bcac" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="http://www.ehn.org/screenings-to-help-pittsburgh-kids-with-asthma-2575985815.html" target="_blank">Can mandatory school screenings solve Pittsburgh's asthma epidemic?</a> </h3>"We see these school-based health clinics as an important way forward, but right now our state doesn't support this kind of model. You need to get some support from the government to help fund something like this. In some states that happens. In Pennsylvania, it doesn't."
Day 4<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzk4MDY1MS9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTYyMjIwNjAyN30.bd4sd5bhDfPe-98jzo_EDXQBMavKP5TsHTlHmZUvdto/img.png?width=980" id="155b8" class="rm-shortcode" data-rm-shortcode-id="9f0758bf295b6da9c3e15144eb1c3aec" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="http://www.ehn.org/video-testing-and-teaching-how-in-school-screenings-can-help-kids-catch-their-breath-2576020947.html" target="_blank">VIDEO —Testing and teaching: How in-school screenings can help kids catch their breath</a> </h3><p>"We didn't want to just come in and do our research and then leave these kids hanging. We certainly need to clean up the air. But in the meantime, somebody also has to help these kids."</p>
One month later<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xODE4MTMwNy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYwOTU0MjgzNH0.vdaam0u00SSqEhiUg1dBNsalYusyFW7_9tn-Ah1hzKc/img.jpg?width=980" id="4e00c" class="rm-shortcode" data-rm-shortcode-id="6fedb4817abde0390f5b4d5a3988e3e8" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="https://www.ehn.org/what-do-politicians-have-to-say-about-pittsburghs-air-pollution-and-asthma-epidemic-2585838314.html" target="_blank">What do politicians have to say about Pittsburgh's air pollution and asthma epidemic?</a></h3><p>"I almost feel like these statistics can't be real."</p><p><br></p>
Related coverage<img lazy-loadable="true" src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xNzkxNTM5OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1NTUwNzQ3MX0.uEqVjZn7q2z_ynd8MXHOoB-knJg1oMMgS118Cs90Uts/img.jpg?width=980" id="729ea" class="rm-shortcode" data-rm-shortcode-id="6b12ea7099e3dcee0d505e188667fa55" data-rm-shortcode-name="rebelmouse-image" /><h3><a href="http://www.ehn.org/shenango-coke-works-closed-asthma-dropped-2566777141.html" target="_blank">ER visits for asthma dropped 38% the year after one of Pittsburgh's biggest polluters shut down.</a> </h3><p>There's some debate over what the findings mean. But one thing is certain—people are breathing easier.</p>
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