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The 2021 State of the Air Report from the American Lung Association (ALA) found that more than 40% of people in the United States live in an area with an unhealthy level of air pollution, while people of color are 3 times more likely to breathe polluted air compared to White people.

The annual State of the Air reports on the most widespread air pollutants, including ozone and fine particulate matter. Data is collected from monitoring sites across the United States and then calculated by the ALA, to rank cities and counties with the most pollution.

The ALA stated that while the data show some progress in cleaning up air pollution, the 3 assessed years (2017, 2018, and 2019) in their 2021 report rank among the 6 hottest years on record.

Polluted air can trigger serious effects, with new data showing it may even worsen outcomes of COVID-19 among infected persons.

Particle pollution is linked to triggers of asthma and cardiovascular (CV) events including heart attacks, as well as dementia. Ozone pollution effects have been linked to asthma attacks, shortened life and an increased risk of metabolic disorders.

The data on air quality in the study was obtained from the US Environmental Protection Agency (EPA) Air Quality System (AQS).

Investigators used AQS data from 2017 – 2019 to calculate daily eight-hour maximum concentration for each ozone monitoring area and the highest maximum in each county was identified. The national ambient air quality standard for ozone was reflected by a 70 parts per billion (ppb) measure over an eight-hour period.

The daily maximum data of an eight-hour average is obtained from 17 consecutive eight-hour averages, beginning with a 7:00 A.M. to 3:00 P.M. period and ending with the 8-hour period from 11:00 P.M. to 7:00 A.M.

The ALA investigators then identified the air quality of each day in the observed counties, as orange (Unhealthy for Sensitive Groups), red (Unhealthy), or purple ( Very Unhealthy).

The team identified the maximum daily 24-hour AQS coarse particle (PM) concentration for the years 2017 – 2019 and data was compiled into 24-hour average PM values.

The standard concentration for moderate air quality index levels is 12.1 µg/m3 to 35.4 µg/m3 n.

Investigators identified the number of days when the maximum of daily PM in each county occurred. 

The ALA identified the number of days each county, with at ≥1 PM monitor, experienced air quality designated as orange (Unhealthy for Sensitive Groups), red (Unhealthy), purple (Very Unhealthy) or maroon (Hazardous).

For year-round particle pollution calculations, the EPA listed counties at 12 µg/m3 and were given grades of “pass.” Counties listed at or above 12.1 µg/m3 were given grades of “fail.” If data was insufficient, counties were given a grade of “incomplete.”

The report found more than 135 million Americans live in the 217 counties with monitors that capture unhealthy pollution levels.

The rate is nearly 15 million fewer people compared to last year’s report, but there was an increase of over 1 million people in areas with unhealthy levels of short-term particle pollution compared to last year.

Over 20 million people live in the 13 counties that fail all 3 measures, and 14 million (~70%) people in this group were people of color. People of color were also 61% more likely to live in a county with a failing grade for 1 pollutant and more than 3 times as likely to live in a county with a failing grade for 3 pollutants.

Los Angeles is the city with the worst pollution in the nation, remaining in this spot for all but 1 of the 22 years observed in the annual report.

The data shows 3 out of every 8 Americans, or 123.2 million people, live in the 163 counties that received an “F” for ozone.

Investigators said the 135 million Americans who live in places with unhealthy levels of pollution are at risk of harm to their health, but some groups are more vulnerable to death and illness from exposure.

These groups included people experiencing poverty, with more 15.8 million people meeting the federal poverty definition living in a county with an “F” in at least 1 pollutant metric. Nearly 3 million people in poverty live in counties that failed all 3 measures.

Investigators additionally reported that 4.9 million children and 2.9 million seniors live in counties that failed all 3 pollutant measures.

Groups with underlying health conditions, including asthma, chronic obstructive pulmonary disease (COPD), lung cancer and CV disease, also experience high rates of exposure to pollutants.

Rates included 2.3 million children and 9.2 million adults with asthma, nearly 5.9 million people with COPD, more than 67,000 people with lung cancer, and nearly 10 million people with CV disease who live in a county that received a “F” for at least 1 measured pollutant.

