 Welcome back. We found out a while back that with this public health crisis came an increase in challenges in poor children with asthma and managing their asthma as well as other lung diseases which includes RSV and now COVID-19. So to address these issues and these lung issues for children, I'm very happy to introduce Dr. Mandy Svatek. She's a faculty member and in the Department of Pediatrics at UT Health and Medical Advisor to the City's Armitra Health's Asthma Intervention Project, Community Asthma Project, SA Kids Breathe. So Dr. Svatek, Mandy. All right, thank you. Thank you, Kathy. Oh, I'm hearing your feedback right now of me talking. How can we fix that? I'm not sure what's causing it. Because otherwise, let's see. I don't hear that. It sounds terrific to me. Okay. Yeah, it's me. Maybe I had another window open. Okay. So everybody can hear me, correct? There we go. I had another window open. So I'm really excited about this opportunity. This is probably one of the biggest crowds that I've presented to yet I'm in my study. So a little unusual and I'm happy that everybody's reached out for this opportunity to learn. I know some of my focus is going to be a little bit within Bear County, San Antonio, but that's okay because then you need to learn about where your resources are outside of where you live. And so this pertains to everybody. I thought to start talking about COVID-19 first to get that out of the way because I know that's on everybody's mind and where we're at, what's going on. So for those that are listening in Bear County, this is as of April 21st where I received this information from University Health System and this is compiled from the Metropolitan Health District. And if you look at this top chart, we can still see the actual number of cases rising, but what's been fortunately positive at this point. So if we look at the bottom chart, March 20th, these are hospitalization rates. And now we're at April. We kind of are now showing maybe perhaps some plateauing, which is really good. And for those that are kind of wondering what's going on in the world, Johns Hopkins has a good dashboard and hopefully I've sent out some resources. We're trying to figure out how we can email those to you guys as well as getting nursing credit. And so hopefully we can put all this together, but you can see what's going on in the world with this Johns Hopkins interactive map. And then we can even see what's going on in the United States. I try to kind of hone in on this. And the darker colors mean that there's a higher number of cases. So fortunately, Texas doesn't, except for North Texas, doesn't have as many, many dark areas, but we're still concerned about the trickle down and what may be affecting our population. And all those that are outside of Texas, what may be affecting your population. So you can see that interactive map link, but you can Google Johns Hopkins interactive COVID map, the spread. So the spread is from coughing, talking or sneezing. And so it's important to understand how that spread happened. So even simply from coughing and talking, just talking alone can spread those droplets. The common symptoms you all have heard about fever, the cough, shortness of breath, feeling tired and weak, but you can have all these other symptoms that are seen here on the right hand side. And for children, so we have a lot of daycare workers, childcare workers. We know that the symptoms can be variable. You may or may not have fever. And so it's one of these symptoms, but not necessarily all fever and, but you can have cough, vomiting and diarrhea without the fever. And so it's good to keep that in mind. I like this chart here. This is from asthma and allergy foundation of America. And they pulled information from the World Health Organization and the Center for Disease Control and Prevention. And you can see the comparison of Corona with the cold, the flu. And because this is the asthma allergy foundation, they've added allergies here. And so you can see the duration of symptoms for Corona is much lengthier than even cold and even flu. The common symptoms cough and you can see the shortness of breath sometimes is present with COVID. So you're hearing about that, as opposed to these others, the cold and the flu, you're not really seeing much of that. The sneezing. So even though it can be transmitted via sneezing, we know that if you have another comorbidity, perhaps such as seasonal allergies, then if you contract COVID and you start sneezing because of your allergies, you can spread the disease even more. But you can look at a lot of these symptoms and there's a lot of similarities. So they can be hard. And that's why sometimes testing is important. Community protection. So just for the community itself, and then we'll hone in on the childcare centers, but you want to wash and clean your hands off. And I can't reiterate that just to do it all the time. So especially after coughing, sneezing or touching something, warm water and soap is the best method. But using an alcohol based cleanser, if you're out having to do that emergent shopping that you need for supplies, it's got to be 60% alcohol based. So look on your cleanser, make sure that that's appropriate. And refrain from touching the eyes and the nose. And so wearing that cloth face covering for the new CDC guidelines, handling it by the handles itself, not touching it, can actually prevent spread of the disease. It won't necessarily prevent you