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Asthma Information for Schools

You must work closely with teachers, the nurse, administration and other parents to ensure that your school's policies and practices provide a safe environment for your child. Schools vary in the appropriateness of their policies and commitment to health planning, the physical conditions in the school building, the accessibility of a certified school nurse, and the level of teacher knowledge about asthma.

The sections listed below were taken from "Asthma at School" in Dr. Tom Plaut's Asthma Guide for People of All Ages. The Asthma Emergency Guides are single page documents that may be copied without charge by a school nurse or school district for posting in the classroom.

Health Planning
Guidelines for Teachers and School Staff
Legal Aspects of Asthma at School
Indoor Air Quality
Health Problems Related to Indoor Air Quality
Understanding Indoor Air Quality in Schools
Summary


How Asthma-Friendly Is Your School?
Individualized Health Plan (IHP)
The Individuals with Disabilities Education Act (IDEA).
Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973
Americans with Disabilities Act (ADA) of 1990
Typical Sources of Indoor Air Pollution

Asthma Emergency Guide for Schools
Asthma Emergency Guide for Pre-schools

The Asthma Learning Tool for Teachers

Asthma Education for Childcare and Preschool Staff


HEALTH PLANNING
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School health professionals have developed a framework for health planning known as the Individualized Health Plan (IHP). An IHP is a written record of a school’s comprehensive health management plan for meeting a particular child’s special health needs. Creating an IHP involves a series of steps to identify those needs, develop strategies to meet them and provide for scheduled evaluation of how well the plan is working. The plan should specifically address the areas of medication, environmental safeguards, physical education, teacher and staff planning and emergencies.

Before your child enters school, notify the administration in writing about her asthma. Ask your child’s doctor to send a formal letter including the diagnosis and medicine needs, and recommending environmental safeguards and guidelines for exercise and emergencies. Request a planning meeting with all school staff who play a role in your child’s well-being.

A school nurse should coordinate the health management team. Other participating staff might include the principal or director of student services, teachers, teacher’s aides and other professionals.

In this meeting, consider the physician’s recommendations in the specific context of the school and the classrooms your child will attend. Give the school the written authorizations it will need to carry out your doctor’s instructions and sign forms allowing designated school staff to discuss confidential information about your child with your doctor.

Several resources include sample IHP forms that can guide your child’s planning team by helping you ask important questions and providing a framework for answering them. Consult The School Nurse’s Source Book of Individualized Health Care Plans, Serving Students with Special Health Care Needs, Massachusetts Comprehensive School Health Manual, and Guidelines for Serving Students with Special Health Care Needs. In addition, check with your state’s Department of Education and Department of Public Health for guidelines for developing an Individualized Health Plan. The NHLBI produces “Managing Asthma: A Guide for Schools,” which offers guidelines for administrators, teachers, coaches, and students, although not within the specific framework of an IHP.

WHAT IF THERE IS NO SCHOOL NURSE?
The development and implementation of an asthma management plan depends heavily upon the school nurse. However, many districts do not have full-time nurses, or they have nurses who provide services to many students, sometimes in different buildings. Since asthma problems do arise when no school nurse is available, the school administration needs to plan for safe delegation of health tasks. State medical practice acts regulate procedures for safe delegation. Contact the school health unit of your state’s Department of Public Health for a copy of the regulations that apply to schools. Simply delegating a health task to an untrained person who is willing to perform it is not safe.

If you are concerned about inadequate staffing at your child’s school, make your concerns known in writing to school administration and the school board.

MEDICATION POLICY AND STUDENT NEEDS
Your child’s medicine routine is guided by your Asthma Action Plan. Ask your doctor to keep the plan as simple as possible and schedule use of controller medicine outside of school hours. The school nurse should concentrate on more essential tasks. Your child may need to take a quick relief medicine during the school day to prevent symptoms of exercise induced asthma or to treat an episode.
According to a ruling by the U.S. Department of Education, Office of Civil Rights, schools are responsible for providing students with reliable access to their prescribed medicines. “Reliable” in this case means that the child can quickly, conveniently, and safely get to his medicine and that school staff is sufficiently knowledgeable about asthma to care for the child’s health and safety.