More than 14.6 million Americans with a history of smoking live in counties that received an “F,” a group with a greater risk of premature death and lung cancer when subjected to long-term pollution exposure.

Ground-level ozone is formed in the lower atmosphere when a combination of pollutants such as nitrogen oxides (NOx) and volatile organic compounds (VOCs), “cook” in sunlight. The chemical reaction can often spread miles from where it originated.

Data show ozone has a harmful effect on the respiratory system, both in short- and long-term exposure to the pollutant. Symptoms that present because of high ozone levels include chest tightness, coughing and shortness of breath, even in healthy adults.

More exposure to ozone can cause lasting damage to the respiratory system, such as new cases of asthma in children and the development of COPD.

Investigators also noted that inflammation and systemic stress caused by exposure to ozone can cause or worsen other diseases, such as metabolic disorders, brain inflammation, reproductive harm, and possible CV events, although evidence is mixed, according to the EPA.

Particle pollution is a mixture of tiny particles of solids and liquids in the air, that originate from sources including factories, motor vehicles and equipment, as well as wildfires, woodburning, and NOx that forms into fine particles in the atmosphere.

In high pollution levels, particles are grouped by size as coarse, fine, and ultrafine, which can penetrate the air sacs of the lungs and the smallest are dispersed to other organs of the body. It is estimated that 48,000 premature deaths in the United States can be attributed to PM.

Short-term exposure to particle pollution that lasts from a few hours to days can result in death, even on the day the particle levels are high. Investigators said in many cases these deaths would not have occurred if the air was cleaner.

Other harmful effects include increased mortality rates in infants, increased hospitalization for CV disease and COPD, and increased severity of asthma attacks.

Year-round exposure to particle pollution can have serious negative effects in both infants and adults. Infants were found to have increased fetal mortality, reduced lung development and a higher likelihood of developing asthma.

Adults were linked to increased risk of CV and respiratory disease, higher likelihood of diabetes and lung cancer, and impaired cognitive functioning. 

Investigators found communities that reduce their year-round particle pollution had a direct improvement in respiratory health.

The team also looked at other studies linking particle pollution and COVID-19, finding other data that a small increase in long-term average exposure to fine particle pollution was associated with an 11% increase in COVID-19 mortality.

In their list of 25 cities most polluted by ozone, the ALA found that the cities mostly remained the same as last year, with a cluster of cities in the west and southwest continuing to be the most polluted. California has 10, while the southwest takes up 8; the remaining 7 are east of the Mississippi River.

The top 5 cities most polluted by ozone are:

In the list of 25 worst cities for short-term particle pollution, there were minor changes, with 13 cities improving since last year’s report with fewer unhealthy days. However, investigators said all the areas remain seriously polluted. These are the 5 worst cities for short-term particle pollution:

San Jose – San Francisco – Oakland, CA

In the list of the 25 cities with the unhealthiest year-round particle pollution levels, 13 worsened since from last year’s report. The 5 worst were:

Investigators also compiled a list of the nation’s cleanest cities, where the city must experience no high ozone or particle pollution days, as well as rank in the 25 cities with the lowest year-round particle pollution levels. The top 5 were:

Burlington-South Burlington-Barre, Vermont

Investigators concluded that climate change remains one of the worst culprits in worsening air pollution. Western cities are experiencing record-breaking particle pollution due to wildfires caused by changing climate patterns, and as temperatures increase, so does ozone pollution.

As more affected groups are the hardest hit by an exposure to poor air quality, including increasing COVID-19 rates, the ALA looks to reduce air pollution to benefit respiratory health for the nation and years to come.

“This report shines a spotlight on the urgent need to curb climate change, clean up air pollution and advance environmental justice,” said ALA President and chief executive officer Harold Wimmer. “The nation has a real opportunity to address all three at once—and to do that, we must center on health and health equity as we move away from combustion and fossil fuels to clean, renewable energy.”

The 2021 State of the Air Report was published online by the American Lung Association.

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The 2021 annual report finds that Los Angeles remains the most polluted US city, while negative impacts of climate change and COVID-19 are both linked to increased pollution rates.

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ALA State of the Air: 4 in 10 Americans Suffer from Unhealthy Air Pollution Levels

 (OUD) and high rates of co-occurring mental health conditions is well-known. However, there is less of an understanding of how suicidal behaviors might be impacted by this condition.