from contracting the disease, except you got a mask on and so you're not likely to touch your hand after touching something. And so just understand if you're out in that public, you can look on the CDC website, get a rendition of how you create a cough mask. We don't want to be using the PPE from the hospital because obviously we need that for healthcare workers when we go in and we need those supplies. And this has become a constant concern even at the hospital that I work at how we're going to preserve those supplies appropriately. And I'll talk about asthma later, but if, you know, I like to, anybody that has a chronic lung disease component or any sort of cardiac component, just complying with your medications. But for childcare guidance, so everyday actions, I need to reiterate is just when you know you've touched something wash off and have that surface at your daycare protected and then also wear appropriate face protection. So a lot of the childcare centers aren't open yet, but those that are taking care of children are the first responders and the healthcare workers. And then as the other daycares start opening up, these are things that we need to be aware of and start ahead of time in taking action to develop plans. So one of the good resources that y'all probably already know is a local childcare resource and referral agency at childcare of America and I'll have a resource sheet for that. But you're going to clean and disinfect anybody that's coughing and sneezing, including the kids, remind them to cover. If they're younger kids, you try to cover and then wash your hands afterwards. And then wearing cloth-based coverings, should we be starting to initiate going back to childcare settings? The biggest thing is babies, so children under the age of two, two and under, it can be a suffocating risk. And so we try not to use it on them. I think even the age of two and six for compliance, I know when I take care of patients in the hospital, they don't like wearing a mask if I have to transport them during that age. And so you're going to have to use some sort of guidance with that as well. And the biggest thing is anybody sick, whether it be children or staff, they need to stay home, whether they're confirmed or not, if they're sick, just to stay home. If they do get sick while they're at that childcare center, it's to keep them separate, create some sort of isolation room so that way until they can get picked up and get home, that they have that to sit in. If it's a confirmed case, you want to close off the area that you can and then open any sort of outside doors or windows and wait up to 24 hours before cleaning. So it seems like you would want to go in and clean, but there are still the droplets in the air and they need to settle and you don't want to be exposed to those. And if this is COVID, you're going to have to wear an N95 mask and those are masks that the public don't have, that's for us as healthcare workers that we're using. And so you've got to wait up to 24 hours. If let's say you found out that an individual was sick and this is seven days later, you don't need to kind of go through that process though, because everything's already kind of dissipated that virus. But you want to follow the CDC guidance on how to clean and disinfect so you can click on the link. You can look at CDC guidance for child care centers. They'll get you to the EPA guidelines. And then returning to work for sick staff members or other members or children, you've got to follow and adhere to these guidelines. And so these are three guidelines. These are ands. These are not ors. But if you have at least three days have passed a resolution of fever without the use of fever reducing medications and you have the improvement in respiratory symptoms, so your cough and shortness of breath are improving and your fever has been gone and at least seven days has passed since symptoms first appeared, then you can have that clearance to go. So the child care guidance, the biggest thing is even implementing social distancing strategies within that child care center. So let's say that you're taking care of health care or first care responders. You want to make sure that you cohort those children of the health care and first care responders together. Also just for every child is that if they're napping, you want them to nap head to toe with meat with the mat six feet apart. And so if you can't spread them six feet apart, at least put them head to toe and you're going to get some distance and then try to get that distance as much you can in between. Having daycare gatherings right now would not be, you can obviously spread the disease. So any sort of events, festivals, you don't want to do any of that. So just like for food, they're having curbside pickup drop off. This is sort of the same thing that we're thinking about is having a curbside drop off situation for when you're sending kids out as opposed to having individuals come in, especially if it's health care, first care responders that are coming to pick up their kids. Admin staff that they're not dealing with children, they may continue to work from home and intensifying cleaning and disinfection efforts. So right now it's talking together about your child care setting or your school setting and what sort of plans you're needing to make to develop right now. And you want to also not overwork your staff. And so understanding that people are still going to, as things open