Environmental Safeguards
Eliminating and avoiding asthma triggers can protect the lungs from sources of inflammation and reduce the amount of medicine needed to keep asthma under control. Once triggers at school are identified they can be removed or exposure to them reduced.

Because schools are complex facilities, you may want to take an environmental “walk-through” with school staff to help identify conditions that are sources of air quality problems. It is best if known or likely triggers are dealt with before students encounter them. Because asthma is provoked and aggravated by environmental exposure, environmental safeguards should be written into the asthma management plan (or IHP).

Some activities or rooms in the school may cause special problems for children with asthma. Field trips may bring a student into contact with an unexpected trigger. Sometimes a one-time exposure to an asthma trigger can cause a problem.

When my patient, Robby, was assigned to a study hall in the wood shop, he told the teacher that this would cause him to have asthma symptoms. The teacher didn't believe Robby and made no change. After he spent one hour in the wood shop Robby missed seven days of school due to asthma and associated problems. I had to double some of his medicines and add an additional one in order to bring his asthma under control. I wrote the following letter to the principal to prevent a repeat incident:

“Please be advised that Robby should not be in the wood shop, the metal shop, or any other place where he is likely to be subjected to dirty air. Although he is only 13, Robby is a good judge of his condition. If he says he should not take gym, the school staff should respect that. His mother and I will follow up to confirm that he’s not just trying to avoid gym. I look forward to working together with you to see that Robby gets the education he needs in an environment that will be safe for him.”

The planning tools available through the Individualized Health Plan process would have anticipated the wood shop problem, avoided placing Robby in a risky environment, and informed teachers that Robby was a good judge of his asthma needs. Robby would have stayed healthy and continued his learning without interruption.

GUIDELINES FOR TEACHERS AND SCHOOL STAFF
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Your child’s teachers may have little or no experience with asthma. The Individualized Health Plan offers an opportunity to provide guidelines and training for them. Using the booklet, One Minute Asthma: What You Need to Know, they can learn the basics of asthma and the medicines used to treat it in about thirty minutes. Make this resource a part of staff training and include it in your child’s asthma management plan. Teachers who have learned about asthma will plan classroom activities and choose materials so every child can participate safely.

Part of the documentation you and your child’s doctor provide to the school should include guidelines for avoiding exposure to asthma triggers. Teachers can integrate these guidelines into their lesson planning. For example, they will know to avoid bringing a guinea pig or rabbit into the classroom because it can provoke inflammation and asthma symptoms. They will know to provide alternative recess activities during cold weather or pollen season. Teachers also need guidelines to plan field trips and other activities outside the school building and instruction in how to handle asthma-related emergencies that occur outside of school. Good planning and communication help put teachers in an informed and comfortable position, able to consider the needs of all their students.

Some materials used in classroom activities are not healthy for any student. The Artist’s Complete Health and Safety Guide discusses classroom hazards created by the use of some art products and identifies safe school supplies. Although the book focuses on products used in art classrooms, many of the same products are used in regular classrooms as well.

PESTICIDES
Does your child’s school use pesticides? When are they applied? Are physical education and other teachers informed? Do students use areas that have been sprayed recently? Are applications on school grounds clearly posted? Are parents notified about pesticide applications? What is the school policy about using pesticides inside the school to control mold, insects, or rodents?

Pesticides present special health hazards for children, whose small body sizes make them more vulnerable to toxic chemicals and whose activities may bring them into closer contact with areas where pesticides are used. Classrooms are often treated with pesticides, and playgrounds and sports fields may be treated with chemicals (including turf treatments like insecticides, fertilizer, lime, and other supplements) which can irritate the lungs. Integrated Pest Management (IPM) is an approach to building and landscape management that corrects and prevents conditions where pests can thrive. These practices can greatly reduce the need for chemicals, protect student and staff health, and often save money.