A team, led by Mir M. Ali, Office of the Assistant Secretary for Planning & Evaluation, US Department of Health & Human Services, examined suicidal behavior, defined as suicidal ideations and/or attempts, and the utilization of behavioral health services for patients with OUD.

In the study, the researchers used the 2015-2018 National Survey of Drug Use and Health to identify the risk of suicidal behavior among individuals with opioid use disorder and examined how the utilization of behavioral health treatment among this patient population might ultimately reduce the risk of suicidal behavior.

The overall rate of suicidal behavior was 22% in individuals with OUD, significantly higher than the 4% found in a cohort of patients without OUD.

In addition, 43% of patients with OUD received neither substance use disorder nor mental health treatment.

After using a multivariable logistic regression, the researchers estimated indicate that individuals with OUD had odds of suicidal behavior 2.9 times as high as those without OUD.

The odds of suicidal behavior of the OUD cohort was 49% lower with substance use disorder treatment, as well as 5% reduced with mental health treatment and 28% lower with both mental health and substance use disorder treatment.

“Individuals with OUD have a high risk of suicidal behavior, which can be mitigated with utilization of behavioral health treatment,” the authors wrote. “These findings underscore the importance of policy initiatives directed at increasing treatment utilization among those with OUD.”

Recently, researchers found the rates of new patients receiving treatment for 

 decreased significantly through the beginning of the pandemic.

Investigators, led by Janet M. Currie, PhD, of the Center for Health and Wellbeing at Princeton University, evaluated how the prescription of medications for OUD changed for new and current patients during COVID-19.

The 2 medications generally prescribed included opioid analgesics for pain management and buprenorphine for OUD. Investigators found a decrease in opioid analgesic prescriptions and an increase in buprenorphine prescriptions for OUD before the COVID-19 pandemic.

The team’s exact numbers included 452,691,261 opioid analgesic prescriptions and 90,420,353 buprenorphine prescriptions.

From March to May, there were 1877 million units of milligrams of morphine equivalents (MME) opioid analgesics prescribed weekly, versus the 1843 million that were projected.

Opioid-naïve patients received 370,051 prescriptions, versus the 564,929 projected. 

Existing OUD patients for buprenorphine experienced similar numbers to those projected by investigators. Despite initial decreases in prescriptions, each prescription was for a larger quantity, causing little change in MME supply rates.

New patients of buprenorphine experienced 9865 prescriptions versus the 12,008 projected, or 18% lower than the expected levels.

From May to September, the prescription of opioids returned to 100%, with levels reaching 90% of projected numbers for new patients by August.

Existing patients did not experience a disruption in their supply during the COVID-19 pandemic, but opioid-naïve patients were less likely to be prescribed.

Suicidal Behavior, Opioid Use Disorder, and Behavioral Health Treatment: Prevalence and Correlates among Adults in the United States 2015–2018

The odds of suicidal behavior was 49% lower for OUD patients receiving substance use disorder treatment.

Opioid-induced Constipation

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Behavioral Therapy Could Reduce Suicidal Behavior for Patients with Opioid Use Disorder

A recent study analyzed data on veterans with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), finding female veterans received poorer secondary prevention 

 (CV) care in comparison with male veterans.

Investigators, led by Salim S. Virani, MD, PhD, of the Health Services Research and Development at the Michael E. DeBakey Veterans Affairs Medical Center, found women with premature ASCVD were also less adherent to statins and have comparatively higher mortality rates than men.

ASCVD is the leading cause of death worldwide, with an event being defined as ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), or peripheral arterial disease (PAD).

For patients with ASCVD, secondary prevention optimization is necessary in reducing disease burden, psychosocial effects and financial costs for the patient.

However, there is a lack of data in comparing secondary prevention between men and women with premature (≤55 years) and extremely premature (≤40 years) ASCVD.

Investigators sought to observe sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

The team conducted a retrospective cohort study of the national Veterans Affairs (VA) electronic medical record system and clinical data sets during 2015. Patients with ASCVD who received care from at least 1 of 30 VA facilities or an associated outpatient clinic were included in the trial.