up, there's that potential people are still going to get sick. So try to have good backup plans so that you have that appropriate coverage so people aren't overworked. As far as other tips for cleaning and sanitizing toys, the biggest thing is don't share. And if it can't be cleaned, don't use. And if it's soiled, put it in a container that's labeled soiled until it can be cleaned. Children's books or envelopes, papers, any of that other stuff, fortunately the CDC says those aren't considered high-risk so you don't have to worry about trying to figure out a way to separate those or clean those. But the bedding, it's important to disinfect often so weekly and then keeping everything together for that one child in a labeled bag. And so looking at drop-off procedures a little bit more, you want to plan and create a good plan for those drop-off procedures, which means having hand hygiene stations outside or telling the families to bring their hand sanitizer so that they can clean off and do that if you don't have the capability of those resources. Placing the sign-in stations outside, cleaning those off every time that somebody uses them and then considering staggering drop-off time. So if you have a healthcare or first responder, maybe those kids of those individuals can come in a little bit earlier and you cohort them and get them over to the room a little bit sooner. And then screening, asking about fever, asking about symptoms and really encouraging parents that we cannot bring in those sick kids that we need to be protective and leave them at home. So I'm going to do a Q&A at the end because I want to make sure I talk about everything because I still have to talk about RSV and then asthma, which is really close to my heart. But RSV bronchiolitis, so this is what I see in the hospital when I take care of kids. And then oftentimes we can see as they're getting sicker and sicker that I'm having to send them to the ICU for higher level of care. So this is an aggressive virus as well. And we have to think about not just RSV but influenza, peroin influenza, metanumovirus. There's plenty of these viruses that act similarly to RSV, but RSV is kind of one of the more predominant. We know that approximately 57,000 children are affected a year. And when we say that a child has bronchiolitis, it's for children that are age two or younger. So those that are above age two, I still see them hospitalized. We call it more of a viral pneumonia due to RSV or any of the other viruses. Who's at highest risk? So it's children that are less than six months or if they have a preterm history, and let's say they're nine months, but they were born preterm and finally made it over, their immune system may not be as robust or lungs may have been affected by prematurity. So you always have to keep that in mind. For RSV, winter, fall and spring are the predominant times. Even we see RSV, influenza, metanumovirus still start to traverse now into the spring and then sometimes the summer. So it's pretty scary that these viruses linger longer. And even with COVID, we're concerned how much longer that we're going to endure this. So you can see the symptoms are very similar to COVID, runny nose, cough, wheezing. They're not wanting to eat. Their bronchiol is that small airway. It's just full of secretions. And so anytime that you put a bottle to their mouth and their nose is congested, it's really difficult for them to breathe. So they're not going to eat as well. And so the transmission, same sort of thing, contact and droplet. And so wiping everything is important. And understanding coughing and sneezing is going to spread it. And so the biggest thing I've already reiterated this is hand washing. But even after using the toilet, changing the diaper, the diaper changing areas need to be cleaned. After you help wipe somebody's nose or if they're the kids are playing the sandbox or they're playing with water, cleaning their hands and doing all those appropriate things to protect them and other individuals around them. And then if you're giving medicine to a child or you're handling waste baskets or any any other handling, just hand wash. I can't reiterate that more. The healthchildren.org website is a great website. And they tell you about how to promote good hygiene in the child care centers as well. And so ideally you want to sink in every room. But if you don't have that, at least separate out your food handling sinks from your toilets or diaper changing areas, having those disposable paper towels, not keeping a towel there that you're constantly using because that can be a night is to spread infant and toddlers, they put things in their mouth, you got to sanitize, you got to look at those door cabinet handles, drinking fountains, all the surfaces and clean those. And so everything that you can think about. And then it's important to really reiterate, fully immunizing your staff and the kids, you know, making a requirement. I'm a pediatrician. I know that vaccines are important. I've seen kids with pertussis come in and die from pertussis. You know, these are things that are important. The flu vaccine extremely important that we need to enforce. Okay, so moving along to asthma and the child care setting. So you can see that child is surrounded by the clinician, the family, the school nurse, the child care worker. And this is the case. When they come to my hospital, this is what I hear on history is that, you know, whatever age it be, but more