PEER EDUCATION
Having students with asthma in a class offers a learning opportunity for everyone. These children are learning life skills that are important to all students: self-monitoring, communicating their needs and taking medicines safely. Health management skills are part of many comprehensive health curricula. In addition, learning about the lungs, triggers, and the asthma reaction is well-suited to a health curriculum and can be integrated into many subjects.

The National Heart, Lung and Blood Institute has produced an asthma curriculum, Asthma Awareness, for elementary students, and a short video for school staff (kindergarten through eighth grade), Making A Difference: Asthma Management in the School.

ABSENCES
Students whose asthma is well controlled will miss no more than one day of school due to asthma each year.

PHYSICAL EDUCATION AND EXERCISE
The goal of physical education is to help students build skills for lifelong fitness and health. Exercise commonly triggers asthma symptoms, but students with asthma should not avoid it. Physical education teachers may unnecessarily limit students with asthma, or they may push them too hard and thereby put them at risk for an asthma episode. Well-informed and thoughtful teachers can help these students perform at their best and gain confidence about physical activity.

Good communication and planning can help your child have a positive and safe experience during physical education class. The pamphlet Asthma & Physical Activity in the School: Making A Difference, developed by the NHLBI, provides an excellent framework for this planning. Its “Safety Guidelines for Physical Education Teachers” state that safe physical activity depends on:

• activities that match a student’s changing asthma status and take into account environmental conditions (outdoor temperature, presence of allergens, etc).
• proper use of medicines before exercise, if needed.
• prompt use of quick relief medicines when needed.
• reliable access to medicines during exercise.

A physical education teacher can adjust the type, pace, or intensity of an activity when a student’s peak flow scores drop, symptoms are present, or the student expresses a need for reduced activity. Because exercise is a common trigger for people with asthma, physical education teachers and peers need to be able to recognize the early signs of an asthma episode and know what action to take. Students whose asthma is under excellent control should also be able to play any sport they choose.
A School Emergency Guide should be in place as part of the school’s overall asthma management plan or IHP. The plan should define emergency situations and outline sequential action steps to be taken by designated staff members. Anyone who is responsible for your child during the school day needs instruction in how to identify an asthma emergency.

A peak flow score that is stuck in the child’s red zone is an emergency. “Stuck” means that the peak flow score fails to improve into the low yellow zone within ten minutes after the child inhales 4 puffs of a quick relief medicine. Once the nurse or staff delegate determines that the child is stuck in the red zone, the child must be taken to a medical facility (emergency room or doctor’s office) without delay.

An extreme asthma emergency exists if a child can barely move the marker on the peak flow meter or if he shows any one of the following signs:

• gray or bluish lips or fingernails
• difficulty talking or walking
• difficulty breathing, with any of the following:
- chest and neck skin pulled in (retractions)
- breathing hunched over
- struggling to breathe

In the case of an extreme emergency, the child must be transferred to medical care within minutes.

Teachers and school staff must be able to identify an emergency and know that it calls for immediate action. A good emergency plan will apply to all children with asthma and specify exactly what a teacher should do and who is responsible for carrying out each step of getting your child to medical care. The specific emergency plan itself will depend on the child’s situation, the school, the personnel, the rescue service available, and many other factors.

Here are some questions to consider as you work with the school to develop the steps in an emergency plan:

• Who gives medicine if a nurse is not available?
• Where are medicines kept?
• How do teachers and staff communicate with the nurse, principal, and people outside the school?
• Are teachers and other staff authorized to call for emergency service?
• What is the emergency phone procedure?
• Do staff members who may be responsible for your child all have a copy of the emergency plan and understand it?
• Do teachers and other staff know the signs of an asthma emergency?
• Where is the emergency plan posted?
• How should staff deal with emergencies that happen outside the classroom?
• How is a substitute teacher informed of the plan?
• Has the staff rehearsed a health emergency?
• Does the rescue team include an emergency medical technician (EMT)? Can team members administer oxygen and albuterol? How close are they? What happens if they are unavailable?
• If the student goes to the hospital in an ambulance, who accompanies the child?
• What are the procedures for contacting parents? What is done if parents cannot be reached?