Investigators identified 1,248,158 ASCVD patients, aged 18 years or older at the time of assessment. Patients needed at least 2 outpatient diagnoses for ASCVD or 1 procedural code for percutaneous intervention.

The team created the Veterans with Premature Atherosclerosis (VITAL) nationwide registry, to determine age cutoff parameters of premature and extremely premature ASCVD patients.

Investigators created 3 phenotypes for each ASCVD subtype (IHD, ICVD, PAD):

IHD included acute coronary syndrome, chronic coronary artery disease, and coronary revascularization.

ICVD included transient ischemic attack or stroke, and cerebral revascularization.

PAD included intermittent claudication, peripheral arterial occlusion, and peripheral revascularization.

The study defined antiplatelet use as patients with an active prescription of aspirin. They excluded patients prescribed anticoagulants.

HIS therapy referred to 40 mg atorvastatin prescriptions or 20 mg rosuvastatin.

Statin adherence assessed proportion of days covered (PDC) and calculated supply divided by total days in a period.

A multivariable regression associated antiplatelet use, any statin and HIS use, and statin adherence in the comparison of males and females.

The cohort analysis included 147,600 patients of the original patient identification with premature ASCVD (10,413 women and 137,187 men).

Women were younger with a mean age of 48 years and had a higher proportion of African American patients, compared to Asian and White patients.

The study found that women had a higher rate of ICVD at 41.8% (n = 4355) compared to men at 26.2% (n = 35,964), as well as major depressive disorder (MDD) and/or PTSD at 54.8% (n = 5711) versus 38.4% (n = 52,681).

A regression analysis found that women with premature ASCVD had a significantly lower likelihood of receiving antiplatelet treatment compared to men, 61.3% versus 79.2% (95% CI, 0.56 - 0.61).

This lower rate continued with any statin in the study, at 57.5% versus 75.1% (95% CI, 0.56-0.61) and HIS therapy, at 23.5% versus 38.1% (95% CI, 0.60 – 0.67).

Women also received less antiplatelet agents, statins and HIS in patients with premature ICVD and premature PAD.

Investigators identified 9485 patients, including 1340 women and 8145 men, with extremely premature ASCVD. Women were again younger with a mean age of 34.5, with a higher proportion of African American patients compared to White and Asian patients.

The team found that in the extremely premature ASCVD group, women received less antiplatelet treatment at 37.7% versus 56.5% (95% CI, 0.53 - 0.70), statins at 29% versus 52.3% (95% CI, 0.44 - 0.58), and HIS therapy at 10.4% versus 27.2% (95% CI, 0.37 - 0.54) compared to men.

Investigators concluded that women with premature and extremely premature ASCVD have a significantly less likelihood of receiving antiplatelets, statins or HIS therapy in comparison with men. The differences remain after adjusted differences regarding clinician and socioeconomic factors.

The team also observed suboptimal secondary prevention therapy in all patient groups, which they believe may be attributed to clinician’s perception of ASCVD risk groups, especially in women with extremely premature ASCVD.

“Such diagnostic inattentiveness toward young patients may result in higher thresholds to initiate or escalate care, resulting in a phenomenon called clinical therapeutic inertia,” investigators wrote.

Despite the increased attention on women’s CV health in the past 2 decades, the team wrote there are gaps in health care delivery for women, particularly in secondary prevention for ASCVD.

“As exact reasons for sex-based heterogeneity in premature and extremely premature ASCVD remain unclear, further investigation and outcomes research are needed to elucidate potential causes and effective solutions,” investigators wrote.

The study, “Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease,” was published online in 

New data show female veterans receive poorer secondary prevention care in treating premature and extremely premature atherosclerotic cardiovascular disease, compared to male veterans. 

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Female Veterans Experience Poorer CV Care, Worse Mortality Rates Than Males

As May 9-15, 2021 is Food Allergy Awareness Week, there is an opportunity to raise awareness for 

. Fortunately, the incidence of fatal food anaphylaxis for an individual is low and adds little mortality risk.

 However, as food allergy anaphylaxis can nevertheless be fatal, it is important to highlight food allergy awareness to provide appropriate treatment and counseling for patients.