close to y'all that are a lot of individuals that are listening, we have a four year old boy, he has asthma. He's noted to come into daycare with some cough, progressing throughout the day. Now he's starting to work hard to breathe. He's playing outside and he seems more short of breath than any of these other classmates. You administer his albuterol, it improves his symptoms and you send him home and say, Hey, mom, you know, he needs to be seen by his primary care physician. And I don't really know what to do because I don't have a plan, but I have this inhaler. So, you know, we need an asthma action plan. She she's picking up her kids. She's unable to get them to the primary care. She doesn't have the out of pocket expense to pay for it because she doesn't have the insurance. And so and she's thought that he got better. And so he's at home and you and the next day he he gets brought back and you see, hey, he's still breathing hard. Social wise, he lives with his parents. There's a genetic component of asthma. So there's three siblings. They all have asthma. They live in an apartment and and there's multiple exposures we have to think about. They have a cat and a father and a father that smokes but outside, but we got to think about the second hand smoke. So why this hits me hard is that there's over 6 million children in the U.S. with asthma. That's one in 12. And then if I think about I take care of a large med Medicaid population, the lower socioeconomic population, that's where I see them come in. And that's one in 10 that are affected by asthma. And we'll talk about that. That's multifactorial. And why that happens is concerning because we can help them. We know that the black population has a little bit higher incidence. And then if we think about within the state of Texas, so for those who are listening within the state of Texas as of 2016 17 from the Texas Department of State and Health Services, we have new data that we have over 57,000 outpatient visits with active asthma symptoms. These aren't preventative care visits and almost 6000 inpatient visits. So we're seeing so many kids and we know that prevalence. So if they're below the federal poverty level, if it's like a family of four, if that family of four makes less than about 22,000, their risk of having asthma is higher at 10.5 as opposed to those that make more money and that are above 250% of the federal poverty level. The thing that hits me hard as well is the cost. And if they look at Medicaid and the cost, we're almost at $173 million spent. So that's missed days from work, missed days from school, hospitalization costs, outpatient costs, Bear County alone $18 million has spent on pediatric asthma. The one thing that hits even further is that within Bear County 2015 2016, we got together, we didn't have that robust data, but we were able to talk to enough pediatric ICU docs and we found that there were four deaths. And then I got the Texas Department of State and Health Services and 100 children died of asthma and no child should die of asthma. This is a disease that's preventable with the appropriate control. You can see for those that live within Bear County, the darker means the higher incidence. And so some of these lower socioeconomic areas, this is what you're looking at, at more higher incidences of having hospitalization rates for children with asthma. So that becomes concerning as well, knowing your areas of town and what your resources are. And so to put COVID and asthma together real briefly, we know and we're hearing that chronic lung diseases as well as cardiac diseases can put that individual at higher risk for hospitalization. It doesn't mean if you have asthma, you have a higher risk of contracting COVID, but let's say you have uncontrolled asthma and you develop COVID, you can have worse or symptoms. And shortness of breath is, as I showed you all, a COVID symptom, but it's also in the asthma symptom. And so during this time, it's going to be hard to delineate whether it's from COVID or asthma. Some of y'all may have read a New York Times article that questions they're right now seeing from what data that they're able to obtain, but it's really early on that maybe asthma patients aren't affected as adversely. And I think you have to take that with a grain of salt. We know our lower socioeconomic families may not be presenting and getting tested for COVID. And so we don't know how bad their symptoms are. But realizing what the effects of COVID and asthma are, are these MDI uses. And so COVID, we try to limit the spread to healthcare workers. Obviously, that's where the N95 mask comes in, but also how we spread those droplets. And so COVID patients, if they are needing a treatment such as Albuterol, we really have to limit that by not giving them a NED because that's going to spread the droplets. And so we're having to use MDIs on those individuals. What that means is that we may develop a shortage. And so you may be hearing about that in the community that there's potential shortages. Hopefully as things start to taper off, we can worry less. But that's still a hot topic is that our MDIs for the general population with asthma may be on a shortage. And so enforcing the use of controller medications, that's what our SA Kids Breathe was doing prior to being called off to the COVID response team. They were calling families of uncontrolled asthmatics to enforce that they need to be using that controller medication, which is