LEGAL ASPECTS OF ASTHMA AT SCHOOL
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The rights of students with disabilities are defined under three federal laws: the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990, as well as state statues and regulations. Federal rulings on specific cases continue to clarify what these laws mean for students with asthma. Your child does not have to be classified as “special needs” to qualify for accommodation or special planning, such as an Individualized Health Plan.

The three sections that follow were taken from the works of Ellie Goldberg, M. Ed., an educational rights specialist. (see “Resource Section).

A SCHOOL’S DUTY TO CARE
Schools have a “duty to care” that is shared by all staff members. This duty arises because students are required to be at school, away from their usual sources of protection (parents). Schools have a duty to exercise “special care” for students known to have physical handicaps, injuries, or impairments. This duty may require administering medication, monitoring health status, providing specialized staffing or training to teachers, and protecting students from emotional distress caused by teasing, neglect, or abuse. Parents cannot waive a child’s right to proper care nor release a school from its obligation to protect a student from harm.

COMPLAINT PROCEDURES
When efforts to work with school officials do not result in appropriate cooperation and supports for your child, you should exercise your due process rights. Federal laws require states to establish a system for working out parent-school disagreements, such as arbitration, mediation, and/or a hearing process. Both IDEA and Section 504 oblige schools to inform parents how to file complaints and seek remedies when they disagree with a school’s decisions or practices.

Every school system should have a “parents’ rights” document explaining its problem-resolution process and naming the person to contact to officially request consideration for a child’s needs or to remedy a situation. If your school handbook or school office does not supply this information, call the district’s director of pupil services, director of special education, or Section 504 coordinator. If you cannot find the appropriate official, call your state’s Department of Education.

SCHOOLS ARE CONCERNED ABOUT LIABILITY
Schools sometimes assume that informal arrangements reduce their liability better than clear written documents that describe procedures, roles, and responsibilities. Many schools do not document accidents, injuries, and medication administration, mistakenly thinking that writing things down somehow exposes staff to liability that they might otherwise avoid. In fact, a school’s best protection against liability is having an ongoing risk-management process that carefully records assigned tasks, responsible parties, and ensures that proper procedures are followed. An accurate reporting system is essential to this process.

INDOOR AIR QUALITY
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The U.S. Environmental Protection Agency has ranked indoor air pollution among the top five environmental health risks. (see Typical Sources of Indoor Air Pollution) Inadequate ventilation and poor maintenance can make the inside of buildings two to five times more polluted than the outdoors. Poor air quality in school can cause a wide range of health problems for occupants, especially for people with asthma.

People who have not been affected previously by allergies or asthma may become sensitized by repeated exposure to a substance or even by a single exposure. To avoid this problem you can create an indoor air quality team that works to promote safe practices, good maintenance, and control of pollutant sources, and promptly reports health symptoms, poor conditions, or hazards. Keeping in-house records of the nature, location, and timing of health symptoms in the school is a reliable and inexpensive way to identify air quality problems.

Construction and remodeling can be major sources of pollution. The work area must be walled off physically and air from the site vented out of the building.

This section discusses the basics of indoor air quality so you can identify potential or existing problems and work to resolve them. The U.S. Environmental Protection Agency recommends measurement of air temperature, relative humidity, air movement, and volume of airflow. Schools should have the basic equipment for measuring these parameters as well as carbon dioxide. This information is more useful than sampling for specific pollutants, and cost much less.

