David Núñez, MD, MPH


Family Health Medical Director, Public Health Services, Orange County Health Care Agency, Sacramento, CA

Dr. Núñez has a primary interest in directing attention and resources to areas of significant disparity in child health, particularly asthma. He is also interested in promoting health initiatives aimed at improving overall health access and the quality of care provided for low-income, minority, and underserved children. He coordinates the statewide Best Practices in Childhood Asthma program that utilizes continuous quality improvement principles and trained clinical asthma coordinators/community health workers to improve the quality of asthma prevention and clinical care for children. He also provides collaborative, strategic support to asthma legislative, policy, prevention, and educational opportunities in the State Department of Public Health and in local schools and communities. He has ten years of previous clinical experience as a primary care pediatrician with Kaiser Permanente, where he also served as the medical center’s lead for quality improvements in pediatric asthma care.

Dr. Núñez received his medical degree at the University of California, San Diego, School of Medicine in 1989, and completed a residency in Pediatrics at Stanford University Medical Center and at UCSD Medical Center in San Diego, CA in 1992. He received an M.P.H. from the Harvard School of Public Health in 2002 as a CFHU Fellow.





Design of a Pediatric Asthma Registry for the Commonwealth of Massachusetts


Asthma is a chronic inflammatory disease of the lungs which results in episodic, partially reversible airway obstruction.  Untreated asthma may result in symptoms of persistent cough or wheeze, sleep disturbance, fatigue, shortness of breath, or death.  The etiology remains unclear.

Between 1980 and 1996 self-reported asthma prevalence in the U.S. increased significantly, translating to nearly 15 million individuals with asthma.  During this same period, children aged 5-14 experienced the highest estimated prevalence of 8.2 percent.

While the most recent data indicate that the steady increase in prevalence may be leveling off, asthma remains a public health dilemma.  In children asthma is the most common chronic disease, the leading cause of serious illness, and one of the primary causes of school absenteeism.  Children under age 14 also experience the highest rates of asthma related emergency room visits and hospitalization for asthma.

The burden of asthma affects Americans of all ages, races, and levels of society.  Yet, at every age, low-income and minority populations experience substantially higher rates of fatalities, hospital admissions and emergency room visits due to asthma.

Despite improvements in pharmacologic therapies and an overall reduction in hospitalization and mortality statistics, these inequalities persist.  These disparities are particularly severe for children in poor, urban, inner-city areas.

There are many potential causes for disparities in asthma outcomes.  These may include inadequate medical treatment, lack of access to appropriate medical services, inability to pay for necessary medications, communication barriers resulting in poor compliance, or persistent exposures to environmental triggers.

To eliminate disparities in asthma treatment and outcomes there must be surveillance on a local level to better document prevalence in high risk populations, assess practices, implement appropriate interventions, and to evaluate the effectiveness of these intervention strategies over time.  Yet, according to many experts in the field, asthma surveillance in the U.S. is minimal.  This is especially true for children.

Recently, state legislative policy in several forms has been introduced that begins to address this problem.  The Massachusetts Senate is considering legislation to establish a statewide asthma registry (S.511) and the House has pending legislation to establish a committee charged with studying cities with the highest levels of asthma (H.3930).

The Bureau of Environmental Health Assessment (BEHA) in the Massachusetts Department of Public Health recently completed a pilot study of asthma prevalence among school children in the Merrimack Valley.  The study utilized the school health record and data collection by school nurses to obtain detailed information on asthma in children ages 5-14.  This study was funded by the Agency for Toxic Substances and Disease Registry (ATSDR) to investigate the possible association of area hazardous air pollutants and associated asthma prevalence (final report to be released September 2002).  Based upon this experience, I was asked to research and design a model for implementing statewide asthma surveillance of public school children ages 5-14.


The research I conducted on asthma surveillance included a review of the relevant literature, assessment of current methods of state and national asthma surveillance, review of pilot studies underway on pediatric asthma surveillance, analysis of BEHA’s experience in the Merrimack Valley Study, and consultation with school nurses, public health officials, and state and national experts on asthma and asthma surveillance.  Based upon these findings I formed specific process recommendations and developed new survey instruments for both an individual asthma registry and for aggregate school surveillance.


  • Apply established model of disease registry confidentiality (cancer, birth defects) to pediatric asthma surveillance.
  • Improve accuracy of data collection by revising the state’s physician school health form to include specific information on asthma classification consistent with National Asthma Education Prevention Program/NIH guidelines.  Integrate OMB/Census 2000 categories of race/ethnicity into school health forms.  Obtain information on type and frequency of asthma medications used and whether an individual asthma action plan is available.
  • Continue to actively engage school health nurses in the process of asthma surveillance.  Phase surveillance program in gradually, beginning with aggregate information at Enhanced School Health Services Program sites and extending to all public schools and other sites in New England over a 3-year period.
  • Standardize and shorten period for data collection.  Utilize current database technology to manage registry with optimal efficiency and affordability.
  • Provide timely feedback to state and local public health officials, school nurses and other school personnel, and community residents and physicians.
  • Utilize database to assess asthma prevalence by individual school, district, and community.  Evaluate patterns of increased prevalence, severity, and disparity.  Apply further analysis and target interventions to specifically address demonstrated needs.  Measure outcomes of these interventions.
  • Document and share with other state and national agencies the challenges, refinements, and results that occur with implementation of this asthma surveillance program.

Faculty Preceptors:

Suzanne Condon, M.S., Assistant Commissioner, Department of Public Health, Bureau of Environmental Health Assessment, the Commonwealth of Massachusetts


Leslie Boss (CDC), Brunilda Torres, Robert Knorr, Roy Petre, Frances Dwyer, Marc Silverman, Anne Sheetz, Larry Baumeister, Robert Leibowitz, Lani Wheeler, BEHA/DPH Staff