not Albuterol, but that inhaled steroid, that flow vent, Q bar. You'll hear about those different medications. And then understanding what's going on in the home environment, which we'll talk about in a minute. But what I'd like to really reiterate, and you all are going to hear about trauma informed and social determinants in lectures later on today, is understanding this model that in the center, you have this person, this child, what their age is, what their race is, any sort of constitutional factors, mental health, and you have individual lifestyle factors, what's happening in their environment smoking or any of the things that you can think about. And then you have what's their social and community networks surrounding them. And then you have their work environments, their living conditions, their education, their healthcare services, even water and sanitation, depending upon where they live, surrounding that. And then what's going on in the general socioeconomic cultural environmental conditions. We know in San Antonio, there's non attainment, the air quality has been deemed not the best. We know COVID is going on around the world. And so we have to be thinking about those things. But social determinants. So those are employment, housing, education, what their health literacy is, what they understand about a certain disease process. And if they have money, economic stability to afford, you know, buying food or, you know, what their social, social context of do they have those resources to help them or do they understand they have resources to help them. And a lot of them, a lot of individuals, they don't remember to get the insurance re updated. And if you don't do that, then you're lagging, you can't get those healthcare resources. And so that leads to increased morbidity and mortality and what your life expectancy is. So you have to seek to understand why that mom with that four year old son, you know, wasn't able to bring him, him back, you know, do she have other kids to pick up and, and she didn't have the funds to pay for things. And so those socioeconomic stressors you can see here, even individuals have lack of transportation, they're using the bus system. And those end up with going to the or the primary care for a non preventative visit for an acute care visit for being sick. And, and on top of that, if you think about the environmental allergens that perhaps they haven't been educated on, they don't know they don't have that knowledge about asthma. They have multiple caregivers, we don't have an asthma action plan, then they don't understand what's going on, why, which medication is quick relief, which medication is a controller. So there's inconsistencies in care. And then, and then later on today, adverse childhood experience is also weighs in. And so if an adverse childhood events has happened to a child or multiple types of events have to happen to a child, then that may increase their propensity to develop something such as asthma. So you can see on this chart here, that you have a propensity to develop any of these COPD, arthritis, heart disease, diabetes, cancer, but asthma, if you have four plus, then your likelihood to develop health, health conditions of asthma is much higher. And so we know that it affects the brain and then affects the body in an adverse way to cause these problems. We also have to think about environments and asthma and disease. So just for diseases worldwide, we know that 26% of the disease burden is attributable to the environment, according to the World Health Association. And then 16% in the United States, because we have a little bit more control measures. But for asthma, 44% of the disease burden worldwide is attributable to the environment. And that includes the U.S. And that excludes pollen and approximately half is from indoor exposures. And so the indoor exposures that we think about are secondhand smoke. And then obviously in secondhand smoke can be carried in on your skin, on your clothes and your hair. And so even though somebody smokes outside, which is better than smoking inside, we know that that's a major trigger. And then the cleaning agents, when I walk into some of the houses of the SA Kids Breeds families, I can smell the fabuloso, that strong scent and you think it elicits cleanness, but it actually elicits asthma exacerbations. And so you have to think about all those scented plugins. And then the furred pets, the dust mites, cockroaches, rodents, molds, a lot of things that we commonly see. Outdoor pollutants, I talked about being in non-attainment. And so the small particulate matter, as well as the ozone, all weigh in and causing triggers for the asthma to be uncontrolled. And then on top of that, we have pollens and outdoor moles. We know that oat came in. But to think about your environment right now, while maybe perhaps your daycare center is not open, go through that process of having a walkthrough program. So I was trying to find some beautiful pictures. Wisconsin had some good ones, some good examples all lumped in together. But thinking about those furry animals and not being washed, those contain dust mites. Tennis balls to keep things from bumping into each other. If they're getting old, they're going to contain dust and allergens. And then the things to make the place smell better, they're actually more harmful than good. And so you really have to keep that in mind, the glade plug-ins. If you have a lot of clutter, that