HEALTH PROBLEMS RELATED TO INDOOR AIR QUALITY
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For a student or school staff member with asthma, poor air quality can cause an increase in the frequency or intensity of asthma symptoms. A school occupant who does not have asthma may experience problems as well. However, people often do not recognize that their symptoms are caused by something in the air. When only a few individuals are affected, their symptoms may not be taken seriously. Even when symptoms are widespread, they may be nonspecific and not easily linked to poor air quality. Symptoms commonly associated with poor indoor air quality include:

• coughing and shortness of breath
• sinus congestion and sneezing
• eye, nose, throat, and skin irritation
• headache, dizziness, nausea, and fatigue

Symptoms related to air quality often begin or intensify after a person has entered the school building and diminish or disappear entirely in the evening, over weekends, or during school vacations. A peak flow diary often can reveal a pattern that identifies a trigger in the school as the cause.

A mother brought her son to see me because he coughed every day he went to school, yet he was fine over the weekend. She thought he was allergic to the gerbil in his second grade classroom but had been unable to convince the teacher of this. I suggested that she check his peak flow Monday morning at the school door and then after an hour of class. His peak flow dropped thirty percent, proving that she was right. Once the gerbil was removed from the room her son’s cough disappeared.
School-wide data collection of symptoms is an excellent way to track down indoor contaminants and ventilation problems. A health log should record the nature, time, and location of health symptoms. These records may reveal certain types of symptoms that are typically caused by specific contaminants. The pattern of symptoms in a building can identify particular areas or activities for closer investigation. For example, when health complaints are clumped in one or two classrooms, the office area, or the gym, the air handling system and activities in these areas may be at fault.
When I was on the Board of health in Amherst Massachusetts, teachers and students complained of respiratory and other health problems. The teachers had logged their complaints in the principal’s office over a period of months. When we mapped these complaints on a floor plan of the building we found that they were concentrated in four areas. A walk-through inspection identified the cause of the problem in each area: a large classroom had been divided into four rooms, depriving three of them of proper circulation, a univent air handling device had been turned off to conserve heat, air filters were clogged and a fan belt was inoperative.

UNDERSTANDING INDOOR AIR QUALITY IN SCHOOLS
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The air quality inside a school building is the result of interactions among many factors: the site and climate, building structures and construction techniques (including any modifications), the mechanical systems in place to handle ventilation, and the activities of the occupants who may introduce pollutants. Good indoor air quality management requires control of pollution sources, introduction and circulation of sufficient outdoor air, and maintenance of an acceptable temperature and humidity.
Understanding these components is a challenging task. However, you and other concerned parents, staff, students, and administrators can learn what you need to know to participate in indoor air quality management and promote responsible practices. The U.S. Environmental Protection Agency has produced two excellent resources to help you: Building Air Quality: A Guide for Building Owners and Facility Managers and Indoor Air Quality: Tools for Schools. These documents are essential guides for learning about air quality, creating a proactive management team, and dealing with problems that arise. The information below is taken largely from these documents.

MECHANICAL AIR HANDLING SYSTEMS
The Heating, Ventilating and Air Conditioning (HVAC) system in a school includes boilers, furnaces, chillers, cooling towers, air handling units, exhaust fans, ductwork, and filters. If it is well designed and maintained and functioning properly, the system should control temperature and relative humidity in the building, distribute adequate amounts of outdoor air, and isolate and remove indoor pollutants through air pressure control, filtration, and exhaust fans.

However, the HVAC system in your child’s school may not have been designed to perform all these functions, or lack of maintenance may have compromised its effectiveness. Depending on a building’s age, design, modifications, changes in use, and quality of maintenance, the system may not perform its job to acceptable current standards.

Ventilation rates specified by building codes may have been much lower at the time your child’s school was constructed than they are now. The energy crisis of the 1970s encouraged tight construction with low air exchange rates to reduce heating costs. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) sets air exchange standards that are the basis for most building ventilation codes. The 1989 standard (Standard 62-1989) calls for the introduction of 15 to 20 cubic feet of fresh air per minute (CFM) for each person in an area served by the ventilation system. Many schools were constructed at a time when standards called for only 5 CFM, far lower than the present recommendation.

School personnel often impair the operation of the HVAC system. In a carefully engineered system, opening a window will improve conditions in one room but, by changing air pressure relationships, may impair ventilation throughout the rest of the building.

