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. 2025 Sep;156(3):627-639.
doi: 10.1016/j.jaci.2025.02.036. Epub 2025 Mar 13.

Child Opportunity Index at birth and asthma with recurrent exacerbations in the US ECHO program

Rachel L Miller  1 , Holly Schuh  2 , Aruna Chandran  2 , Rima Habre  3 , Jyoti Angal  4 , Izzuddin M Aris  5 , Judy L Aschner  6 , Casper G Bendixsen  7 , Jeffrey Blossom  8 , Michelle Bosquet-Enlow  9 , Carrie V Breton  3 , Carlos A Camargo Jr  10 , Kecia N Carroll  11 , Sarah Commodore  12 , Lisa A Croen  13 , Dana M Dabelea  14 , Sean C L Deoni  15 , Assiamira Ferrara  13 , Rebecca C Fry  16 , Jody M Ganiban  17 , Sarah D Geiger  18 , James E Gern  19 , Frank D Gilliland  3 , Semsa Gogcu  20 , Diane R Gold  21 , Marion E Hare  22 , Robyn N Harte  23 , Tina V Hartert  24 , Irva Hertz-Picciotto  25 , Alison E Hipwell  26 , Daniel J Jackson  19 , Margaret K Karagas  27 , Gurjit K Khurana Hershey  28 , Haejin Kim  29 , Augusto A Litonjua  30 , Carmen J Marsit  31 , Cynthia T McEvoy  32 , Eneida A Mendonça  28 , Paul E Moore  24 , Anh P Nguyen  25 , Flory L Nkoy  33 , Thomas G O'Connor  30 , Emily Oken  5 , Dennis R Ownby  34 , Matthew Perzanowski  35 , Katherine Rivera-Spoljaric  36 , Sheela Sathyanarayana  37 , Anne Marie Singh  19 , Joseph B Stanford  33 , Annemarie Stroustrup  38 , Nissa Towe-Goodman  17 , Veronica A Wang  39 , Tracey J Woodruff  40 , Robert O Wright  11 , Rosalind J Wright  11 , Antonella Zanobetti  39 , Edward M Zoratti  29 , Christine C Johnson  29 ; ECHO Cohort Consortium
Collaborators, Affiliations

Child Opportunity Index at birth and asthma with recurrent exacerbations in the US ECHO program

Rachel L Miller et al. J Allergy Clin Immunol. 2025 Sep.

Abstract

Background: Environmental exposures and social determinants likely influence specific childhood asthma phenotypes.

Objective: We hypothesized that the Child Opportunity Index (COI) at birth, measuring multiple neighborhood opportunities, influences incidence rates (IRs) for asthma with recurrent exacerbations (ARE).

Methods: We tested for COI associations with ARE IRs in 15,877 children born between 1990 and 2018 in the ECHO (Environmental Influences on Child Health Outcomes) program. Parent-reported race and ethnicity and other demographics were assessed as effect modifiers.

Results: The IRs of ARE for children born in very low COI neighborhoods was higher (IR = 10.98; 95% CI: 9.71, 12.25) than for other COI categories. Rates for non-Hispanic Black (NHB) children were significantly higher than non-Hispanic White children in every COI category. The ARE IRs for children born in very low COI neighborhoods were several-fold higher for NHB and Hispanic Black children (IR = 15.30; 95% CI: 13.10, 17.49; and IR = 18.48; 95% CI: 8.80, 28.15, respectively) when compared to White children. Adjusting for individual-level characteristics, children born in very low COI neighborhoods demonstrated an ARE IR ratio of 1.26 (95% CI: 0.99, 1.59) with a higher incidence of cases among children ages 2 to 4 years and with a parental history of asthma.

Conclusions: Rates of ARE were higher among children born in under-resourced communities, and this relationship is strongest for young minoritized children with a parental history of asthma. Higher rates for NHB even in the highest COI categories suggest that risk associated with race persists regardless of social disadvantage.

Keywords: Asthma; child opportunity index; environmental and social determinants of asthma; incidence rates; recurrent asthma exacerbations.

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Conflict of interest statement