carries a lot of dust and can exacerbate asthma. If you have windows that have curtains, you've got to think about cleaning those curtains often or getting ones that are non-cloth, because that can spread dust into the air, particles in the air. And then your AC filters, your HVAC filters, you've got to change those out for the protocol or if they're dirty sooner. So think about looking at those things right now and eliciting those preventative measures. So let's go back to this child. He has no asthma action plan. He can't get to the doctor. They're waiting to reapply for insurance. And then his living conditions that he lives in. So the asthma action plan, that's at least the most important thing that we can get is a good plan to help. So his symptoms, if they're out of control and we're getting into the yellow area where we have cough, leaves, tight chest, we're waking up at night, then that gives you a plan of what you need to do as far as step-up therapy. And the National Institute of Health and Lung is making some changes to how we step up those therapies. Obviously, the expert panel had to take some time off because of COVID and couldn't have the appropriate meetings. And so you might start seeing changes in asthma action plans. But red, that means danger. So if they're breathing hard and fast, their nose is open wide, they can't talk, the medicine doesn't seem to be helping, that gives you that ability from your daycare center, your nursing center to say, look, this is where your child's at. I need a call for help. I need to call 911. I need to send them to the emergency room and get help. And so requiring every daycare center to have that or school to have that asthma action plan is truly important. And this is another resource I'm hoping to hand out at the end somehow as we work for that. But having that MDI inhaler with the spacer and giving the appropriate education. So this is from the University Children's Health System where I work and RT there was kind enough to create this. And you can see this inhaler has a face mask. And so most of your population is going to need that face mask. If they're under the age of six or under, I say they need a face mask because they're still learning how to use it. But most of the individuals aren't even learning how to use the the spacer with a face mask or don't even have one. And so learning how to do this, I'll have links QR codes where you can actually watch videos and then start to teach the children how to use this medication well. So last but not least, and I know a lot of you aren't out of San Antonio and that's okay because you need to think about what resources that you have within your area. And as we continue to develop this sort of program and this program that is in San Antonio is actually emulated from Seattle and Michigan. So we know that this program does work well and we're still in our infancy of really trying to collect data on this program. We went through our first year and we're supposed to tally up information. But Essay Kids Breathe, one of our school respiratory therapists who is a proponent in the Northeast Independent School District and improving asthma care within her school system within her community. Diane Rhodes came up. I wanted an acronym that could explain this program well. And Breathe stands for Building Relationships, Effective Asthma Teaching in Home Environments. And I think that explains it well. Kara Housler is the program manager and our program staff are currently out of the Metro Health Department and they are on a COVID response team. And so that's why I'm talking about this hiatus. But I serve as a medical advisor as well as the advisory council chair for this program. And why we have this program, this is one of the slides that I felt was impactful for you all. We know that the total number of days missed in millions from the CDC shows an insurmountable, you know, over the course of years, even we're seeing increases, we're at almost 14 million as far as data that we could collect across the United States. These are for older kids age 5 to 17. But we know that we're missing a lot of days of school. If we're missing a lot of days, then literacy goes down and then cognition development goes down. And then we lead to them not pursuing, you know, further degrees and becoming better in obtaining jobs. And so this is an entourage effect of causing problems. So the South Texas Asthma Coalition, how this developed, and I think this is why this is important to know what your resources are and how you can drive your community to be impactful. Well, in the 90s, there was individuals like my mentor, Dr. Pamela Wood, that helped form this coalition to improve the care of asthma within the South Texas. And one of the major products that they did was that asthma action plan that you saw and they required, they went out on the venture and said, look, schools, school nurses need this asthma action plan if a child has asthma and to require it. And so the stack went dormant. And then we reformed in 2018 after my mentor had really pushed me to have an asthma summit to educate school nurses about how we can better care for these children with asthma. And then at that time when I was forming this summit, Dr. Bridger at the time the director of the San Antonio Metropolitan Health District heard what was going on and provided resources from her staff because she knew that the asthma admission rates to hospitals for children were highest