Current ventilation standards (15 to 20 CFM) are not adequate for spaces with certain kinds of indoor contaminants. Toxic airborne substances must be exhausted to the outside directly from the source. For example, a metal shop should have a local exhaust system in place to vent welding fumes away from students, out of the building, away from air-intake areas. The same applies to construction or remodeling work being done to the school building.

Unfortunately, not all harmful materials are easy to recognize as toxic airborne contaminants. Schools are filled with materials, furnishings, supplies, and activities that can create airborne hazards. Students or staff with asthma are particularly sensitive to these inhaled triggers and may become more sensitive if the exposure continues. Although individual concentrations of specific contaminants may be low, the combined effect of multiple pollutants may be much greater due to interactions among them. Therefore, achieving and maintaining good indoor air quality requires your school to remove sources of indoor contaminants from construction, furnishings, cleaning, and daily activities. No ventilation system is as effective as avoiding the hazard in the first place.

REMOVING SOURCES OF INDOOR POLLUTION
Many potential sources of indoor air pollution exist in a school. Some Typical Sources of Indoor Air Pollutants include exhaust from idling buses and cars. I will discuss several categories of contaminants here and refer you to the resources mentioned previously. Manufacturer’s Safety Data Sheets (MSDSs) for individual products provide safety information and should be available from your school’s vendors. A committee of parents, staff, and other concerned citizens can establish purchasing criteria for all supplies and materials used by the school district. This committee, or an indoor air quality team, can also make sure that storage, handling, use, and disposal conform with manufacturer recommendations.

CLEANING
Good housekeeping is part of good maintenance. Regular and thorough cleaning of the school reduces the amount of dust and other particles that can become airborne. In addition to causing trouble for people with asthma, dust, lint, and other particles can clog filters in the air-handling system and decrease their effectiveness. Schools can improve house cleaning by damp dusting, using high-efficiency vacuum cleaners, upgrading filters in ventilation systems, and changing filters frequently. Carpeting poses special difficulty, as it is a breeding ground for dust mites, mold, and bacteria. It usually harbors dust, moisture, allergens or irritants.

To avoid creating health problems, schools should not have carpeting at all. However, if your child’s school does have carpeting, daily vacuuming using double-thickness vacuum bags can remove allergens and irritants without exhausting them into the air. Removal of carpeting can provide a safer school environment in the long term, but removal itself may be hazardous. It should be done under strict guidelines for contaminant control. After carpet is removed, be alert to the need for more frequent air filter changes to keep small particles, previously trapped in the carpet, out of circulation.
Cleaning can introduce a range of chemical products into the school that may be sources of indoor air pollution. Solvent-based cleaners are hazardous. Fumes and vapors remain in the building long after cleaning is complete and may be present during after-hours activities.

Find out what materials are used for cleaning and how they are stored in your child’s school. You should have access to labels and Manufacturer’s Safety Data Sheets (MSDSs) for these materials. Select materials carefully and be aware that “natural” or “nontoxic” materials are not necessarily safe. Judge them by the same criteria you develop for any cleaning material. Some preliminary recommendations include:

• Avoid solvents and volatile organic compounds (VOCs).
• Find out about inert ingredients that are not fully disclosed on package labels; though “inert,” these chemicals may pollute the air.
• Avoid vinyl, products with formaldehyde, and other products that off-gas.
• Remember that “environmentally friendly” does not mean that a product is safe for people.

Some states and organizations are developing purchasing guidelines based on human health and environmental criteria.

GASES
A volatile organic chemical is any carbon-containing substance that becomes airborne when it is used or that off-gasses from a product over time. Such products and substances include paint, cleaners, glues, varnishes, pesticides, formaldehyde, laminators, copier toners, and chemicals used in science, industrial arts, welding, auto shop, or other vocational classes. Any area that uses volatile chemicals routinely, such as a science lab or art room, should have a special ventilation system that keeps fumes out of a student’s breathing zone. Depending on the material, exhaust fans or local exhaust hoods may be necessary.