Food allergy is an allergic reaction that involves the immune system. For food allergies—specifically immunoglobulin E (IgE)-mediated food allergic reactions—there are specific food proteins against which the body mounts an immune response. In the most common type of food allergy, IgE antibodies target certain proteins in food that they mistakenly see as a threat. Food-specific IgE antibodies are formed that bind to receptors on mast cells, basophils, macrophages, and dendritic cells, and when allergens reach cell-bound IgE antibodies in susceptible individuals, mediators are released that induce allergy symptoms. There are non-IgE-mediated or mixed IgE-mediated reactions, as well, but the IgE-mediated immunologic basis is key to understanding how food allergies work.

Research from 2019 suggests that at least 10.7% (>26 million) of US adults are food allergic, whereas 19% of US adults believe they have a food allergy.

 Having confirmatory testing with a strong clinical history is important to avoid undue quality of life burden and to provide appropriate counseling, treatment, and dietary management, if necessary.

Anaphylaxis is a multisystemic, severe, and potentially life-threatening allergic reaction. Symptoms can vary from confusion and agitation to lip and mouth swelling, difficulty breathing, wheezing, hypotension/weak pulse, and/or hives or redness all over the body. Epinephrine is the treatment of choice for this reaction. Many patients with food allergies have epinephrine autoinjectors. Epinephrine is generally not needed for mild hives—but if there is any concern for respiratory symptoms or persistent vomiting or abdominal pain, epinephrine is typically necessary. Delayed epinephrine administration has been cited as the most common cause of death from food allergies.

 In addition, as we enter the summer months, patients and providers need to be aware that epinephrine autoinjectors may lose potency within hours if stored in a heated car.

Any food can cause an allergic reaction. However, there are 8 types of food that account for about 90% of all reactions: milk, wheat, egg, peanuts, tree nuts, fish, crustacean shellfish, and soy.

 For those affected, education in treatment and prevention of food allergy reactions is crucial—which is why patients should be provided help in reading and understanding food labels.

 This is especially true for children with food allergies, who should be encouraged to start reading food labels as soon as they can read with practice at home from caregivers.

There are multiple organizations that can provide assistance for food allergy education, diagnosis, treatment, and advocacy. These include, but are not limited to:

The American Academy of Allergy, Asthma & Immunology (AAAAI)

The American College of Allergy, Asthma & Immunology (ACAAI)

The Food Allergy Research & Education Organization (FARE)

Kids With Food Allergies (KFA), a division of the Asthma and Allergy Foundation of America

These organizations have various online resources also available for patients and providers.

Eevar Benjamin Rossavik, DO, is a chief pediatrics resident who will soon join his program’s faculty to be a pediatrics attending. He has a specific interest in allergy, asthma, and immunology.

Clinicians and experts interested in responding to this piece, or submitting their own articles to

Turner PJ, Jerschow E, Umasunthar T, Lin R, Campbell DE, Boyle RJ. Fatal Anaphylaxis: Mortality Rate and Risk Factors. 

. 2017;5(5):1169-1178. doi:10.1016/j.jaip.2017.06.031

Umasunthar T, Leonardi-Bee J, Hodes M, et al. Incidence of fatal food anaphylaxis in people with food allergy: a systematic review and meta-analysis. 

. 2013;43(12):1333-1341. doi:10.1111/cea.12211

Gupta RS, Warren CM, Smith BM, et al. Prevalence and Severity of Food Allergies Among US Adults. 

. 2019;2(1):e185630. Published 2019 Jan 4. doi:10.1001/jamanetworkopen.2018.5630

Chooniedass R, Temple B, Becker A. Epinephrine use for anaphylaxis: Too seldom, too late: Current practices and guidelines in health care. 

. 2017;119(2):108-110. doi:10.1016/j.anai.2017.06.004

Lieberman P. Biphasic anaphylactic reactions. 