in San Antonio than in the state of Texas, 170% higher. And we know that if you get admitted to the hospital, the average cost is about 3,400 per child. And so what I ended up finding at this summit was that there was all these individuals, all these organizations, and you can see some of them down here that really were engaged and wanted to improve care. And so we approached city council to say, look, we have some high priority areas and you can see this map at the time was a little bit different from further collection of data that we were able to obtain. But this is kind of from around 2015 that we knew that these are some of our lower socioeconomic zip coded regions that we're having higher hospitalization rates. So we knew we had a problem. We approached city council and city council was able to fund us for a two year pilot program to send community health workers into a home to assess that child's environment, assess their social determinants, what was causing problems, and to help them. And so we have four community health workers, one supervisor who's that supervisor has been in the business for 30 years, Paul Kloppy, he is really motivated to help the community health workers get into the home and provide asthma education. He's a certified asthma educator. And we have an advisory council. So a lot of those people that were motivated on stack are brought into an advisory council and then we sit monthly and talk about the program and how we can continue to improve it. And then we have Green and Healthy Homes Initiative, GHHI, that we applied for grants. And we now this was our first grant, but we have two grants with them to build a model that we that we have have the managed care organizations fund this model so we don't continue to have the city funded. And so that's what's important is that if we prove that we're improving outcomes, we're decreasing hospital admission rates, that we can we can help children obviously from having better control, having better control of your asthma, but we can also save the managed care organization's money. And so other programs, other other cities across the United States can emulate a program such as this across the state of Texas. So eligibility three to 17, I think it's a little bit hard to diagnose children with asthma under the age of three. Right now they have to live within the city limits of San Antonio. They have to have at least one criteria. So either your one hospital admission and considered uncontrolled, you can see if they're having greater than two days of symptoms per week, or greater than two nights per month for greater than two months with asthma symptoms, then they can get into the program. Or if they have two ED visits or unscheduled urgent care visits in the past 12 months, or if they have two or more separate episodes of unscheduled school treatment visits for asthma, then you can solidify and say they keep coming back to us in the school office, or into the child care center and I'm having to give them treatments or chronic absenteeism. The biggest thing that anyone can refer, whether it be this caregiver, the childcare worker, the school nurse, so understand that, that anyone can refer. If you're referring, make sure you're letting the family know that you know this program is important and then that we can get resources. So you can see here, this is what we provide is at least five to six visits. Three to four of those go into the home and assess how they're using their inhaler. Do they have an asthma action plan? What their home environment looks like, just like we had pictures of the school environment. So one of the homes that I was able to go in on a visit, I've been in on a few visits, I walked up to the home, it was a housing, a home, housed by San Antonio Housing Authority. Two doors down was secondhand smoke that I could easily breathe as I walked into the home. As I walked in, the air didn't smell as good. And the first things that we looked at were the HVAC filter, which was full of mold and dust. And then the heater system was full of dust and mold. Mom had a newborn baby that was upstairs. The heater and the AC really weren't working well. So it was a cold day and she had that one heater up there where the baby was. And you could tell that she was even having problems breathing. She had asthma. And we reached out and talked to her and understood just simply by trying to remove her from that environment. She said that she had to prop the door open on warmer days. The cats from the neighbors would get in. So she had all this insult. She fortunately had contacted the Housing Authority. They were able to, and we had sent a letter as well, and able to move her. But these are the patients, the participants that we're seeing in the program. And that's where our community health workers know, hey, what sort of resource? Can I get them a letter or can I get them the number to the Housing Authority? Or if they have food insecurities, can we get them over the food bank? Or even the food bank helps with applications for Medicaid? Can we do all those things to help them? The biggest thing is that this is provided to them at no cost. And that's where we need to reiterate that. And so you can see the education and services because we're running out of time, but they teach how to use the device more than once, go through the Asthma Action Plan, go through their medications, and then they go back to the primary care and the school nurses