Formaldehyde, a colorless gas and volatile organic compound, is released from many building products (like plywood or particleboard), wood furniture, carpeting, and some consumer products. This gas has a pungent odor, irritates the lining of the nose and respiratory tract, is considered a sensitizer, and can cause cancer. Find out if formaldehyde is present in construction materials, new furnishings, computers, and other products the school wants to purchase.

Carbon dioxide is not itself a toxic gas, although a concentration of 15,000 ppm does cause symptoms of asphyxia including reduced mental acuity. Carbon dioxide is a natural byproduct of human metabolism, so the concentration of carbon dioxide in a room is one indicator of how well the ventilation is working. The ASHRAE standards recommend 1,000 ppm as the upper limit of carbon dioxide for comfort reasons. An elevated level indicates that ventilation is inadequate or that there is contamination from a furnace, vehicle, or other combustion source.

BIOLOGICAL CONTAMINANTS
Biological sources of indoor pollution include bacteria, fungi (mold or mildew), pollens, insect parts, and other allergens. Harmful bacteria and fungi flourish in warm, moist environments, such as damp carpets, moist insulation, or leaky roofs and walls. Contaminants that grow in the ducts, cooling pans, or other air-handling system components can be circulated throughout the building. Outdoor pollen and allergens can also be drawn in through open windows and doors.

TOBACCO SMOKE
Second-hand tobacco smoke, also called environmental tobacco smoke is a common trigger of asthma symptoms. Even in people who do not have asthma, it can cause irritation of the eyes, nose, throat and lungs. Secondhand smoke has been strongly implicated in thousands of cancer deaths each year. People who are chronically exposed to secondary smoke are at increased risk of developing asthma and experience greater severity of asthma problems. Many communities have banned smoking in school buildings and on school grounds. Effective implementation of this policy protects the health of all school occupants, especially students and staff with asthma.

CONSTRUCTION, RENOVATION AND REPAIR
Construction creates dust from all kinds of materials, ranging from irritants to known carcinogens. In addition, glues, varnish, stripping chemicals and cleaners used in construction present potential health hazards. These contaminants can provoke airway inflammation and symptoms in an individual with asthma who is sensitive to them, and can sensitize individuals who were not previously affected. Any construction, repair or renovation work done to the school must be sealed off and vented outside and away from the renovation site. If students or staff can see dust in spaces they are using, it means that they are being exposed to small particles that can be inhaled into the lungs. Demolition, renovation, and new construction are hazardous activities and should be handled as such.

SUMMARY
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You can work with your child’s school to promote policies and practices that make it a safe and healthy environment for all children. As a concerned parent, you share many goals with other parents and school staff. Seek out your allies; you can’t do the job alone. Build a team approach that deals with problems throughout the school, not only in your child’s classroom. No student should be denied medicine because the school administration has not worked out a responsive and responsible policy. No student should have to take extra medicine because a building is poorly ventilated.


How Asthma-Friendly is Your School?
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1. Is your school free of tobacco smoke all of the time, including during “after-hours” events?
2. Does the school maintain good indoor air quality? Does it reduce or eliminate allergens and irritants that can make asthma worse?
3. Is there a school nurse in your school all day, every day? If not, is a nurse regularly available to the school to help write plans and give students with asthma guidance about medicines, physical education, and field trips?
4. May children take medicines at school as recommended by their doctor and parents? May children carry their own asthma medicines?
5. Does your school have an emergency plan for taking care of a child with a severe asthma episode? Does it state clearly what to do? Whom to call? When to call?
6. Does someone teach school staff about asthma, asthma management plans, and asthma medicines? Does someone teach all students about asthma and how to help a classmate who has it?
7. Do students with asthma have good options for fully and safely participating in physical education class and recess? (For example, do students have access to their medicines before exercise? Can they choose modified or alternate activities when medically necessary?)

