For Clinicians | The September Asthma Epidemic

For Clinicians | The September Asthma Epidemic

Why the Controller Refill Matters More Than the Rescue Inhaler

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed and edited by Kristen Carpenter, PA-C

Right now your patients are buying pencils, brand new white sneakers that’ll stay white for only a few days, a graphing calculator they’ll use twice, and a backpack with so much storage space. They’re paying registration fees and signing a stack of forms about photo permissions and field trips. Very few of them are making a back-to-school doctor’s appointment, and almost none of them are thinking about the inhaler that has been sitting in a drawer since late May.

Asthma doesn’t make the back-to-school list. For most of these kids, the next time they cross our radar is the third week of September, when a refill request hits the pharmacy, a parent calls the office at 7am, or the exacerbation lands in the ED.

This season is the most predictable respiratory event of the school year, and the medication that blunts it has to be restarted before the first bell. Not after the first bad night strikes.

So this is the time to dust off the inhalers. Today we’re talking about the September asthma epidemic: why hospitalizations spike two to three weeks after school starts, why the controller is the inhaler that matters here and the rescue inhaler isn’t, and what has to be signed before the surge instead of during it.

Why does childhood asthma get worse in September?

Because three separate things arrive in the same two weeks. A rhinovirus moves through a building full of kids who haven’t shared air since May. Ragweed peaks in September and mold counts climb as leaves come down. And controller inhaler use is sitting at its annual low.1,2

The size of it is bigger than you’re probably mentally calculating it is as well. In Canadian surveillance, 20% to 25% of all childhood asthma exacerbations requiring hospitalization occurred in September.¹ In school-age children the peak lands on average 17.7 days after Labor Day. Preschoolers peak at 19.4 days, and adults at 24.¹ The surge starts in the classroom and affects everyone else in the family in a domino effect after that.

You’re reading this thinking it’s just fall, and asthma is worse in fall. That was the assumption for years. Yet, it’s the school calendar that actually broke it. Scotland and Sweden send kids back in the third week of August, and that is when their peaks land. England and Canada go back the first week of September, and theirs land then.¹ Large peaks show up two to three weeks after school return in all four countries, with Scotland’s and Sweden’s smaller in amplitude.¹ Move the return date, move the peak. The epidemic has been documented in the US, the UK, Mexico, Israel, Finland, Trinidad, and Canada.1

Viral infection, mostly rhinovirus, is associated with roughly 80% of asthma exacerbations in this age group.¹ Which matters, because the medication that lowers exacerbation risk in that setting is the most important one. Prescription data show fewer asthma medication fills over the summer months, especially for children, and inhaled corticosteroid adherence is poor at baseline and likely worse in summer.¹

Controller or rescue inhaler: which one prevents the September spike?

The controller. The rescue inhaler treats an attack that has already started. The controller is what makes that attack less likely when a rhinovirus comes through the classroom. Nearly every back-to-school checklist tells parents to make sure there’s a rescue inhaler at school. That advice is correct. Yet, it’s still the wrong thing to lead with, because a rescue inhaler is what you reach for after prevention has already failed.

Current GINA guidance is pretty blunt: a short-acting beta agonist should not be used alone at any step.³ For adults and adolescents the preferred track is as-needed ICS-formoterol, which cuts severe exacerbations by roughly 60% compared with a SABA-only reliever.³ For children 6 to 11 with mild persistent asthma it’s daily low-dose ICS with as-needed SABA, and at the mildest step, ICS whenever the SABA is taken.³ So a child whose only asthma medication is albuterol is undertreated by current guidance. A child who has a controller prescription and stopped filling it in May is in the same position.

A lapsed controller medication doesn’t announce itself, either. The kid feels fine in July, which is partly what a working controller is for, and can feel superfluous so it gets dropped. There’s no symptom to report, no visit to schedule, and nothing in the chart to look at. Asthma that has been well controlled all summer can look and feel identical to asthma nobody has treated since May.

One place that this is visible is through a pharmacist’s eyes checking out their Rx fill history. A last 30-day ICS fill in April with three refills untouched is a big flag that asthma for this child is likely uncontrolled. The pharmacy for most of these families is the only place a clinician touches them before September. An albuterol refill request in August is worth two minutes of fill-history review, and a technician can pull it before the counseling conversation ever reaches you.

What has to be signed before the first bell

Almost no parents are scheduling back-to-school visits for their kids with you. So all the work is done with parent phone calls or pharmacy requests.

Three documents to know about to be able to refer patients to:

1. The self-carry authorization. All 50 states have laws letting a student carry and self-administer their own inhaler at school.⁴ The laws vary, and many districts still require written parent and prescriber permission on file, often renewed each year. Last year’s form doesn’t always carry over so double check that. 
2. The asthma action plan. Clinician-completed, listing medications, triggers, and the step-by-step response. Schools want a current one.
3. The medication the school keeps. Where district policy requires a supply in the health office, that’s a second labeled inhaler and a second prescription.

A national analysis of these state policies found enough gray area in how they’re written that schools misinterpret them, and children end up without immediate access to an inhaler they are legally entitled to carry.⁵ 

One more thing that stalls August refills: albuterol shortage headlines. The current shortage is nebulizer solution, not the metered-dose inhaler most of these kids carry. But it is a good reminder that drug shortages happen frequently and it is a very good idea to have the medication you need already on the shelf, instead of hoping you can get it in an emergency.

Preparation is the whole point

School inverts the way parents can help kids during a health event. A kid in a classroom, or a student three states away at college, handles the first ten minutes alone with whatever is in the backpack or the dorm room. That’s what appropriate medical preparation means in practice: the clinical decisions made ahead of time, so nobody is improvising during the emergency.

For September asthma the thing that has to be in hand in August is the controller medication, and that comes from your office and your pharmacy. Jase carries albuterol and epinephrine auto-injectors as JaseCase add-ons, which covers the emergency layer rather than the daily one. That complements what you’re already doing. We’re here for the times you aren’t reachable.

The bottom line

The September asthma peak is already on the calendar for 2026 in your area. It’ll hit two to three weeks after the first school bell rings. The medication that changes the outcome is the controller nobody has filled (or thought of) since spring. That gets fixed in August by you, over the phone or at the counter. A fill-history check and a signed form now are cheaper than an ED visit in six weeks.

Sources

1. Sears MR, Johnston NW. Understanding the September asthma epidemic. J Allergy Clin Immunol. 2007;120(3):526-529. The 20% to 25% September share is Canadian surveillance data.
2. Asthma and Allergy Foundation of America. The September asthma epidemic. community.aafa.org/blog/september-asthma-epidemic
3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025 update. ginasthma.org
4. Allergy & Asthma Network. State laws on student self-carry and self-administration. advocacy.allergyasthmanetwork.org/state-laws
5. National Analysis of State Health Policies on Students’ Right to Self-Carry and Self-Administer Asthma Inhalers at School. Journal of School Health. 2018.