or childcare provider, and they go and visit with them, with that child and the parent, and let them know what's going on in their environment so that we can understand that and we can help them to their best. And so that's what we're trying to do, like I said, reduce hospitalization rates, ED visits, miss days from the school because we need them learning, we need them growing up to be smart kids that are going to pursue further degrees and have better job opportunities. And so, uh-huh. And then, uh-huh. We're going to have to take questions in a minute. These are some of the resources. Fantastic. Yep. And so, they take facts and phone referrals. You cannot email referral. It's not HIPAA related, but if you have questions, you've got this opportunity to do that. This is a great program. I hope that you guys have learned a lot. If we have any questions, I'm going to let Kathy moderate. Okay. Thank you so much, Dr. Svatic. This was fantastic. asthma is one of those things that we realized was getting worse because of the COVID-19 crisis, particularly with children home, with stay at home, with the stay at home orders, where they're exposed to the triggers that they may not be exposed to all day. So there were a lot of excellent comments. The major question revolves around, can they get your excellent slides, the asthma plan? Absolutely yes. We will figure out how to get everything to you all afterwards. So that's the most important thing. Yeah. I actually created a resource page. I'm hoping to get that to you guys so that has links to the internet to make it simpler. The slides, I'd love to share. Thank you. I love hearing about excellent. And then I actually, from one of our summits, tried to take out some pieces and put in some pieces that were pertinent to you guys as far as resources that we can PDF send over. So we're working on that. I'm hoping we can do that. We're trying to figure that all out, but we will get it to you because they truly are excellent. One quick question. Are infants more at risk for RSV if they've had it previously? So what I do see is that if they've gotten one illness from bronchiolitis, so whether it be RSV influenza, parainfluenza, we do see at times that they're more prone to get another virus that can cause those same symptoms of bronchiolitis. And we do see repeat offenders, they've had RSV when they were, let's say, six months old. And now that they're two, they have RSV again. So it is possible. We know that RSV can potentially cause lung remodeling and may lead to asthma in the future. And so we advise kids, kids' parents on that as well. And so that's, that's a great question. Okay. The other one is, how do you disinfect an isolation room when there's no ventilation, no windows? Yeah. So I would close that room off, just close it off, stay out of that room for 24 hours, at least 24 hours, and then go back in after that. So those droplets have settled, they're not, they're not going to get into your lungs. Just go in and, and obviously be cautious wear gloves and continue to wear those face masks for right now until the CDC tells us otherwise and then do use your EPA provided cleaners. Super. The only, the other question, and there, many of them were lumped together, well kids over 10 or do kids over 10 need to wear a mask all day? I, at this point, yes, we advise that, especially if the childcare centers are opening up and we're still, the CDC is saying still continue to social distance as much as you can. Those kids even San Antonio is saying 10 and up need to wear a mask if, for whatever reason, they're out in the public, which, you know, they shouldn't, shouldn't be, but advising that 10 and up need to wear a mask. And again, it's not a hospital mask because we need those for staff. You can look at the resources on the CDC, even folding up a t-shirt. It's really neat and taking two rubber bands really creative that you can make your own mask. And after a day's use, or if you're touching it, or it gets, gets dirty, it's got to go, it's got to be cleaned. And you can put it in the wash. Yeah. The other, the other question is, what is your full name? And I believe it's on the bottom of one of the slides. Dr. Mandy Alice Tbil Svatek, UT Health Pediatrics in San Antonio, but I believe it's on the bottom of the slide. And we can always get that to you. Right. Or just my name, but we'll get it to you. Yeah. So my question, you can see some of my roles. SA Kids Breeze, San Antonio Asthma Coalition with UT Health. I work at University Hospital. I'm a pediatric hospitalist. So we see plenty of sick kids. Fortunately, we haven't had any COVID positive cases of kids. We've had had persons under investigation. Those have fortunately been negative at this point. We're hoping to keep it that way with the social distancing. And what are the best cleaning products to use in a child care setting? Right. I would reference the EPA cleaning resources. So that cleaning resource guide will give you a direct link to the child care center agency recommendations for the environmental protection agency cleaning products that you need to be using because there's many products on the market. So the best resource is going to that resource that I sent to you all and clicking on it and finding those best resources to start cleaning up your environment. Okay. Thank you very much. Thank you, Kathy. Very, very important topic. And we will see you back in about 10, 15 minutes. Thank you all. Thank you.