If the answer to any question is no, a student may be facing obstacles to asthma control. Asthma that is out of control can hinder a student’s attendance, participation, and learning. Contact the organizations in the Resource Section for information about asthma and for ideas to help make school policies and practices more asthma-friendly. Federal and state laws exist to help children with asthma.
Adapted from the National Heart, Lung and Blood Institute, National Asthma Education and Prevention Project.

An Individualized Health Plan (IHP) provides for:
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• opportunities for collaborative planning and problem-solving among staff and parents.
• timely and convenient access to medication at all times.
• the achievement of personal fitness goals and safe participation in physical education and sports, field trips, and other special events.
• environmental controls and safeguards (maintaining air quality, eliminating irritants, allergens, pesticides, and other toxic hazards).
• coordination of physical, social, emotional, and academic goals.
• staff training and peer sensitization.
• academic and social continuity during periods of disrupted attendance.
• individualized crisis and emergency management.
The asthma plan for your child should include instructions that define the situations when modification of exercise is necessary. This will avoid the need for your child to negotiate with the physical education teacher.
Goldberg, E., “Individual Health Plans: A Strategy for Achieving Educational Equity,” 1997.

Federal laws protecting students with disabilities
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The Individuals with Disabilities Education Act (IDEA). Students are eligible for special education services if they have one or more of thirteen disabling conditions. An individual education plan (IEP) is designed for each student by an IEP team in which parents and school staff are equal partners in the process of identifying the student’s needs and the school’s options for meeting those needs. The IEP describes the student’s learning objectives, and the instructional strategies and related services the school will provide to ensure that the student receives a free and appropriate public education in the least restrictive environment. A student eligible for services under IDEA is also protected by Section 504 (below). However, not every student covered by Section 504 is eligible under IDEA.

Section 504 of the Rehabilitation Act of 1973 is a civil rights law that prohibits discrimination against individuals with disabilities in education or employment programs that receive federal funds. Schools are required to modify programs, policies or practices and provide related aids and services for any student who has a physical or mental impairment that limits one or more of the student’s major life activities, such as breathing. This is a “functional” definition of disability, as compared with the “categorical” definition under IDEA. A “504 plan” serves to remove barriers to a student’s meaningful access to academic and non-academic programs or extracurricular activities. Asthma may be covered under Section 504 but is not typically covered under IDEA.
Americans with Disabilities Act (ADA) incorporates and extends the rights and responsibilities of Section 504 to include public services and places of public accommodation, such as preschools, day care centers, and private schools.
Adapted from Goldberg, E., “Integrating Students with Chronic Illness,” 1996.

Typical Sources of Indoor Air Pollutants
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Outside Sources
• Polluted Outdoor Air: pollen, dust, fungal spores, industrial emissions, emissions from school buses and other vehicles.
• Nearby Sources: loading docks, odors from dumpsters, unsanitary debris, building exhausts near outdoor air intakes
• Underground Sources: radon, pesticides, leakage from underground storage tanks
Building Equipment
• HVAC Equipment: microbe growth in drip pans, ductwork, coils, and humidifiers; improper venting of combustion products; dust or debris in ductwork
• Non-HVAC Equipment: emissions from office equipment (volatile organic compounds, ozone); emissions from shops, labs, cleaning processes
Components/Furnishings
• Components: microbe growth on soiled or water-damaged materials, dry traps that allow the passage of sewer gas, materials containing volatile organic compounds, or damaged asbestos materials that produce particles (dust)
• Furnishings: emissions from new furnishings and floorings, microbe growth on or in soiled or water-damaged furnishings
Other Indoor Sources
• Science laboratories; vocational arts areas; copy/print areas; food prep areas; smoking lounges; cleaning materials; emissions from trash; pesticides; odors; volatile organic compounds from paint, caulk, and adhesives; occupants with communicable diseases; dry-erase markers and similar pens; insects and other pests; personal care products
Adapted from United States Environmental Protection Agency, Indoor Air Quality: Tools for Schools, 1995.

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