. 2005;95(3):217-258. doi:10.1016/S1081-1206(10)61217-3

https://www.aaaai.org/about-aaaai/newsroom/news-releases/epipens-heat#:~:text=Epinephrine%20autoinjectors%20(EAIs)%20have%20recommended,59%20%E2%80%93%2086%20degrees%20Fahrenheit%20permitted

https://www.fda.gov/food/buy-store-serve-safe-food/food-allergies-what-you-need-know

https://www.foodallergy.org/resources/how-read-food-label

https://www.aaaai.org/conditions-and-treatments/library/allergy-library/food-allergy

https://acaai.org/allergies/types/food-allergy

https://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/food-allergy

An expert writes on the value of shared knowledge into the intricacies of allergic risks.

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Food Allergy and Anaphylaxis: Promoting Awareness and Understanding

New data show a pediatric formulation of the direct-acting antiviral (DAAs) therapy glecaprevir/pibrentasvir (GLE/PIB) is highly effective and well-tolerated in pediatric patients with 

, since the data suggest that the dramatic results DAAs have brought about in adults can also be realized in children as young as 3.

Corresponding author Maureen M. Jonas, MD, of Boston Children’s Hospital and Harvard Medical School, said she was pleased with the way the drug’s manufacturer, AbbVie, embraced the effort to make the therapy available to children, something that does not happen in every therapeutic area.

“Often, we have to wait many years for things to percolate down to children,” she told 

. “But these companies across the board addressed the issue of pediatric (patients) relatively early in the process.”

The drugs have a good safety profile in adults, and Jonas said there was good reason to believe they would be successful in children, in part because an earlier phase of the study showed success in children ages 12 up to 18. About 13.2 million of the world’s estimated 71 million people with HCV infection are children between the ages of 1 and 15.

The challenge of the present phase, which focused on children between the ages of 3 and 12, was to find the right dose and also to find a formulation that children would take. In this case, the winning formulation turned out to be small film-coated granules of 

The study enrolled 80 patients with chronic HCV infection, genotypes 1-6, with or without compensated cirrhosis. The children were split into three age-based cohorts and given weight-based doses for either 8, 12 or 16 weeks. The primary endpoints were sustained virologic response at 12 weeks (SVR12) and steady-state exposure.

Of the 80 patients in the study, 77 achieved SVR12. One patient on the initial dose ratio had relapsed within 4 weeks of the end of treatment and 2 non-responders discontinued the study.

In the end, the investigators found doses of 250 mg GLE and 100 mg PIB were efficacious for children weighing 30 up to 45 kg. A dose of 200 mg GLE plus 80 mg PIB worked for children from 20 up to 30 kg, and the smallest patients (those 12-20 kg) achieved results at a dose of 150 mg GLE plus 60 mg PIB. No serious drug-related adverse events were reported and pharmacokinetic exposures were comparable to those of adults.

The majority of children become infected with HCV as a result of vertical transmission. While a minority of patients (roughly one-quarter) will see their infection resolve on its own, most patients will develop long-term infections. The ability to successfully treat HCV when the patients are young could prevent potential long-term damage, the investigators wrote. Jonas said the therapy would also open up new possibilities for organ donation, since the organs of patients with HCV infection could be transplanted to patients in need and the recipients could then be treated with DAAs to cure the infection.

Perhaps the bigger question, Jonas said, is not so much whether the therapy will work in children, but rather whether it will be available to children. She noted that DAAs typically have a steep price tag. While patients in wealthier regions, such as the United States and Europe, might be able to easily access the therapies, that access is not guaranteed in many developing countries. She said the highest prevalence of the disease is in less-wealthy regions like Egypt, Asia, southeast Asia, and Africa.

“If we really want to eradicate it and decrease global prevalence we’ve got to get out there and not just the developing world,” she said.

Pharmacokinetics, safety, and efficacy of glecaprevir/pibrentasvir in children with chronic hepatitis C virus: part 2 of the DORA study

Direct-acting antivirals have been a major milestone in the treatment of hepatitis C virus, new data show they also work in nearly all children, without serious adverse events.

Hepatitis C

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Latest Clinical News

ALA State of the Air: 4 in 10 Americans Suffer from Unhealthy Air Pollution Levels

Behavioral Therapy Could Reduce Suicidal Behavior for Patients with Opioid Use Disorder

Female Veterans Experience Poorer CV Care, Worse Mortality Rates Than Males

Food Allergy and Anaphylaxis: Promoting Awareness and Understanding

DAA Safe, Effective in Children with HCV Infection, Study Finds