Disclosure statement Research reported in this publication was supported by the ECHO program, Office of the Director, National Institutes of Health (NIH), under award numbers U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center), U24OD023319 with cofunding from the Office of Behavioral and Social Science Research (Measurement Core), U24OD035523 (Lab Core), ES0266542 (Human Health Exposure Analysis Resource [HHEAR]), U24ES026539 (HHEAR B. O’Brien), U2CES026533 (HHEAR L. Peterson), U2CES026542 (HHEAR P. Parsons, K. Kurunthacalam), U2CES030859 (HHEAR M. Arora), U2CES030857 (HHEAR T.R. Fennell, S.J. Sumner, X. Du), U2CES026555 (HHEAR S.L. Teitelbaum), U2CES026561 (HHEAR R.O. Wright), U2CES030851 (HHEAR H.M. Stapleton, P.L. Ferguson), UG3/UH3OD023251 (A. Alshawabkeh), UH3OD023320 and UG3OD035546 (J.L. Aschner), UH3OD023332 (C. Blair, L. Trasande), UG3/UH3OD023253 (C.A. Camargo, Jr), UG3/UH3OD023248 and UG3OD035526 (D.M. Dabelea), UG3/UH3OD023313 (D. Koinis Mitchell), UH3OD023328 (C. Duarte), UH3OD023318 (A. Dunlop), UG3/UH3OD023279 (A. Elliott), UG3/UH3OD023289 (A. Ferrara), UG3/UH3OD023282 (J.E. Gern), UH3OD023287 (C.V. Breton), UG3/UH3OD023365 (I. Hertz-Picciotto), UG3/UH3OD023244 (A.E. Hipwell), UG3/UH3OD023275 (M.K. Karagas), UH3OD023271 and UG3OD035528 (C. Karr), UH3OD023347 (B. Lester), UG3/UH3OD023389 (L. Leve), UG3/UH3OD023344 (D. MacKenzie), UH3OD023268 (S. Weiss), UG3/UH3OD023288 (C.T. McEvoy), UG3/UH3OD023342 (K. Lyall), UG3/UH3OD023349 (T.G. O’Connor), UH3OD023286 and UG3OD035533 (E. Oken), UG3/UH3OD023348 (M. O’Shea), UG3/UH3OD023285 (J. Kerver), UG3/UH3OD023290 (J. Herbstman), UG3/UH3OD023272 (S. Schantz), UG3/UH3OD023249 (J.B. Stanford), UG3/UH3OD023305 (L. Trasande), UG3/UH3OD023337 (R.J. Wright), UG3OD035508 (S. Sathyanarayana), UG3OD035509 (A.M. Singh), UG3OD035513 and UG3OD035532 (A. Stroustrup), UG3OD035516 and UG3OD035517 (T.V. Hartert), UG3OD035518 (J. Straughen), UG3OD035519 (Q. Zhao), UG3OD035521 (K. Rivera-Spoljaric), UG3OD035527 (E.S. Barrett), UG3OD035540 (M.M. Hedderson), UG3OD035543 (K.J. Hunt), UG3OD035537 (S.L. Mumford), UG3OD035529 (H.-N. Nguyen), UG3OD035542 (H. Santos), UG3OD035550 (R. Schmidt), UG3OD035536 (J. Slaughter), and UG3OD035544 (K. Whitworth). This research was funded by the ECHO program, Office of the Director, NIH, under award number UG3OD023316 (J. Vena and R. Wapner); by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Intramural Funding; and included American Recovery and Reinvestment Act funding via contract numbers HHSN275200800013C, HHSN275200800002I, HHSN27500006, HHSN275200800003IC, HHSN275200800014C, HHSN275200800012C, HHSN275200800028C, and HHSN275201000009C. Additional funding included the following awards/grants: Clinical and Translational Science Award UL1 TR002373 NIH-ICTR; U19 AI104317/AI/NIAID NIH HHS/United States; Harvard NIEHS Center P30-ES000002; U19 AI 095227; R01-ES015359; R01-ES01031701; NIH P01ES022841; Environmental Protection Agency RD 83543301; NIH P30ES030284. NIH disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsor, NIH, participated in the overall design and implementation of the ECHO program, which was funded as a cooperative agreement between NIH and grant awardees. The sponsor approved the Steering Committee–developed ECHO protocol and its amendments including coronavirus disease 19 measures. The sponsor had no access to the central database, which was housed at the ECHO Data Analysis Center. Data management and site monitoring were performed by the ECHO Data Analysis Center and Coordinating Center. All analyses for scientific publication were performed by the study statistician, independently of the sponsor. The lead author wrote all drafts of the manuscript and made revisions based on coauthors and the ECHO Publication Committee (a subcommittee of the ECHO Operations Committee) feedback without input from the sponsor. The study sponsor did not review or approve the manuscript for submission to the journal. Disclosure of potential conflict of interest: C.A. Camargo, Jr, served on asthma-related Scientific Advisory Boards for AstraZeneca (in 2020) and Sanofi Genzyme (in 2021). J.E. Gern has received consulting fees from AstraZeneca and Meissa Vaccines, Inc, and has stock options in MeissaVaccines, Inc. T.V. Hartert has served on vaccine Data and Safety Monitoring Boards and advisory panels for Pfizer and Sanofi (without funding). D.J. Jackson has received funding from GlaxoSmithKline and Regeneron; personal fees for Data and Safety Monitoring Board from Pfizer; and personal fees for consulting from AstraZeneca, Avillion, GlaxoSmithKline, Sanofi, and Regeneron; and has served as a consultant to Apogee Therapeutics. A.A. Litonjua was a consultant for Apogee Therapeutics. S. Sathyanarayana has served on the board of the Children’s Environmental Health Network; this is a non-paid position. The rest of the authors declare that they have no relevant conflicts of interest.

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